Boston
Medical Library
Association,
19 BOYLSTON PLACE,
Received By
yJZifa
^VL'
ORIGINAL CASES
WITH
DISSECTIONS AND OBSERVATIONS
&c. &c.
S&-//. J7?J~i /V
ORIGINAL CASES
WITH DISSECTIONS AND OBSERVATIONS
ILLUSTRATING THE VSB OF
THE STETHOSCOPE AND PERCUSSION
IN THE DIAGNOSIS OF
DISEASES OF THE CHEST;
ALSO
COMMENTARIES ON THE SAME SUBJECTS
SELECTED AND TRANSLATED FROM
AVENBRUGGER, CORVISART, LAENNEC
AND OTHERS.
BY JOHN FORBES, M. D.
PHYSICIAN TO THE CHICHESTER* DISPENSARY.
Scripsi ilia quae sensuum testimonio inter labores et taedia iterum iterumque expertus sum. Avenbrugoer.
LONDON:
PRINTED FOR T. AND G. UNDERWOOD, FLEET STREET.
1824.
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IM.U8TRISSIM0 DOCTISSIMOQUX VIRO
R. T. H. LAENNEC, M. D.
MEDICINE IN COLLEGIO REGIO GALLICO ET IN FACULTATE MEDICA PARISIENSI PROFESSORI,
PATHOLOGORUM SUI TEMPORIS FACILE PRINCIPI, AUSCULTATIONIS MEDICO OPE STETHOSCOPII EXCOGITATORI ET AUCTORI, OPUSCULUM HOC EJUS LABORIBUS APPRIME INNIXUM ET INVENTI MAGNI UTILITATEM ILLUSTRANDI STUDIO CONSCRIPTUM, VENERATIONIS SUMMJE TESTIMONIUM ET AMICITIiE PIGNUS
D. D. D. JOANNES FORBES.
PREFACE.
IN Publishing the present volume, I believe that I am actu- ated by the very best motive which a medical man can alledge for becoming an author, — namely, the conviction that the work is wanted, and will be useful to the profession. No other motive, indeed, could have had sufficient weight, to induce me to come before the public with a performance so obviously and avowedly imperfect ; and even this should not have been permittted to influence my conduct at this time, but for the additional consideration, that any advantages likely to be derived by the profession from a more finished work, would be greatly counterbalanced by the delay that must necessarily be incurred by its construction. The following pages, I am well assured, contain sufficient evidence to convince any can- did enquirer, of the great value of the diagnostic measures which it is their object to recommend ; and although there can be no doubt, that the additional experience of a few more years, might have enabled me greatly to strengthen this evidence, and to present it in a form, probably more agreeable to the reader, and certainly more creditable to the author, I should have only then attained the very same object (at least all that is really valuable in it) which I can at once secure by the pre- sent publication, Beside the positive injustice of withholding
vm PREFACE.
from the profession, information which, I conscientiously think, it imports it to have, I conceive that there exists one other very powerful reason, for the speedy appearance of my little work ; namely, the presumption that the important subject of which it treats, will be more favourably received at the present moment, than it would be at a subsequent period. A few years since, when the work of M. Laennec was first introduced to the knowledge of the profession in this country, it appeared from the reports of the Medical Journals, and the unusally rapid sale of the Translation, that a very considerable impres-t sionhad been made on the public mind, in favour of the diagnos- tic measures therein recommended. Since that time, however, if we may judge from the same Journals, the impression then made seems to have been productive of few practical results ; as I am not aware that even a single case, illustrative of the use of Auscultation, has appeared in any one of them. From this circumstance, and from not having heard of its employment in any hospital, or indeed by any individual practitioner in this country (with the exception of my friend Dr. Duncan, Jun. of Edinburgh), I am led to fear that the impression made was more lively than profound, and that through the influence of prejudice, theory and indolence, — one or all,— the greatest medical improvement of the present age, is in danger of sharing the fate of those thousand idle and useless projects which daily spring up among us, and which, after obtaining a tempo- rary notoriety through the patronage of inexperienced and over-zealous individuals, soon sink into merited oblivion.
When I published, in 1821, my Translation of Laennec's invaluable work, I had but a very imperfect practical acquain- tance with Mediate Auscultation, as a means of diagnosis, and was altogether a stranger to the employment of Percussion. Since that time, however, I have made much use of both these measures, especially the first, in my public and private prac- tice ; and have thereby accumulated a very considerable mass of materials, illustrative of their employment ; and have also acquired, T hope, a tolerable degree of facility in practically
PREFACE. IX
applying them to the diagnosis of diseases. It is to communi- cate to my medical brethren, some of the results of this expe- rience, and thereby to recommend, in the most effective man- ner, the practice to their adoption, that I have undertaken the present task.
That the attention of the reader may be usefully bestowed on the series of cases which is here submitted to his inspection, it is absolutely necessaiy that he should also be made ac- quainted with the diagnostic measures, to the illustration of which these cases are principally devoted. As far as regards the Stethoscope, this task has, indeed, been already accom- plished, by the publication of the Treatise on Mediate Aus- cultation. But as that work can scarcely now be procured, either in its original form or as translated, and as there is reason to believe that the present volume will come into the hands of many who have not seen the Treatise in question, it has been thought requisite to the utility of this publication, to include in it a brief outline of the principles and prac- tice of Mediate Auscultation. As this outline is reprinted, with very inconsiderable alterations, from my Translation of that work, I only think it proper here to repeat what I have stated in the notice prefixed to it, that, though I consider this as sufficient to make the Cases intelligible to any one, I by no means reckon it sufficient to direct the practical application of Mediate Auscultation, or even to convey a just notion of its importance. To obtain both these objects, the treatise of M. Laennec must be not merely consulted, but studied. Be- side my reluctance to swell unnecessarily the bulk of the present volume, I was unwilling to trespass on the indul- gence of my readers by minute details, which many of them already possess, and which I hope, before long, to be able to lay before them in an improved form.* As some a-
* M. Laennec is preparing for publication a new and improved Edition of his Treatise, on the appearance of which I purpose giving a new Edition of my Translation,— the former being now out of print.
X PREFACE,
mends, however, for the scantiness of this outline, I have given, from the little work of Dr. Collin, in the Appendix, many details, which, I hope will be found useful in direct- ing the practical application of the Stethoscope, as well as the other instruments of Physical Diagnosis.
Although the practice of Percussion be of much older date than that of Mediate Auscultation, I was well aware that the English reader stood more in need of information re- specting the former than the latter. Feeling it necessary, for this reason, to give a full account of the principles and practice of this diagnostic measure ; I soon came to the resolution of giving a translation of the original treatise of the discoverer of percussion, with a selection of the commentaries of Cor- visart, as being the means most likely satisfactorily to at- tain the object I had in view. This I have done in the First Part of this volume ; and I feel that, if I have executed this part of my task in a manner worthy of it, I have thereby con- ferred an important benefit on the medical literature of this country.
Independently of its high value as being the original re- cord, and even at this day still the best record, of the princi- ples and practice of percussion, this little treatise merits the regard of practitioners for the numerous original and profound pathological truths and descriptions contained in it. That there are in it both false theory, and incorrect opinions relating to matters of fact, I am well aware ; but that it contains also many sterling truths, and several, the discovery or perfection of which has been attributed to more modern writers, I am equally well assured. Indeed, when it is recollected that the work of Avenbrugger was published upwards of sixty years since, and especially when we compare it with most others of the same date, we cannot do otherwise than consider it as one of extraordinary merit. Of the value of the diagnostic measure, first promulgated in it, I shall have occasion to speak hereaf- ter ; but considering this, as I do, with Laennec, as one of the greatest discoveries ever made in medicine, I cannot help, in
PREFACE. XI
this place, recording my astonishment at the reception which it has met with from the profession, and more especially in this country. With these opinions and feelings relative to the character and fortunes of Percussion, I hope I may be for- given, if I here add a few words more respecting it and its discoverer.
Of Leopold Auenbrug or Avenbrugger himself, I have been able to obtain but little information. He was born at Graets in Styria, in 1722, graduated at Vienna, and after- wards became physician in ordinary, of the Spanish Nation, in the Imperial Hospital in that City.* In Ersch and Pu- chelt's Literatur der Medicin, besides the treatise on Percus- sion, he is recorded as the author of two works on subjects relating to Madness ; and in the Biographie Medicale he is further said to be the author of a Drama, and to have published on Dysentery. In the Literatur, he is stated to have lived till 1809. If this be correct, and its correctness, I presume, can hardly be questioned, it seems very singular that the In- ventum Novum should be the only thing published by him on the subject of his great discovery, or on that class of diseases, on which it threw so much light. This work was first pub- lished in 1761 ; but it appears to have made but a slight im- pression in Germany. We are told by Sprengel that the obser- vations of Avenbrugger are partly confirmed in a work by Isenflamm, published in 1773 ; and we further find both the treatise on Percussion and its author, commended by Stoll (Ephem. 1779). It however seems that the practice of per- cussion has been greatly neglected in the country which gave it birth.f
Its fortunes were better in a neighbouring kingdom. Avenbrugger's Treatise was translated into French, by Ro- ziere, as early as 1770, but appears to have drawn little at- tention at that time. Indeed, percussion seems to have been
* Corvisart's 1 itle-page. t Sprengel, Hist, de la Med. T. vi. p. 27.
XH PREFACE.
altogether unknown practically in France until introduced by Corvisart (about the year 1788), when it was enforced by his precept and example.
After twenty years' experience, this distinguished phy- sician finally established the practice on a firm and lasting foundation, by means of his translation of, and admirable Commentary on, the neglected original treatise of Avenbrugger. Corvisart's work was published in 1808 ; and by means of it, and through the example and lectures of this great man, the practice became extensively diffused over France ; and for many years past it has been considered by every intelligent practitioner, more especially in Paris, as a common and in- deed indispensable measure in studying diseases of the chest. To Avenbrugger alone belongs unquestionably the honor of the discovery of Percussion ; but it is to its reviver and second founder, Corvisart, that it is almost entirely indebted for the present rank and estimation which it has obtained.
I need hardly inform the English reader, how very slight an impression was made in this country either by the original treatise of Avenbrugger, or Corvisart's excellent Commentary ; since, I think, the probability is, that to the majority of those who may peruse these pages, even the name of the dis- coverer of percussion is unknown ; while still fewer of them have seen practised the diagnostic measure which must (never- theless^ render that name immortal. Dr. Cullen, in his ac- count of Hydrothorax, in the Frst Lines (mdccii.), just alludes to percussion, as a practice with which he is personally un- acquainted. Dr. Young, also, in his Treatise on Consump- tion, p. 22, briefly notices it ; but his account of it does not occupy more than half a page. It is not even named in Parr's Medical Dictionary, nor in the greater number of the elemen- tary or systematic works, which profess to give, and common- ly do give, the existing state of theory and practice at the pe- riod of their publication, — e. g. Dr. G. Gregory's excellent Compendium, and Dr. Good's voluminous System. It is, how- ever, named in Thomas's popular work ; and in a small volume
PREFACE. Xlii
just published, on the subject of Diagnosis, it is mentioned in a manner sufficiently characteristic of the degree of information respecting it, which prevails in this country. " Foreign phy- sicians (says this writer) are of opinion that much knowledge of the nature of affections of the lungs may be derived from the percussion of the Thorax ; and for the purpose of convey- ing the sound they employ a peculiar instrument."* In this sentence it is evident that the author confounds together Per- cussion and Mediate Auscultation.
In determining to give an English dress to the treatise on Percussion, it became a matter of consideration whether to present it in its original quaint form, of Observation, Axiom, and Scholium ; or, by melting down and remoulding it, toge- ther with the French commentary, to give to the whole the ap- pearance of a new work both in manner and matter. By adopting this plan, there is little doubt, I think, that I might have produced a more agreeable and more readable performance ; though I question whether I could have rendered the subject clearer or more impressive. But against this proceeding, were there no other reasons, I think those so honorably ad- duced by Corvisart, for a similar forbearance on his part, are all-sufficient, and indeed unanswerable. His words are — ° Sachant bien le peu de gloire devolu a presque tous les tra- ducteurs , comme au tres grand-nombre des commentateurs , j'aurais pu m'elever au rang d'auteur en refondant Poeuvre d'Avenbrugger , et en publiant un ouvrage sur la percussion. Mais , par-la , je sacrifiais le nom d' Avenbrugger a ma propre vanite ; je ne l'ai pas voulu ; c'est lui , c'est sa belle et legitime decouverte , (inventum novum , comVne il le dit justement) que j'ai voulu faire revivre, Heureux , si je contribue seulement a en faire sentir Pimportance , et si les praticiens scrupuleux ne dedaignent point d*ajouter a beaucoup de signes infideles , un moyen plus sur de s'eclairer dans la recherche de la plupart des affections de la poitrine." Pref. p. xm.
* Buchan's Symptomatology, p. 36.
XIV FREFACE.
I fear I cannot, with justice, extend the same commen- dations to the manner as to the matter of my author's treatise ; as it is certainly written in no very classical style of latinity, and is, moreover, occasionally not a little obscure. In two or three places, I am by no means sure that I have given the true meaning of the author, more especially where I have thought it necessary to adopt a different interpretation from that of Corvisart.
The mere fact of the publication of the present volume, is sufficient proof of the high importance attached by me to the diagnostic measures which it is its object to recommend. I think it, however, necessary, in this place, to state more ex- plicitly the judgment which 1 have been led to form of them from my own personal experience. I have already said that, during the last two years and a half, I have been in the habi- tual employment of Auscultation and Percussion (more espe- cially the former), in my public and private practice, and in a pretty extensive field ; and I can most conscientiously add, that the additional experience of every successive month and week, has only tended to increase more and more the confi- dence previously reposed in them. If I may be allowed to judge from the benefit which I have myself derived from them, in all the departments of medicine ; in pathology, diagnosis, prognosis, and treatment ; I cannot but consider their general adoption by the profession in this country, as an event to be most ardently desired, and their comparative rejection hi- therto, as a circumstance to be much deplored. The whole question respecting the propriety of adoption or rejection, lies in narrow compass, and is of most easy decision. It is simply, whether a more correct, more certain, and more minute diagno- sis of many of the diseases of the chest, than can be obtained by means of the common symptoms and modes of investigation, be desirable or not? I presume it will be admitted by every intel- ligent and experienced practitioner, that the diagnosis of many diseases of the chest (as indeed of those of every important or- gan of the body) is often a matter of extreme difficulty ; and that
PREFACE. XV
doubts very often, and mistakes not seldom, as to their real character, are things of daily observation, in the practice of even the most skilful. That the general adoption of the diagnostics recommended in this volume, would remove all these doubts, difficulties, and mistakes, I am very far from believing ; but that it would remove some of them, and lessen others, I cannot possibly doubt. Indeed, the superior cer- tainty and precision of diagnosis afforded by the Stethoscope and Percussion, in many diseases of the chest, is so much a matter of simple fact, and can be so easily demonstrated in practice, that it would be idle to attempt to prove the thing by reasoning. For more than one instance of this kind, I hope I may be allowed to refer to the Cases in the present volume. At least, I can safely say, that the degree of precision of di- agnosis obtained in several of these, conld not have been at- tained by me, whatever it might have been by others, without the aid of the physical diagnostics employed. Any objections, therefore, that can be made against the adoption of these in practice, must apply to the utility of the minute diagnosis ob- tained by them, and not to their specific fitness to supply it. And as it is, I apprehend, with objections precisely of this kind, that they have to contend, 1 deem it necessary, in this place, to make a few cursory observations on the subject.
Respecting minute diagnosis, it is said that, in most cura- ble diseases, it is useless, because the same treatment applies to the greater number of those likely to be confounded ; while in incurable diseases, it is obviously useless, because in them all treatment is equally unavailing. These objections seem, at first sight, pertinent ; but I conceive they are more of appa- rent than real strength.
The history of every science shows, that, generally speaking, every addition of knowledge has been an increase of power; and innumerable discoveries could be mentioned, which, at the time they were made, seemed of no value, but which eventually proved of the greatest importance. Many striking illustrations of this truth could easily be adduced from the history of Medicine. On this principle alone, then, were
XT1 PREFACE.
there no other reason, I would maintain the utility and impor- tance of a minute diagnosis. 1 admit that this precise discri- mination of different diseases, or of their different shades and stages, may not, at present, increase our power of curing or relieving many of them, even in the slightest degree : But who shall assert that this will always be the case ?
But I contend, further, that accurate and minute diag- nosis is highly valuable in itself, and for itself alone ; and de- serving the utmost regard of the practitioner, even if it should neither confer on him any present superiority, nor yet hold out any prospective advantages to medicine. This will, perhaps, hardly be understood by those, who are content to exercise their profession, merely as an art or trade ; in whose routine system, a happy ignorance precludes alike the apprehension of doubt and difficulty ; and who are equally strangers to the higher pleasures and pains of practice. To the great majority of my readers, however, who cultivate their profession with the philosophic spirit, zeal and disinterestedness, which the most comprehensive and beneficial of the sciences demands, I trust it is unnecessary to enlarge on the value of the satisfaction which results from certainty, or the misery that springs from doubt. To treat a disease, with the nature of which we are unacquainted, especially if it be of any severity, is, at least, al- ways unpleasant, often extremely painful ; and the satisfaction derived from the casual recovery of a patient, under such cir- cumstances, is very different from that which accompanies a cure, which, if we have not produced it, we can, at least, under- stand,— which we may perhaps have foreseen, — and which, certainly, we have not protracted.
Indeed, I am sometimes disposed to doubt, whether the untoward event of a disease, which his science had enabled him to predict, and which he had assiduously endeavoured to avert with all the resources of his art, is not productive of more real satisfaction (as it certainly is more creditable) to the phi- losophic practitioner, than the recovery of a patient, of the nature of whose disease he is ignorant.
Put I am far from admitting that the benefits of minute
PREFACE. XV11
diagnosis are confined to these negative advantages. On the contrary, I maintain this to be highly useful and important, in the actual practice of medicine, — in prognosis and treatment ; and in incurable, as well as curable diseases.
Jn respect of the important subject of Prognosis, — by the practical application of his knowledge of which, probably, the skill 6"'f the physician is more frequently judged of, than by any other circumstance, — it may be stated as generally true, that those prognostics can alone be depended on which are founded on the practitioner's acquaintance with the natural history of the disease before him ; that is to say, its seat, nature and cha- racter, as ascertained by obvious symptoms, or by any other means in our power, and its usual progress and termina- tion. By this remark, I am far from wishing to condemn as useless, the more common system of prognosis, which, under the guidance of experience, attempts to judge of the event of diseases from the symptoms only, without endea- vouring to look through and beyond them, at the actual patho- logical state, of which they are, at most, the attendants, and frequently but the accidental attendants. I mean merely to assert, that any system of prognosis, derived exclusively from such a source, must always be unsatisfactory, and must fre- quently lead into error ; and can be safe or useful only, when combined with, and considered merely as accessory to that other kind which is based on the knowledge of pathology. If then it be true, as I maintain it is, that the diagnostic measures which we have been considering, bring us, in very many in- stances, to a closer and more precise acquaintance with the actual pathological condition that exists in any particular case, it follows as a necessary consequence, that our prognosis, in every such case, must be thereby directly and greatly improved.
To adduce a very common case in illustration : — Sup- pose two physicians of equal skill and experience, but only one an Auscultator, met in consultation, for the first time, on a a case of Chronic Pleurisy or Peripneumony, in no very ad- vanced stage. Probably the only remarkable symptoms are, a
B
XV1U PREFACE.
violent cough with little or no expectoration, more or less dys- pnoea, especially on motion, and incapacity to assume, with com- fort, certain postures ; the pulse perhaps is natural, there is no pain, no febrile heat, no hectic, and inconsiderable loss of flesh; or, perhaps, one or other of these states may exist. From these general symptoms, will he who is not the Aus- cultator venture to pronounce, with any degree of confi- dence, his opinion of the precise nature of the disease ; much more, to declare it to be one that will almost certainly prove fatal, and scarcely even admit of relief from any kind of treat- ment? No practitioner, I affirm, judging from the common symptoms only, can be justified in entertaining such opinions. But if, to the examination of the symptoms, be superadded the exercise of percussion, or the exploration by the stethoscope, for only two or three minutes ; and if the former elicits the pre- ternatural or fleshy sound over the whole of one side of the chest, or the latter indicates the absence of respiration over the same space ; then, at once, are obtained sufficient mate- rials (conjointly with the previous history and present symp- toms of the case) to form a correct diagnosis, and to jus- tify and authorise the most ominous prognosis. Were the benefits of Auscultation confined to this single case of disease, it would, even then, be entitled to the highest consideration.
In respect of the Treatment of disease, the same line of argument, and nearly the same observations, apply. As no empiric, however experienced or learned, can ever be a faith- ful or consistent prognosticator of the event of diseases, so nei- ther, for the same reasons, can he be a consistent or generally successful practitioner. And as the true pathology of exist- ing diseases can only be known by means of a just diagnosis, it necessarily follows that this latter is essential to good prac- tice. But we have already seen that in the case of many of the diseases of the chest, a true diagnosis cannot be obtained without the aid of Auscultation aud Percussion. And in point of fact, and speaking from observation, 1 scarcely think that there is one of the numerous affections to which this cavity is
PREFACE. XIX
subject, in which the minute diagnosis in question is not more or less beneficial in practice. In the more prominent instance of Empyema and Hydrothorax, in some examples of which, perhaps the operation of paracentesis is the only measure left from which we can expect any relief, it is needless to point out the immense advantage of this kind of diagnosis ; since it is often from this alone that we can derive any certain knowledge — not merely of the particular site, but even of the very exist- ence of the fluid to be evacuated. (See the Remarks on Case xxv, p. 215, and the Observations on the operation of empy- ema, p. 251.)
In regard to the objections that have been made to phy- sical diagnostics, on the score of their being solely or chiefly applicable to incurable diseases, or to the last and nearly hope- less stages only, of such as are curable, it may perhaps be sufficient to refer to what has been said above, of the superior advantages of the former, in all diseases of the chest. But as I am further of opinion, that these advantages extend to the Treatment also of incurable diseases, I think it necessary to add a few words on the subject, in this place. It is of no slight importance to the sufferer from an incurable malady, that the medical attendant understands the nature of it, and knows it to be incurable. This knowledge will, at least, prevent the employment of painful, disagreeable, or merely useless reme- dies ; and, what is of yet greater consequence, will forbid the use (otherwise very likely) of measures which might aggravate the symptoms or precipitate their course. Besides, there is no disease, however hopeless, of which there is not a right and a wrong treatment, and which does not admit of some mitiga- tion, if not suspension, when managed according to the dictates of experience and sound pathology. The observations for- merly made, when speaking of diseases generally, on the pos- sibility of these becoming eventually more under the power of remedies ; the comfort and satisfaction to the physician of knowing the nature of the affections he is treating; and the in*
XX PREFACE.
finite importance, practically, of being able to pronounce a correct prognosis ; are, of course, equally applicable to the most incurable diseases.
In respect of the other class of cases ; if it were even true, which it is not, that our physical diagnostics took cogni- zance only of the latter stages of organic affections, they would still, even in this limited sphere of operation, be of great va- lue. In the early stages, the Auscultator would have, at least, all the advantages possessed by other practitioners, while in the latter stages, he would have many more. Besides, it need scarcely be said how frequently it happens, more especially to physicians, that the latter stages of diseases are the only ones which the practitioner has an opportunity of observing.
I hope it will not be inferred from the preceding observa- tions, that I am disposed to overrate the importance of patho- logy or diagnosis ; or the powers of the measures employed to acquire the knowledge of these, in actual practice. All that has been said in relation to diagnosis, prognosis and treatment, I wish to be understood merely comparatively, and as appli- cable to states rather of comparative ignorance than know- ledge.
Every practitioner, I presume, of common experience and common candour, must have received too many lessons from his own doubts and errors, not to be impressed with the unsurmountable difficulties and uncertainties that surround the whole subject of practical medicine, or to run any risk of in- dulging in Utopian dreams of attainable perfection in it. At the same time, I trust, no one need be ashamed to confess that he hopes and believes that both the science and practice of medicine will become eventually more perfect than they are at present ; or to feel assured that it is principally from the de- crease of empiricism, and the assiduous and legitimate cultiva- tion of pathology, that such improvements as are attainable, may be expected.
And as directly bearing on this subject, I must here be
PREFACE. XXI
permitted to make a few remarks on certain incorrect and par- tial views of pathology entertained by some practitioners, lest I should be accused of abetting the very error, which I feel myself called upon to censure. I allude to the disposition evinced of late years, of looking to the result of diseases, ra- ther than to diseases themselves ; or rather, of regarding dis- eases as constituted by the more striking phenomena of their last stage, and by the appearances on dissection, than by the phenomena of their whole course. This mode of judging of the character of diseases, is scarcely more just than would be that of the biographer, who should draw the character of his hero from the last act of his life only, without any regard to his previous conduct.
The error in question is, perhaps, a very natural result of the great progress that has been made of late years in the pathology of organic diseases, and of the much greater preva- lence of the practice of examining dead bodies. It is, how- ever, not the less injurious on this account. The truth un- questionably is, that there are many diseases, of the pathology of which we are entirely ignorant ; and there is every reason for believing, that not a few of these, if really consisting in any change of organic structure, are of such a nature as will never be exhibited beneath the knife of the dissector. Nay more, it is certain that, even in those diseases with the pa- thology of which we seem to be well acquainted, almost all our beneficial practical efforts must be directed to a state of parts which preceded that which we see in the dead bodies of our patients. It is indeed, with me, I confess, a matter of con- siderable doubt, whether we are not accustomed greatly to overrate the powers of our remedial agents, to remove diseases that consist in any considerable physical alteration of an organ ; and whether, in our attempts to do so, we do not some- times establish the morbid state, by interfering with the reme- dial powers of nature, which, perhaps, are alone capable to effect the wished for change. It has been a similar convic- tion, on their part, I presume, that has obtained for some of
XXU PREFACE.
the most eminent professors in our art, the character of feeble and routine practitioners. It is this which has led some of the most distinguished pathologists to lean towards the creed of medical fatalism ; and may be partly the cause of entailing on the French practice of medicine, generally, at least in the estimation of the practitioners of this country, the reproach of indecision and imbecility. Taking into consideration the whole course of diseases, I should be sorry to be thought the apologist, much more the advocate of this timid and expect- ant system; and I fear our continental neighbours are much to blame for their inactivity in the earlier stage of diseases ; but I cannot help fearing, that the irrational vigour of some British practitioners, in the latter stages, may almost counter- balance their beneficial activity in the former ; and that thus the accounts between the two may come, in the end, to be nearly balanced.
The practical conclusion from all this ought to be, not to disregard pathology, but only to cultivate it in a more philo- sophic spirit. To derive benefit from our dissections, we ought quite as much to reflect on what was the cause and early character of the organic change which we see consummated, as to study the actual nature and final amount of this change. Without this retrospective ratiocination, and practical dedica- tion of his researches, the morbid anatomist is more an artist than a physician ; and his devotion to science is, to use the language of Bacon, rather idolatry than true worship.
It is obvious that this view of the subject does not mate- rially lessen the importance of the diagnostic measures, which it is the object of this volume to recommend ; although the most conspicuous evidence of their powers, is certainly found in that stage of diseases, wherein I have accused the compa- rative impotency of medicine.
In like manner, I would wish to guard against the dan- ger of overrating the extent of applicability of the stetho- scope in practice ; the extent of its diagnostic powers where applicable ; and the degree of confidence to be reposed in its
PREFACE. XxHi
positive results. From my own experience I should be dis- posed to believe, that in the greater number of the more recent inflammatory affections, auscultation might be dispensed with, because, in such cases, the common symptoms are, in general, sufficient to regulate the practice ; although I must admit, that percussion and the stethoscope would, even here, render our judgement and practice, in many cases, more satisfactory and certain. In all diseases, however, which are essentially chronic, in acute diseases which have become so, and in all cases of a doubtful nature, whether of a long or short standing, I should deem the trial, at least, of these measures, to be almost indis- pensable.
In having recourse to these, however, in any case, I would earnestly caution the inexperienced, not to be too for- ward in forming a diagnosis from the results furnished by them. It is highly proper and necessary that it should be generally understood, that the practice of auscultation, &c, although easi- ly acquired by care and attention, is not to be acquired (in such a degree of perfection as to be useful), without these, and without considerable experience. And 1 would advise every one to be extremely cautious in drawing from his explorations, any conclusions which are to influence the treatment of dis- eases, until he has been able to convince himself thoroughly of the correctness of these, by a good deal of experience, and, if possible, by the unerring testimony of dissection.
The reason of this caution will be obvious on considering the relative characters of the physical, and the common, or sympathetic diagnostics. In general, we depend so little on any one symptom of a disease, that we seldom risk any mo- mentous treatment, or hazard a decided prognosis on it; and, therefore, it is not a matter of very great consequence, practi- cally, whether we are right or wrong respecting its supposed import in any individual case. It is very different, however, with many of the indications furnished by mediate ausculta- tion or percussion. To such persons as admit their authority, these carry with them the conviction of almost physical demon-
XXIV PREFACE.
stration; and it is impossible not to yield to opinions founded on such a basis, assent of a very different kind from that which follows the contemplation of a mere sympathetic symptom. We may deem lightly of a quick pulse, or a hurried respira- tion, or an acute pain, because we know that all these may accompany an affection of the most temporary kind, and of no danger ; but when we know that the fleshy sound, or absence of respiration, over one side of the chest, can only arise from a great organic change, it is impossible that we can regard such a sign but as one of the highest consequence, and as worthy to determine our prognosis, and direct our practice. I would therefore advise the young auscultator, not to act upon his earlier explorations, unless the practical indications fur- nished by them accord with those which are supplied by the common symptoms. A little learning, may, in this case, be truly a dangerous thing. I am even disposed to recommend some degree of the same caution to the most experienced; since I think it may be laid down as an axiom, that in proportion as we consider our diagnostics certain, ought we to be cautious not to misapply or misconceive them.
After these remarks on the general subject to which this volume is devoted, and on those parts of the work derived from external sources, it will be expected that I should say some- thing, in this place, relative to the nature and form of that por- tion of it, for which I am exclusively responsible.
It will be seen, by a reference to the Table of Contents, that the Cases consist of Diseases of the Heart and Pericar- dium, Chronic Pleurisy, Hydrothorax, Chronic Peripneu- mony, and Asthma. With one or two exceptions, I have excluded all the more acute inflammatory affections, and have altogether omitted cases of Phthisis. Of the parti- cular selection and exclusion made, I do not know that any other explanation is necessary, but the general one, that it was never my intention to give examples of all the dis- eases of the chest. I may say, however, that the particular choice made, was directed partly by the relative frequency of
PREFACE. XXV
diseases, and partly by the desire of giving such cases as were, at once, interesting- from their general character, and best calculated to promote the main object of the work. Ano- ther reason has operated in diminishing the number of the diseases noticed, as well as cases, viz. my wish to keep the volume within certain bounds. When I began printing the cases, 1 did not expect that they would be nearly so volumi- nous, as they proved to be ; and when I found that those de- voted to the diseases of the heart took up so large a portion of my allotted space, I decided, at once, to omit many others which I originally intended to publish. This determination led me to suppress nearly all the examples of recent inflamma- tions which I had prepared, and the whole of those of Con- sumption. I made this sacrifice (the reader may not think it one) the more willingly, because my experience had been much less extensive, and also less satisfactory (perhaps because less extensive), in acute than in chronic diseases ; and because, in phthisis, the results furnished by the new diagnostic measures, although sufficiently satisfactory, and consistent with the doc- trines of Laennec, appeared to me of very inferior practical value, inasmuch as they were obtained only when the disease had reached a hopeless stage (if, indeed, all its stages are not hopeless), and when, moreover, the same results were furnished by the ordinary symptoms.
In looking at the imperfections conspicuous in almost all the Cases contained in this volume, of which no one can be more sensible than the writer, I confess it to be a subject of just regret, that the task of disabusing the mind of the medical profession in this country, in respect of the value of the stetho- scope and percussion, has not fallen to the lot of some one better qualified than myself, both by his abilities and opportu- nities. In Hospital practice, it is obvious that much greater justice conld be done to the subject, than either in private or Dispensary practice ; as, in all cases, the hospital physician can have the disease constantly under his eye during the life of the patient; and, in most cases, when the event has been fatal,
c
XXVI PREFACE.
he can bring the evidence of dissection to confute or confirm his judgements. In regard to this latter circumstance, how- ever, I think it due to the good sense of the lower classes in this country, to declare it as my own opinion, that there is much less difliculty in obtaining permission to inspect dead bodies, than is commonly imagined. In proof of this, perhaps, I may be allowed to instance the dissections recorded in this volume, together with many more, — all performed (with two exceptions) by myself, in a provincial situation, in private houses, and within a period of little more than two years.
It is more especially in a comparison with those of M. Laennec, that the deficiencies of my cases will appear ; and had it not been from a conviction produced by my own obser- vation, and strengthened by the concurring opinions of many friends, that/ in the present state of the public mind, original English Cases are absolutely necessary to produce the proper impression in favour of the stethoscope, I should never have presumed to publish my own at full length, while the greater number of M. Laennec's are still untranslated, or only given, in my translation, in a greatly abridged form.
Although I am well assured that almost all the records of disease in the present volume are deficient in many essen- tial points, I think it probable that my readers (they more es- pecially who have not previously studied the subject of Aus- cultation) will be more disposed to condemn the extreme pro- lixity of my cases, than to blame their incompleteness. To the charge of prolixity, as well as of defectiveness, I must plead guilty ; but I can exculpate myself from the former much bet- ter than from the latter. In publishing my cases, I felt that the diagnostic measures employed in them must be new to the greater number of my readers, and that it was, on this account, absolutely necessary, that the detail of these should be as full as possible ; that it should be, in fact, such as constituted the identical grounds on which I myself (a scholar like them) had come to the conclusions therein recorded, respecting the na- ture and event of each particular case. And I would fain
PREFACE. XXV11
hope, that the cases will be to my readers, what they have been to me, not merely proofs of the value of the diagnostic measures therein recorded, but studies, from the examination of which they may be able to decide, whether the conclusions drawn are just, and also themselves to draw others, as from actual explorations of the living subject. Keeping this gene- ral principle in view, then, I think that although many of the stethoscopic details may seem unnecessarily minute, in refer- ence to the individual case in which they occur, they will not be found to be useless in relation to this more important ob- ject. I am well aware that such lengthened reports cannot be interesting; but if I had not considered them as highly use- ful, not to say necessary to the furtherance of the important object of this work, they certainly should not have appeared in it.
It may, perhaps, be thought likewise, that many of the general histories are unnecessarily minute. I hope however, that this can also be satisfactorily accounted for. Deeming the greater number of the cases interesting in themselves, as spe- cimens of pathology,* I was desirous of making the account of their general history and symptoms sufficiently complete to render them as useful as such observations usually are, inde- pendently of any peculiarities in their diagnostic details. And I was. perhaps, in some respects, even more than usually minute, from a wish to exhibit the relative character and value of the physical and the common diagnostics, in specimens respecting the positive nature of many of which there could be no doubt. And this— not with the view of raising the one at the expence of the other ; but in the simple desire of discovering the truth. For, however partial to the use of the Stethoscope and Per- cussion, I must here and everywhere avow my conviction of the propriety and necessity of attending, in every case, to the
* It will be seen that I have introduced several Cases entirety on this ac- count, and which have little "mo connexion with the uhject of th< p< < uliatdi- ^ics recommended in this volnrnc.
XXV111 PREFACE.
general symptoms also. Indeed, I look upon it as the great recommendation of the stethoscope, and the other instruments of physical diagnosis, that they are additional to the common means, and not in any degree exclusive of these ; so that, as I formerly observed, the employer of the new measures can, in no case, be injured by them, while in many he may be bene- fited.
That a master of auscultation will find many other imper- fections in the Cases, I do not doubt. I think it even very pos- sible that some of the examples of my recorded Diagnosis may be at variance with the explorations on which they are founded. I do not know that any such discrepancy really does exist ; but I own I shall be neither surprised nor hurt, if it should prove to be the case. The correctness of the explo- rations I can certainly vouch for, as the simple records of ob- served phenomena ; but I am by no means prepared to say that my conclusions drawn from these, have always been cor- rect or legitimate. I trust, however, that my avowed charac- ter of a scholar, will screen me from some of the blame that might properly attach to similar delinquencies in the work of an avowed professor. In justice to myself I must say, that I cannot accuse myself of wilful negligence or want of reflection. I have been most anxious to learn ; and hope I have not been mistaken in supposing that the surest way of instructing others, was to lay before them the very lessons, literally transcribed, from which I have myself derived the knowledge I possess. It is certainly one of the disadvantages of mediate ausculta- tion, that it requires much time and trouble to enable one to acquire even a moderate degree of adroitness in the practical application of it. For these reasons, I must request such of my readers as may meet with any of the defects alluded to, to consider them rather as owing to the unskil fulness of the artist, than to any unfitness in the materials. I would only further ask, that a judgement of the work may not be formed from any detached portion of it, but from the combined effect of the whole. In this case, however little credit may re-
PREFACE. XXIX
dound to the advocate from the scrutiny, I have no apprehen- sion for the triumph of the cause.
As the greater part of the present volume was writ- ten under somewhat peculiar circumstances, perhaps I may be permitted, before 1 conclude, to say one word on a subject which it is commonly deemed unnecessary to notice in a prac- tical work like this. I allude to the style. As every explo- ration recorded in the volume was made by myself, so was every case witten by me, either in the presence of the patient, or immediately after the examination ; and generally in great haste. Under such circumstances, it was hardly to be ex- pected that the language should be always correct, much less good ; but, on the contrary, that there should be much same- ness of expression, frequent repetitions, and occasional tauto- logy. In transcribing the cases for the press, I was unwilling to alter, in any considerable degree, the original records ; for fear of conveying, by new expressions, other, or less clear ideas, than would be communicated by those (however inele- gant) which were suggested by the immediate presence of the objects. I make this remark principally, because by much the greater portion of this work is of the above character ; and be- cause I should be sorry to be considered as wilfully assisting in lowering the literary character of the profession.
CONTENTS.
PAGE
Dedication, „ v.
Preface, vii.
avenbrugger's treatise on percussion of the
CHEST.
Author's Preface, 3
Observation i. Of the natural sound of the chest, and its character in different parts, 5
II. Of the method of Percussion, 8
ill. Of the preternatural or morbid sound of the chest, and its general import, ..11
iv. Of the diseases in general in which the morbid sound of the chest is observed, 17
v. Of Acute diseases in which the chest yields the morbid sound, 18
vi. Of Chronic diseases in which the preternatural sound is observed, 23
vn. Of the preternatural sound of the chest which re- sults from copious extravasation of the fluids contained in the vessels of the cavity, 29
viii. Of those affections of the chest which are not in- dicated by percussion, 30
ix. Of the appearances on dissection in cases where the preternatural sound of the chest had been observed,. #.33
XXXU CONTENTS.
PAGE
x. Of Scirrhus of the Lungs and its symptoms, 34
xi. Of Vomica in general, 38
1. Ichorous Vomica, 39
2. Close purulent Vomica, 40
3. Open purulent Vomica, 41
4. Empyema, 43
xii. Of Dropsy of the Chest, 45
1. Dropsy of one side, , 47
2. Dropsy of both sides, .47
3. Dropsy of the Pericardium, 54
xiii. Of the symptoms of an extravasation of blood, ...61 xiv. Of Aneurism of the Heart, 62
on mediate auscultation (from Laennec) 65
Description of the Stethoscope, 68
Kinds of Exploration, 69
1. The Voice, ib
2. The Respiration, • 71
Different Rattles, 75
3* The Circulation, 75
Sound, 76
Impulse, 79
Rythm, M 80
CASES.
CASE I. Ilypcrtrophla with Dilatation of the Heart. — Diseased Valves
— Dilatation of the Aorta. — Peripneumony, 85
Dissection, . • • • 89
Remarks, .... ... • 91
II. Ifypertrophia with Dilatation of the Heart in a moderate degree.
— Peripneumony. — Pleurisy............ 92
Dissection, .*....... 94
Remarks, ♦ • • 95
III. Dilatation with Hypertrophia of the Heart, ._..... 96
Dissection, • 98
Remarks, ■»..,... .......♦•».. #9
CONTENTS. XXXlii
t
PACK
CASE IV. Dilatation of the Heart. — Haematemesis, 102
Dissection, ,...106
Remarks, , 108
V. (Supposed) Hypertrophia with Dilatation of the Heart, and val-
vular disease, -- 109
Remarks...... Ill
VI. Contraction of the Mitral Orifice. — Slight Dilatation of the
Heart. — Chronic Peripneumony. — Anasarca of the Lungs,. .112
Dissection, ......... 116
Remarks, 117
VII. Hypertrophia of the right Ventricle, — Hypertrophia with Dilata- tion of the left, — Ossification of the Sigmoid Valves, — Dilata- tion of the arch of the Aorta, — Pleuritis and Peripneumony
of the left side, 121
Dissection, 125
Remarks, 128
VIII. Complete adhesion of the Pericardium to the Heart, — Ossifica- tion of the pillars of the mitral valve, — Chronic Peripneu- mony of the right lung .133
Dissection, 135
Remarks 136
IX. Enlarged Heart — Pericarditis.— Pleuritis, 138
Dissection, 146
Remarks, ... 148
X. Hypertrophia with dilatation of the left ventricle, and Dilata- tion of the right. — Pericarditis. — Hy drothorax, 152
Dissection, ,... ]55
Remarks, 156
XL (Supposed) Chronic Pericarditis 159
Remarks, 163
XII. (Supposed) Dilatation of the Heart, from contraction of one of
valvular orifices, 165
Remarks, , 167
XIII. (Supposed) Original Debility [extenuation] of the Heart, 168
Remarks, 169
XIV. Angina Pectoris, from (supposed) weakness of the parietes of the
Heart. (Nervous or Spasmodic Angina.) 171
Remarks, 173
XV. Sympathetic Angina Pectoris, 1 76
Remarks, • 177
XVI. (Supposed) Dilatation of the Heart, with contraction of an orifice, 1 78
Remarks, ...... .«*r ... • • 182
d
XXXIV CONTENTS.
PAOF
CASE XVII. (Supposed) Hypertrophia with Dilatation of the Heart, and
contraction of an orifice, .....183
Remarks, 186
XYIIT. (Supposed) Hypertrophia with Dilatation of the Heait, 187
Remarks, 190
XIX. (Supposed) Valvular disease, with Dilatation of the Heart.—
Pulmonary Catarrh, 1 91
Remarks, 1 95
XX. Aneurism of the Aorta, 196
Dissection, 202
Remarks 203
XXI. Symptomatic Hydrothorax. — Hypertrophia with Dilatation of the
left Ventricle.— Slight (recent) Pleurisy, 204
Dissection, , 206
Remarks, 207
XXII. Symptomatic Hydrothorax, 208
Remarks 210
XXIII. Symptomatic Hydrothorax. — Diseased Heart, . . 211
Remarks, 21S
XXIV. Hydrothorax of the left side, 213
Remarks, ....._. .214
XXV. (Supposed) Idiopathic Hydrothorax, .215
Remarks, 218
XXVI. Anasarca of the Lungs. — Hydrothorax, .....220
Remarks, 221
XXVII. Hydrothorax .,.., 222
Remarks, 224
XXVIII. Chronic Pleurisy. — Dilatation of the Heart, -. 224
Dissection, 234
Remarks,.. 236
XXIX. Chronic Pleurisy, with contraction of the Chest. — Fatal Peripneu-
mony, 237
Remarks, ... .-... 243
XXX. Acute, ending in Chronic Pleurisy.— Contraction of the Chest. . . .245
Remarks, ....,• 246
XXXI. Chronic Pleurisy — Scirrhous Lung 247
Dissection, 250
Remarks, 255
XXXII. Pleuro-Peripneumony, 225
Remarks, - -.- 257
XXXIII. Pleuro-Peripneumony, ...259
Remarks, 263
CONTENTS. XXXV
PAGE
CASE XXXIV. (Supposed) Chronic Pleurisy, 263
Remarks, 265
XXXV. Chronic Peripneumony, ....... , ..265
Dissection 267
Remarks, , 267
XXXVI. Chronic Peripneumony, without the usual symptoms, 268
Dissection, . . .268
Remarks, 269
XXXVII. Pulmonary Catarrh, or Bronchitis, 270
Remarks, 270
XXXVIII. (Suspected) Emphysema of the Lungs, 271
Remarks, 273
XXXIX. Asthma 278
Remarks, .- 276
Appendix: dr. collin's essay on the differ- ent MODES OF EXPLORING THE CHEST, 277
Prefatory notice by the Translator, ...279
On the different modes of Exploration.
Chap. I. Examination of the motions of the chest in
respiration, 280
II. Percussion, 281
III. Auscultation, 282
iv. Mensuration, 284
v. Succussion, 285
vi. (Additional) Pulmometry, 286
vii. (Additional) Abdominal Pressure, 286
Application of these to Diagnosis.
DISEASES OF THE ORGANS OF RESPIRATION.
I. Pleurodyne, ,.288
II. Pulmonary Catarrh, 288
III. Pulmonary Apoplexy, 289
iv. (Edema of the Lungs, 290
v. Emphysema of the Lungs, 290
vi. Peripneumony, 292
Vii. Empyema and Hydrothorax, ♦„.... 294
XXXVI CONTENTS
PAGE
viii. Pleurisy, ......294
ix. Phthisis Pulmonalis, 296
x. Gangrene of the Lungs, 297
xi. Pneumo-Thorax, 297
DISEASES OF THE HEART.
I. Hypertrophia* * . 299
Of the left Ventricle, 299
Of the right Ventricle, 300
ii. Dilatation, 300
in. Dilatation with Hypertrophia, 300
vi. Contraction of the Orifices, 301
v. Softening of the Heart, 301
vi. Aneurism of the Aorta, 301
vii. Pericarditis, ......301
Viii. Hydropericardium, 30*2
EXPLANATION OF THE PLATES.
Plate i. The Stethoscope.
ii. and in. Contraction of the Chest.
©n ?9trctt00ioti of ti&e ©f)e$t ••
BEING A TRANSLATION OF
AVENBRUGGERS ORIGINAL TREATISE,
ENTITLED
" INVENTUM NOVUM EX PERCUSSIONE THORACIS HUMANI, UT SICNO, ABSTRUSOS INTERN! PECTORIS MORBOS DETEGENDi;"
AND OF
A* SELECTION OF THE MORE IMPORTANT
COMMENTARIES OF CORVISART
ON THAT WORK: The former first Published in 1761, the latter in 1808.
Expertus affirmo, quod signum , de quo hicagitivr, gravisshm moraenti sit , non tantdm in cognoscendis , sed etiam curandis morbis : atque ideo pri- raum locum mereatur post explorationem pulsus et respirationis. Enim vero , in quocumque morbo praeternaturalis sonus thoracis observatus fuerit , majus esse periculum indicabit semper. Avenbrugger.
I/auteur semble craindre qu'on meprise , ou qu'on fourne en ridicule ce pyocede : mais quel serait le medecin asscz leger , ou trop prevenu , pour se refuser a un moyen qui porte avec lui une conviction complete , fondee sur un phenomene physique , a, l'abri de 1'crreur et de toute illusion ? Quel homme raisonable et desireux des progres de son art, hesiterait de recourir a ce pro- cede, dans la foulc de ces maladies obscures, ou toutes les ressources de la symptomatologie sont si souvent infideles , et sur la nature desquelles , la per- cussion seule peut jeter une vive lumiere , en faisant connaitre le veritable etat des organes de la poitrine. Pour moi , convaincu d'apres une experience r6- petee , depuis plus de vingt ans , non pas seulement de l'utilite , mais de l'in- dispensable n6cessite de la percussion du thorax dans un tresgrand nombre d'af- fections aigues et chroniques , je ne puis croire qu'on neglige a l'avenir un moyen si precieux , et j'ai la conscience, qu'en publiant , a cet egard , mes ob- servations, j'enrichis l'art de connaissances positives ; je rends hommage au travail trop oublie d'un medecin estimable, et je pense que les horames qui cul- tivent avec zele la medecine, en tirerant un parti fort avantageux pour le bien de l'humanit6. Corvisart.
La percussion de la poitrine est , sans contredit , Tune des decouvertes les plus pr^cieuses dont la medecine se soit jamais enrichie. Elle a soumis au juge- ment immediat des sens, plusieurs maladies que Ton ne reconnaissait jusque la qu' a des signes generaux et equivoques , et en a rendu le diagnostic aussi sur que facile. Laenmec.
THE AUTHOR'S PREFACE.
I here present the Reader with a new sign which I have discovered for detecting diseases of the chest. This consists in the Percussion of the human thorax, whereby, according to the character of the particular sounds thence eli- cited, an opinion is formed of the internal state of that cavity. In making public my discoveries respecting this matter, I have been actuated neither by an itch for writing, nor a fondness for speculation, but by the desire of submitting to my brethren the fruits of seven years' observation and reflexion. In doing so, I have not been unconscious of the dangers I must encounter ; since it has always been the fate of those who have illustrated or improved the arts and sciences by their discoveries, to be be- set by envy, malice, hatred, detraction and calumny. This the common lot, I have chosen to undergo ; but with the determi- nation of refusing to every one who is actuated by such mo- tives as these, all explanation of my doctrines. What I have written I have proved again and again, by the testimony of my own senses, and amid laborious and tedious exertions ; — still guarding, on all occasions, against the seductive influence of self-love.
And here, lest any one should imagine that this new sign has been thoroughly investigated, even as far as regards the diseases noticed in my Treatise, I think it necessary candidly to confess, that there still remain many defects to be remedied, — and which I expect will be remedied — by careful observation and experience. Perhaps, also, the same observation and
b2
author's preface.
experience may lead to the discovery of other truths, in these or other diseases, of like value in the diagnosis, prognosis and cure of thoracic affections. Owing to this acknowledged im- perfection, it will be seen, that, in my difficulties, I have had recource to the Commentaries of the most illustrious Baron Van Swieten, as containing everything which can be desired by the faithful observer of natnre ; by which means I have not only avoided the vice of tedious and prolix writing, but have, at the same time, possessed myself of the firmest basis whereon to raise, most securely and creditably, the rudiments of my dis - covery. In submitting this to the public, I doubt not that I shall be considered, by all those who can justly appreciate medical science, as having thereby rendered a grateful service to our art, — inasmuch as it must be allowed to throw no small degree of light upon the obscurer diseases of the chest, of which a more perfect knowledge has hitherto been much
wanted.
In drawing up my little work I have omitted many things
that were doubtful, and not sufficiently digested ; to the due
perfection of which it will be my endeavour henceforth to apply
myself. To conclude, I have not been ambitious of ornament
in my mode or style of writing, being contented if I shall be
understood.
December 31, 1760.
NOTE BY THE TRANSLATOR.
In the following Treatise, the text of the original author, Avenbrugger, is distinguished by having prefixed to the different axioms or paragraphs, either the Roman or Arabic numerals, or the word Scholium, and by being, in the technical phrase, set out beyond the Commentary. This latter has the abbre- viated title (Cowim.) prefixed, and is set in. The whole of the Commentaries are taken from Corvisart, with the exception of those few to which % is prefixed, and the abbreviation Trans, subjoined. These have been added by the Translator. J. F.
ON PERCUS&ION OF THE CHEST.
FIRST OBSERVATION.
Of the natural sound of the Chest, and its character in
different parts,
I. The thorax of a healthy person sounds, when struck.
Scholium. I deem it unnecessary to give in this place, any description of the thorax. I think it sufficient to say, that by this term I mean that cavity bounded above by the neck and clavicles, and below by the diaphragm : in the sound state, the viscera it contains are fitted for their re- spective uses.
Commentary, The method of Percussion is founded on the property possessed by the human thorax, in com- mon with most hollow bodies, of giving out certain sounds when struck in a particular manner.
II. The sound thus elicited (i.) from the healthy chest, resembles the stifled sound of a drum covered with a thick woollen cloth or other envelope.
Comm. This illustration gives a good idea of the kind
b ON PERCUSSION
of sound ; of course, the intensity is very different in the two cases.
III. This sound is perceptible on different parts of the chest in the following manner :
1 . On the right side anteriorly it is observed from the clavicle to the sixth true rib ; laterally, from the axilla to the seventh rib ; and posteriorly, from the scapula to the second and third false ribs.
Comm. This paragraph is not rigidly exact. Disease of the liver, or other abdominal organs, by encroaching on the chest, will sometimes contract the sonorous sphere, as above described. It is necessary, therefore, to attend to the state of the abdomen, the previous history of the case, &c. before we form our judgement.
2. The left side yields this sound from the clavicle to the fourth true rib, anteriorly 5 and on the back and la- terally, in the same extent as the other side : over the space occupied by the heart the sound loses part of its usual clear- ness, and becomes dull,
Comm. It is not quite correct to say that the left side yields the sound only as low as the right. On the con- trary, it is generally perceptible over the corresponding space occupied by the liver, but depends in this case, upon the presence of the stomach or colon, containing air, &c. The sound obtained by percussion of the cardiac region varies extremely in different persons. In those spare persons with a weak pulse &c, and in whom the organ is probably small, the sound is scarcely at all altered in the region of the heart; while in others of opposite temperament and habit, it is with difficulty perceived. Analogous effects arise from certain diseases : thus, in hectical subjects, as in phthisis with much emaciation, the presence ©f the heart seems hardly to weaken the sound at all.
OF THE CHEST. 7
3. The whole sternum yields as distinct a sound as the sides of the chest, except in the cardiac region where it is somewhat duller.
Comm. This diminution of sound in the region of the heart is very often not perceptible.
4. The same sound is perceptible over that part of the spinal column which contributes to form the chest.
Comm. The sound is here commonly less loud and duller than on the sides ; especially below the fourth true rib.
Scholium. The sound is more distinct in the lean, and proportionably duller in the robust ; in very fat persons it is almost lost. The most sonorous region is from the cla- vicle to the fourth rib anteriorly ; lower down, the mammae and pectoral muscles deaden the sound. Sometimes, owing to the presence of muscle, the sound is dull beneath the axilla. In the scapular regions on the back, owing to the obstacle afforded by the bones and thick muscles there, it is also less distinct. Sometimes, but rarely, it exists over the third false rib — owing, I conceive, to a very unwonted length of the thoracic cavity.
Comm. These remarks are very correct ; but I would add, that, even in those parts of the chest whence, for the reasons stated, hardly any sound can be elicited, an experienced operator can generally judge of the state of parts within, from the peculiar and undescribable sen- sation conveyed by the fingers. I myself so continually experience this, that I am not often baulked by the in- terposition of fleshy pectoral muscles, or bulky mammae. Cases however occur, wherein, from this cause, percussion is quite useless.
In addition to the explanation given of the cause of the sound sometimes observed as low as the third false rib, I would remark, that this anomaly arises still more
$ ON PERCUSSION
frequently perhaps, especially on the left side, — not from the chest9 but from the subjacence in the abdomen, of the stomach or colon distended with air.
SECOND OBSERVATION.
Of the method of Percussion.
IV. The thorax ought to be struck, slowly and gently, with the points of the fingers, brought close together and at the same time extended.
Comm. Percussion with the flat of the open hand is also useful, especially on the lateral and posterior parts, in ascertaining the precise extent of the cause obstruct- ing the sound. These two modes should often be con- joined in the same case. I think it unnecessary to strike slowly, as recommended.
Schol. Robust and fat subjects require a stronger percussion ; such, indeed, as to elicit a degree of sound equal to that produced, by a slight percussion, in a lean subject.
Comm. The degree of percussion ought to be varied according to the subject, and the place; and it is in duly apportioning the impulse, according to the thickness and other circumstances of the parietes, integuments, &c. in each individual and situation, that the per- fection of the art consists. For example, if we employ only the same force in the case of a very robust and fat subject, as in one who is lean and fleshless, we may evoke no sound whatever from the former, but a very good one from the latter : shall we then in the former case conclude that the lungs are compressed or ob- structed ? I cannot too much insist upon the import- ance of this remark.
OF THE CHiST. 9
V. During percussion the shirt is to be drawn tight over the chest, or the hand of the operator covered with a glove made of unpolished leather.
Comm. I consider this precept as entirely unneces- sary. Percussion may be equally well performed, with or without the interposition of either the shirt or glove. Schol. If the naked chest is struck by the naked hand, the contact of the polished surfaces produces a kind of noise which alters or obscures the natural character of the sound.
Comm, I cannot assent to the correctness of this ob- servation.
% I here agree with Corvisart, both in his opinions and practice. In most cases I employ percussion on the naked chest. Trans.
VI. During the application of percussion, the patient is first to go on breathing in the natural manner, and then is to hold his breath after a full inspiration. The difference of sound during inspiration, expiration, and the retention of the breath, is important in fixing our diagnosis.
Comm. During inspiration and retention of the breath, the sound is every where louder : and the reverse during expiration.
N. B. The sitting posture is always understood, al- though not expressed by the author.
VII. While undergoing percussion on the fore parts of the chest, the patient is to hold his head erect, and the shoul- ders are to be thrown back; in order that the chest may protrude, and the skin and muscles be drawn tight over it : a clear sound is thus obtained.
Comm. The propriety, and indeed necessity, of these measures cannot be too much insisted on: the appreci- ation of all the nicer shades of sound depends on their being attended to.
10 ON PERCUSSION
VIII. While we are striking the lateral parts of the chest, the patient is to hold his arms across his head ; as, thereby, the thoracic parietes are made more tense, and a clearer sound obtained.
IX. When operating on the back, you are to cause the patient to bend forwards, and draw his shoulders to» wards the anterior parts of the chest, so as to render the dorsal region rounded ; and for the same reasons, as stated in vin.
Comm. I would add that the arms should be crossed, or extended as much as possible. With this remark, I would say that all these precautions (vr. vn. vin. ix.) are extremely necessary, and must be observed whenever practicable. In many cases, however, of acute and even of chronic disease, the various positions mentioned are too painful to be assumed by the patient. The same re- mark applies to the retention of the breath : yet, by watching favorable opportunities, and by striking gently and quickly, the necessary results may in most cases be obtained, with care and attention, Scholium. Any healthy person may make experience of percussion in his own person or that of other sound sub- jects; and will thus be convinced, from the variety of the sounds obtained, that this sign is not to be despised in form- ing a diagnosis.
Comm, I fully agree with the author in the necessity of making frequent trials of percussion, on sound per- sons, but cannot admit that it can be advantageously — or, in some cases, at all, — practised on one's own chest. In order to obtain that fine and ready tact in the exer- cise of this method, experience alone can be our guide ; and we ought, therefore, to exercise ourselves on every variety of subject, and at every convenient occasion.
OF THE CHEST. H
THIRD OBSERVATION.
Of the preternatural or morbid sound of the Chest, and its
general import.
X. And Schol. To be able justly to appreciate the value of the various sounds elicited from the chest in cases of disease, it is necessary to have learned by experience on many subjects, the modifications of sound, general or partial, produced by the habit of body, natural conformation as to the scapulae, mamma?, the heart, the capacity of the thorax, the degree of fleshiness, fatness, &c. &c. ; inasmuch as these various circumstances modify the sound very con- siderably.*
Comm. The same remark as to the necessity of ex- perience to procure the just tact, is applicable here. I have seen many instances of failure from a premature confidence in the operator, of having obtained the ne- cessary tact.
XI. If, then, a distinct sound, equal on both sides, and commensurate to the degree of percussion, is not obtained from the sonorous regions above mentioned, a morbid condition of some of the parts within the chest is indi- cated.
Comm. It is a circumstance too obvious to be much insisted on, that the percussion must be strictly similar,
* I have purposely avoided a literal translation of the text in this place, as it is difficult to know the precise meaning attached by the author to one or two of the epithets used by him to designate the particular modifications of sound al- luded to. Trans.
12 ON PERCUSSION
and equal on both sides. The least sonorous side is certainly diseased. And even the knowledge of this fact simply, is a matter of great consequence to the prac- titioner. He will thereby be enabled to form a more cor- rect estimate of tire symptoms : and the phenomena which to others seem obscure, will appear to him only the necessary consequence of the organic affection the existence of which he has ascertained by percussion. Scholium. On this truth a general rule is founded, and from this certain predictions can be deduced, as will be shown in order. Fori have learned from much experiencethat diseases of the worst description may exist within the chest, unmarked by any symptoms, and undiscoverable by any other means than percussion alone.
A clear and equal sound elicited from both sides of the chest indicates that the air cells of the lungs are free, and uncompressed either by a solid or liquid body. [Ex- ceptions to this rule will be mentioned in their place.]
Com?n. The Commentator confirms by his testimony founded on much experience, the various statements in the above Scholium, viz : the certainty of the indications afforded by percussion ; the complete latency of many pectoral diseases ; and exclusive detection of these by the method of Avenbrugger. Even in those cases where the sound is every where sufficient, the practitioner de- rives this great advantage from percussion, — that he can feel assured, that, however much the chest seem engag- ed in the disease, there is, as yet, no organic lesion of consequence there. This conviction will allow his ob- servation to be directed, with more freedom and steadi- ness, to other parts of the body, and may thus enable him more readily to ascertain the real nature of the af- fection, some of the sympathetic effects only of which had previously engaged his attention.
OF THE CHEST. 13
XII. and XIII. If a sonorous part of the chest, struck with the same intensity, yields a sound duller than natu- ral, disease exists in that part.*
Comm. This axiom is universally true.f By means of it I have often discovered diseases eventually fatal but of which the patients themselves were at the time ig- norant, e. g. Scirrhous Lung — Aneurism of the heart. XIV. If a sonorous region of the chest appears, on percussion, entirely destitute of the natural sound, — that is, if it yields only a sound like that of a fleshy limb when struck, — disease exists in that region.
* The same reason that induced me to avoid a literal translation of the Scho- lium of x. (p. 11.) has led me, in this place, entirely to omit the paragraph, No. xu. in the original ; which, with the exception of one word (altior), is almost precisely the same as the following one, No. xui. From the employment of this word, in this and several other parts of the treatise, it is somewhat difficult to consider it as admitting any other interpretation than that of " less" or " ob- scurer," as applied to the sound produced by percussion. In this sense, it is synonymous with the word " obscurior" of the subsequent paragraph, and is therefore superfluous. It seems, however, quite improbable, that, in a work written in the aphoristic style of the present, such an oversight could have oc- curred in two adjoining sentences ; and I have no doubt whatever, that the au- thor attached a meaning to the " sonus altior" of No. xu. very different from that of the " sonus obscurior" of No. xm« The most probable solution of the difficulty appears to me to be, to consider the terms altior and profundior as applying to varieties in the tune or key of the sound, and clarior and obscurior as relating to differences of intensity simply. But still it is not easy to assign ^ satisfactory meaning to all these terms, even on this principle.
The paragraph No. xu. might be retained with advantage, if it were per- mitted to give the gratuitous meaning of " louder" to the word " altior" ; as it might thereby be made to apply to the disease Pneumo-Thorax , of which no notice is taken in this treatise, and with the nature of which the author does not appear to have been acquainted. For a full and accurate description of this affec- tion, and of the application of Percussion in its diagnosis, see Laennec, torn. 1, p. 432. Trans.
t With the exception in the preceding Note. Trans.
14 ON PERCUSSION
Comm. The same remark as on nil. Schol. The nature of the indications above pointed out, will be understood by any one who attends to the diffe- rence of sound elicited by percussion of the chest, and of the thigh, in his own person.
Comm, The difference will be more remarkable in percussion with the open hand, — a mode of operating with which the author appears to have been entirely un- acquainted.
XV. The superficial extent of this unnatural sound
(xiv.) in a sonorous region,, is commensurate with the extent
of the morbid affection.
Comm. It may be added that, in this case, the ob- struction, whether solid or fluid, must be very conside- rable, else it would not so entirely destroy the natural resonance of the part.
XVI. If a place, naturally sonorous, and now sound- ing only as a piece of flesh when struck, still retains the same sound (on percussion) when the breath is held after a deep inspiration, — we are to conclude that the disease ex- tends deep into the cavity of the chest.
XVII. If the same results (xvi.) are obtained both be- fore and behind, on points precisely opposite, we are to con- clude that the disease occupies the whole diameter of the chest.
Comm* Nothing can be clearer, more precise, or more true, than the preceding paragraphs. Under the cir- cumstances mentioned (xvi. xyn.) we are authorized to conclude that the obstructing body either entirely per- vades, or has in a great measure displaced, the lung, since the air seems to be entirely excluded from the parts in question.
Schol. These varying results depend on the greater or less diminution of the volume of air usually contained in the thorax [lungs] ; and the cause which occasions this
OF THE CHEST. 15
diminution, whether solid or liquid, produces analogous re- sults to those obtained by striking a cask, for example, in different degrees of emptiness or fulness : the diminution of sound being proportioned to the diminution of the volume of air contained in it.
Co?nm. The illustration of the author is very happy ; but he affords us no criterion for discovering whether the obstructing body is solid or liquid. I obtain this important information by using percussion in dif- ferent positions of the patients, e. g. in the erect and horizontal ; in which case if the obstructing cause is a fluid, it will be found to vary its level (with corres- ponding variation of sound) according to the laws of hy- drostatics ; while, if it is a solid, the same results will be obtained in every position. This, however, will not hold good when the cavity of the chest is quite full of fluid.*
If The following remarks on the great precaution ne- cessary to ensure correct results from percussion are by M. Laennec. In considering their import, it is, per- haps, well to remember that, although on the whole de- cidedly friendly to the invention of Avenbrugger, the writer is the discoverer and zealous rec. mmender of a method (Mediate Auscultation) calculated in a great measure, to supercede the practice of Percussion.
" In the first place, percussion requires that we com- pare the same points precisely on both sides of the chest. For instance, if we have percussed on a rib on the one
* Neither will this rule hold good in cases of chronic pleurisy occupying only a part of the chest, in which we almost always find the fluid confined by false membranes : it is only applicable to cases of simple Hydrothorax, in which dis- ease, in fact, the very process here recommended by the commentator, is pointed out by the author. Vide Ons, Twelfth. XLV. Schol. Trans.
16 ON PERCUSSION
side, we must be careful not to percuss on an intercos- tal space on the other : we must likewise be careful that the skin and muscles are equally tense on both sides, which is often not readily effected, when the patient is lean. It is still more essential to use the same degree of force on each side, an 1 to strike with the same degree of perpendicularity; for even a slight degree of obliquity in the stroke will diminish the intensity of the sound one- half, — a circumstance which might lead to great mistakes.
It is also necessary to percuss the similar parts of both sides in the same manner, and over the same extent : for example, a very different result will be obtained from striking several ribs across, and from striking one rib lengthwise. The employment of different hands also, or the application of the same hand differently, will vary the results obtained. Thus I have frequently found that, when standing on the right of the patient and operating with the right hand, the left side of the chest, before and behind, seemed less sonorous than the right, while on the contrary, the lateral portion of the left side was more sonorous than the right ; — and that the results were ex- actly reversed in changing to the other side of the patient. The difference in this case depends on the difference of theangle under which the chest is struck in the different positions : and I may add that it is almost impossible to preserve the same precise degree of perpendicularity in operating on both sides of the chest.
These precautions are especially requisite when the difference of sound, as frequently happens, is not very great." DeLAuscult. Med. torn. I. p. 180.
In another place he says — H Many physicians cannot elicit a sufficient sound, but by using a degree of force that is painful to the patient. Circumstances extraneous to the patient also modify the sound obtained : thus, a
OF THE CHEST. 17
chest which has yielded a very dull sound when percussed in a small room full of furniture, or in a bed surrounded by thick curtains, has been found, on the following day, to be much more sonorous when the patient was seated in a chair, or laid in a larger apartment." lb. p. 5.
Trans.
FOURTH OBSERVATION.
Of the diseases in general in which the morbid sound of
the Chest is observed.
XVIII. The preternatural or morbid sound occurs in
acute and chronic diseases; it always accompanies a copious
effusion of fluid in the thoracic cavity.
Schol. It must be admitted that whatever diminishes the volume of air within the chest, diminishes the natural sound of that cavity; but we know from the nature, the causes, and the effects, of acute and chronic diseases of the chest, that such a result is possible in these cases ; and the fact is finally demonstrated by examinations after death. The effect of effused fluids in producing the morbid sound, is at once proved by the injection of water into the thorax of a dead body ; in which case it will be found that the sound elicited by percussion, will be obscure over the portion of the cavity occupied by the injected liquid.
Comm. It may be stated as a general fact that all di- seases of the chest, whether acute or chronic, occasion the preternatural sound, either during their progress, or towards their termination. I do not even exclude from this remark those nervous asthmas, and violent coughs, which, in the first instance at least, appear dependent on irritation of the nerves of the part, either idiopathic or sympathetic. In almost all these cases, we find after death, in some part or other of the thorax, some in- duration, effusion, &c.
c
18 ON PERCUSSION
FIFTH OBSERVATION.
Of Acute diseases in which the chest yields the morbid sound.
Coram. Notwithstanding this title, the author does not give any account of particular diseases, but only of the period at which this sign is perceived. I will en- deavour to supply this defect in some degree.
XIX. The morbid sound which is observed in acute diseases, occurs during their progress, or at their termi- nation.
Sghol. This consideration ought to lead all medical men to use percussion in acute diseases ; as they will there- by be enabled to form a more correct judgment, which in such cases is always a matter of difficulty. It has often occurred to me to see cases of acute diseases, apparently over, and imposing on the physician under the mask of in- termittent or remittent fevers, and which have eventually ended in a fatal vomica or fatal scirrhus of the lungs.
Comnu In peripneumony and pleuro-peripneumony> if the inflammation is acute, the morbid sound is percep- tible on the second, third, or fourth day at farthest: the na- tural resonance gradually lessens, and is entirely lost by the sixth or seventh day, if the disease is to terminate fatally. On the other hand, it gradually reappears if a recovery takes place. In the more severe and simpler cases, the common symptoms are less equivocal ; but in the more complicated and obscure examples of the same disease, — without percussion, how shall we ascertain the real state of the lungs, or be able to avoid commit- ting ourselves by unwarranted opinions and false prog- nostics ? In such cases, effusions into the pleura, or vomicae take place insensibly; and frequently under
OF THE CHEST. 19
the deceitful mask of an amendment of symptoms, or even of convalescence. The result, however, soon shows the false security of the practitioner. These grievous mistakes can only be avoided by the employment of percussion.
XX The preternatural sound which is perceived during the course of acute diseases of the chest, occurs most fre- quently in inflammatory affections.
Schol. The reason of this observation (xx.) will be obvious to any one acquainted with the nature of inflamma- tion. The preternatural sound may also be observed some- times in epidemic exanthematous diseases, previously to the eruption ; — as was the case in the petechial epidemic of '757? 1758, 1759, and in the miliary epidemic of the pre- sent year (1 760). In the latter instance, I observed that the preternatural sound, when once present, continued to the termination of the eruption.
Comm. In these cases, the peculiar sound is not con- fined to one spot, but extends over the whole chest — and is projmrtioncd to the amount of the subsequent eruption. The remarks of Avenbrugger ought to lead physicians to attend to the state of the chest in these affections.
XXI. The morbid sound which occurs towards the termination of acute diseases, is observed, when the excre- tion of morbid matter is not adequate to the severity of the affection.
Comm, This observation is not always correct,
XXII. The morbid sound occurring in inflamma- tory diseases is commonly observable on the fourth day ; it rarely precedes, but often follows this period.
Comm, I have already remarked the inaccuracy of
that part of the statement that limits the occurrence of
the sound to the fourth day {Comm, on xix).
c 2
20 ON PERCUSSION
Schol. This sign occurs rarely on the third, and very often on the fourth, fifth, and seventh day — but never later.* It is observed in those inflammatory affections of the pleura or lungs, or both, which are accompanied by a humid cough ; but not in those attended by a dry cough, — such (e. g.) as the dry pleurisy, and inflammation of the mediastinum, peri- cardium, and heart. At least in these latter affections, the sound is not observed, until such time as they verge towards a fatal termination, or have degenerated into obvious ab- scesses or vomicae.
Comm. This Scholium is incorrect in many respects :^ 1 . as to the days on which the preternatural sound makes its appearance ; 2. as to the power of percussion in de- tecting the diseases last named in their earlier stages* In regard to this point, I would say, in opposition to Avenbrugger, that I have seldom been disappointed in detecting them by means of percussion, sooner or later according to their severity and rapidity ; — but generally within a few days after their invasion,
XXIII. The morbid sound increases, from the time of its appearance, according to the nature, severity, and du- ration of the disease ; it diminishes proportionably to the nature, duration, and copiousness of the excretions.
Comm. I have to repeat here, that the sound often diminishes (and the disease disappears) without any discoverable excretion.
Schol. The progressive augmentation of the preterna- tural sound depends on the gradual deposition of the morbific matter, which I have often found in such quantity as to oc- cupy the inferior two- thirds of the affected side.
* The author explains this on the principle of critical days. I have omitted this part of the text, as purely theoretical- I douht not, also, that his theory has, in this and some other places, biassed his judgment, and observation. Trans.
OF THE CHEST. 21
Comm. I do not think that the author here means an -effusion of serum or pus into the cavity of the pleura; but only an engorgement of the lungs or pleura.
1f On the contrary I should say, that as some degree of effusion exists in every case of pleurisy, it is to this disease especially that the observation of Avenbrugger applies ; and I may add, that, by translating the old phrase "deposition of morbific matter" by the modern term "effusion," it applies exactly. Laennec's testimony, both as to the pathology and diagnosis, is very conclu- sive on this point. Med. Aus: Tom. 1. He says "the inflammation of the pleura is always accompanied by an exhalation from its inner surface, and this appears to commence with the very origin of the disease." p. 331. " Percussion indicates the existence of pleurisy much more certainly [than any of the ordinary symptoms]. As soon as the effusion takes place, the natural reso- nance is wantingover the whole space occupied by this." p. 346. Trans.
XXIV, The disease in which the preternatural sound is once present, either proves fatal [on a decretory day, reckoning from its origin] ; passes off with due excretion ; or terminates in other affections.
Comm. The theory (false) of the two first statements has been already noticed,
XXV. The following corollaries are the result of my observation of inflammatory diseases of the chest, studied under the sign of morbid resonance :
1. The duller the sound, and the more nearly ap- proaching that of a fleshy limb stricken, the more severe is the disease.
Comm. This is universally true, but requires some restriction in the class of exanthematous diseases (see xx.)
22 ON PERCUSSION
2. The more extensive the space over which the mor- bid sound is perceived, the more certain is the danger from the disease.
Comm. This is equally true, with the restriction as above.
3. The disease is more dangerous on the left than on the right side.
Comm, The difference arises, I presume, from the vicinity of the pericardium and heart in the former.
4. The existence of the morbid sound on the superior and anterior part of the chest (i. e. from the clavicle to the fourth rib) indicates less danger, than on the inferior parts of the chest,
Comm. Is this difference supposed to depend on the vicinity of the diaphragm and pericardium, in the latter case ?
5. The want of the natural sound behind, indicates more danger than it does on the anterior and superior part of the chest.
Comm, This difference is sufficiently accounted for by the greater volume of the lungs behind.
6. The total destitution of sound over one whole side, is generally (passim) a fatal sign.
Comm. This total want of the natural sound over one whole side of the chest, may arise either from a hepatisation of the lung, or from an effusion into the cavity of the pleura : in either case, I am of opinion with Stoll (Aph. 140), that, if not always, at least in an im- mense majority of cases, the event is fatal.
^[. My own experience and (what is of much greater authority with me) the testimony of Laennec, would lead me, on the contrary, to believe that the pro- portion of fatal cases, under such a sign, is not so im- mense. In that particular termination of acute pleurisy,
OF THE CHEST. 23
so beautifully described by Laennec under the name of " contraction of the chest" — and of which instances are by no means extremely rare, — the natural sound is not only wanting over the whole affected side, but, ac- cording to the author just mentioned, never returns, even after the recovery of the patient. Trans.
7. The absence of sound along the course of the ster- num is a fatal sign.
Coram, A collection of matter in the anterior medi- astinum (the only case likely to produce this sign) is generally, though not always, a fatal affection.
8. The entire absence of the natural sound over a large space in the region of the heart, is a fatal sign.
Comm, This sign indicates an inflammation, acute or chronic, of the pericardium (or perhaps the heart) with a purulent or serous effusion in this membrane.*
Schol. I have sometimes observed that the fatal prog- nostics given in the corollaries 6 and 79 were not verified when the matter made its way outwards, or abscesses formed in parts less essential to life. And this natural process has been often happily imitated by the antieats, by cauterising or otherwise incising, the affected parts.
SIXTH OBSERVATION.
Of Chronic Diseases in which the preternatural sound is
observed, Comm, As in the former section, the Author in this omits noticing many of the diseases, which would seem to be included under the above title.
See the case of Mr. N n, in this volume. Trans,
24 ON PERCUSSION
XXVI. The preternatural sound observed in chronic diseases is owing either to — ( I .) some hidden condition of the organs, which disorders them with a slow progress and finally destroys them ; or exists (2.) when certain obvious causes have induced a slow disorganization of the same.
Schol. These are the general sources of chronic di- seases of the chest ; and from whichever of the two classes of causes these arise, the morbid sound will equally and al- ways be present.
Comm. Percussion will therefore be always proper and useful ; for whether we know the precise cause or even nature of the disease, it will be at least some advantage to know that there is organic disease, and that it exists in a certain part: — a kind of knowledge that can only be gained by percussion.
XXVII. The diseases of the first class are, 1. those which depend on hereditary predisposition ; 2. those which arise from affections of the mind, particularly ungratified desires, the principal of which is Nostalgia; 3. those which affect certain artisans, naturally possessing weak lungs.
Schol. 1. The influence of an hereditary taint in pro- ducing diseases we know by experience, though we cannot explain it. — See Van Swiet.
2. Mental affections, we find, produce quite opposite effects, while acting as causes of pectoral diseases. Of these affections of the mind I have observed none more powerful in rendering obscure the natural resonance of the chest, than the destruction of cherished hopes. And as among this class of diseases, Nostalgia (commonly called heimwehe — home-ail) occupies the first place, I shall here give a short history of it.
When young men, not yet arrived at their full growth, arc forcibly impressed into the military service, and thereby
OF THE CHEST. 25
at once lose all hope of returning safe and sound to their be- loved home and country, they become sad, silent, list- less, solitary, musing and full of sighs and moans, and fi- nally quite regardless of, and indifferent to, all the cares and duties of life. From this state of mental disorder nothing can rouse them, — neither argument, nor promises, nor the dread of punishment; and the body gradually pines and wastes away, under the pressure of ungratifled desires, and with the preternatural sound of one side of the chest. This is the disease Nostalgia. I have examined the bodies of many youths who have fallen victims to it, and have uni- formly found the lungs firmly united to the pleura, and the lobes on that side where the obscure sound had existed, callous, indurated, and more or less purulent. Some years ago, this disease was very common, but is now rarely met with, since the wise arrangement has been adopted of limit- ing the period of military service to a certain number of years only.
3. The various arts and occupations of life have their peculiar diseases, in like manner as the ages, temperaments, and sexes have theirs. This truth is exemplified in the case of the man of letters, the husbandman, the workers in metals, painters, &c. &c. Our particular business, however, at pre- sent, is with those arts which dispose to diseases of the chest indicated by the sound so often described. Thus I have remarked that Tailors, Millers, &c. who are forced to inhale, during their labours, a fine dust, become phthisical ; while shoemakers, weavers, &c. from the forced position or application of their weak chests, during their various oc- cupations, become asthmatical, with scirrhous lungs, &c*
* The Author here admits that these cases are improperly placed under the head of affections produced by secret and occult causes ; but excuses himself under the plea that the occurrence of such diseases and their imperceptible progress— only in some few of the numbers exposed to the noxious influences, fa a proof of original debility of the affected organ. Trans9
26 ON PERCUSSION
I may here state afact which I have frequently proved by dissection, but which I cannot well account for — it 4s this: in the abovementioned class of cases it is extremely rare to find both lungs affected at the same time ; and, when this happens, one lung is always more diseased than the other.
Comm. (Note on Nostalgia.) All the greater and more profound mental affections are powerful causes in the production of corporeal disease. They principally af- fect the functions of the organic life : the organs con- cerned in circulation, respiration and digestion are es- pecially modified; but the functions of secretion, exha- lation, absorption, and nutrition, which seem at first untouched, eventually undergo no less essential changes. These organic modifications vary with the particular causes. Thus anger, by directly acting on the circula- tion, occasions dilatations of the heart, &c. Joy, on the other hand, merely augments the action of the same organs in a slight degree, and determines the blood to- wards the surface. Grief produces a directly opposite effect : it debilitates the whole vascular system, ob- structs the course of blood towards the capillaries, and thus occasions that general paleness, which is most con- spicuous in the face : from this result a deficiency of blood on the surface of the body, and a superabundance in the larger vessels, — occasioning the sighing, op- pression, and palpitations, the passive dilatations of the heart, the engorgement of the lungs, their adhesion to the pleura, and the diminished resonance described by Aven- brugger. To these causes may be added the derange- ment of digestion, which is found to be an inseparable attendant of long-continued moral affections, and which inevitably induces such a state of general debility as greatly predisposes our various organs to be acted on by the morbific causes to which they are exposed.
OF THE CHEST. 27
It is to be regretted that Avenbrugger confined his anatomical examination of such cases to the lungs ; as I am led to believe from the causes and symptoms of the disease, that the heart and great vessels would have been found equally affected. [The Commentator here gives some account of an analogous disorder of children, produced by moral causes and which he denominates Infantine Jealousy — jalousie des enfans.]
XXVIII. The diseases mentioned (inxxvi. 2.) arise either from (1.) a vitiated condition of the fluids, gradually produced ; or (2.) from acute affections imperfectly cured. Comm. Considering the period at which Avenbrugger wrote, and that he was the pupil of the pupil of Boer- haave, it is not to be wondered that he follows the hu- moral pathology.
Schol. 1. The vitiation of the humours arises from ingesta which cannot be assimilated, the effect of which in producing chronic diseases is well known.
2. An acute disease is said to be imperfectly cured when some morbid affection still remains after it, in some part of the body. This morbid condition will be observed either in the site of the primary disease, or, at least, in that portion of the chest which yields the morbid sound ; — name- ly, the pleura, or lungs, or both these together, or the me- diastinum or pericardium. When the primary inflamma- tory disease is succeeded by a collection of pus in the chest, the affection is readily recognised; but if the secondary affec- tion is a scirrhus of the lung, how often and how grievously are medical men thereby deceived !* Often have I met with cases of fancied convalescence from acute fevers, in which
* In the above paragraph I have literally given the Author's facts, but have translated the statement of these divested of the humoral phraseology of the time.
Trans.
28 ON PERCUSSION
there was hardly any cough or dyspnoea, or indeed any other sign of disease fas appeared to the attendants) but a trifling degree of irregular fever. In these cases, however, on per- cussion the preternatural sound was found over one whole side of the chest, and the final result was death, preceded either by dropsy or extreme emaciation ; the real seat of the disease remaining, perhaps, unknown to the very last ! Cojnm. My practical experience entirely confirms the exactitude and precision of the foregoing observations. Under how many different forms have I seen organic le- sions of this nature concealed, — simulating the most dif- ferent diseases, exhibiting the most complicated and ir- regular course, and retaining, in certain cases, no mark whatsoever of an affection of the chest ! The conse- quence was, that their real nature was entirely overlooked and mistaken by those practitioners who did not employ the only certain guide in such cases — percussion. These observations throw much light on the nature and proper treatment of the greater number of dropsies, which, in- stead of being, as commonly imagined, idiopathic affec- tions, are, at least in a very great proportion, merely the effects of some organic lesion of a viscus.
XXIX. For the above reasons, it may be received as a general rule in chronic diseases, that when, together with the indication stated xxvi., there are emaciation and debility, — the case is desperate.
Schol. This result is inevitable whensoever the dis- ease does not yield to medicine. In such cases we may always conclude, that the lung of the side which yields the preter- natural sound, is either compressed by some foreign body, is indurated by disease, or destroyed by some morbid acrU mony developed within its own structure.
OF THE CHEST. 29
SEVENTH OBSERVATION.
Of the preternatural sound of the chest ivhich results from copious extravasation of the fluids contained in the vessels of that cavity,
XXX. The fluids contained in the vessels of the chest are : 1. Chyle ; 2. Blood; 3. Serum and Lymph.
Schol. I must candidly admit that I have never seen a case of extravasated chyle. 1 however believe the thing possible, although I am well aware that the thoracic duct runs outside the pleura : the same causes that produce ero- sion and perforation of the thoracic parietes, may produce this.
XXXI. The extravasation of these fluids (xxx.) may arise from the following causes : 1 . rupture of the containing vessels ; 2. too great tenuity of the contained fluids ; 3. non- absorption of the same &c. &c.
Schol. 1. Under this head come wounds, contu- sions, &c.
2. Extravasations from internal causes arise from rupture of relaxed and debilitated vessels, during a state of plethora and over-activity of the circulation.
3. A third class of causes are obstructions originat- ing in a bad habit of body.
XXXII. When from these causes the fluids mention- ed are poured out in considerable quantity, the preturnatural sound will exist over the space occupied by them.
Schol. The correctness of this statement is evinced by the experiment mentioned at the end of the scholium of XVII.
According to the plan formerly proposed (xi.) I shall now proceed to notice those affections of the chest which are not indicated by percussion.
30 ON PERCUSSION
EIGHTH OBSERVATION.
Of those affections of the chest which are not indicated
by percussion. Comm, The title of this Observation is not correct, since, by the testimony of the author himself, many of the diseases mentioned have their seat, not in the chest, but abdomen, the affection of the lungs being merely sympathetic. Nevertheless, percussion is still very useful even in these : In the first instance, it shews the inte- grity of the thorax, and directs the attention elsewhere ; secondly, it detects the presence of organic disease in this cavity, should this arise in the course of the affec- tion; in every period of the disease, it will assist the phy- sician in his diagnosis, prognosis, and treatment.
XXXIII. Certain diseases attended by a violent cough, and thereby creating a suspicion that the lungs are certainly implicated, are nevertheless truly diseases of the abdomen, and affect the pulmonary organs merely sympathetically.
Schol. Under this head are ranged the gastric and convulsive coughs of infants, pregnant women, and such other persons as have their abdominal viscera oppressed by the lentor of autumnal agues, or a superfluity of phlegm.
XXXIV. Violent coughs, dyspnoeas, asthmas and con- sumptions, are also occasionally observed, which originate in some incomprehensible irritability of the nerves of the chest.
Affections of this sort rarely give rise to the preterna- tural sound: from the absence of this, however, and the presence of a copious watery urine, their existence may be pretty confidently presumed.
Comm. Most of the affections mentioned in the pre- ceding paragraph, I consider as purely sympathetic, and as depending, in general, on disorder of the digestive
OP THE CHEST. 31
organs. I agree with the author thai such affections are, in their earlier stage, not discoverable by means of per- cussion ; but as nothing is more common than the con- version of those disorders which are called nervous, into affections truly organic of the heart or lungs, there is no doubt that eventually they become discoverable by this means. The origin of pulmonary disorders, in ner- vous affections attended by a cough is easily explained. Besides, who has not observed that a great proportion of nervous women die phthisical ? It is also true that dis- orders of the stomach induce pulmonary phthisis. In long continued derangements of the digestive organs, congestions will almost certainly ensue in some of the abdominal viscera, which while they impede the function of respiration (mechanically or by sympathy), will neces- sarily in the end affect the lungs themselves. The con- tinued irritation will produce an indolent state of phlo- gosis, which may be considered as the first stage of those structural lesions which constitute phthisis ; and which will be followed by tubercles, &c. I may add, that those secondary consumptions, whether the consequence of nervous affections or gastric disorder, would be of ex- tremely difficult recognition, but for the aid afforded by percussion, — inasmuch as it is their peculiar character, that the symptoms of the primary disease still continue, for some time, the more conspicuous of the two.*
Schol. Under this head are ranged the coughs, dys- pnseas, and asthmas so common in hysterical and hypochon- driacal affections; the nervous consumption and asthma of old persons; and, perhaps we may add, the polypous con- cretions found near the heart in young subjects.
* I need hardly point out to the English reader the exact coincidence of the opinions and experience of Corvisart with those of Dr. Philip. See his papers on Dyspeptic Phthisis. Trans.
32 ON PERCUSSION
XXXV. A slight engorgement of the lung, a scirrhus of small extent, a small vomica, and a trifling extravasation, are not detected by percussion, — unless, sometimes, by the decreased resonance of the affected part.
Comm. With the view of restricting, in some degree, the meaning of the above paragraph, I would observe, that, in detecting slight lesions, much will depend on the particular situation of the disease, on the habit of percussion, &c. For example, T think that a scirrhus or vomica of the size of a common walnut, situated on the surface of the lungs or immediately beneath the pleura, may be recognised, or at least suspected ; while if placed more centrically, the chance of discovering it would be much less. In like manner, I would say, that three or four ounces of extravasated fluid might be discovered by care, if existing in one side of the chest, or, more par- ticularly, in the substance of the lungs ; — while the same quantity, if distributed between both cavities, would not admit of detection by the most careful per- cussion.
Schol. These affections are not dangerous until they
reach a size when they become more readily discoverable
by means of percussion.
XXXVI. There is another class of diseases of the lungs [undiscoverable by percussion] in which the distin- guishing symptoms are a very severe cough, with expecto- ration of fatty, chalky, gypseous and stony matters.
Schol. These cases are known by the nature of the expectoration. I have frequently observed a cough of this kind (but without the peculiar expectoration) succeeding miliary fevers improperly treated.
OF THE CHEST. 33
NINTH OBSERVATION.
Of the appearances on dissection, in cases where the preternatural sound of the chest had been observed. XXXVII. These are the following : !. Scirrhus of the lungs ;
2. The eonversion of this into an ichorous vomica ;
3. A purulent vomica (simple or ruptured), in the pleura, lungs, mediastinum or pericardium ;
4. Empyema;
5. Dropsy of the chest, in one or both cavities; 6*. Dropsy of the pericardium ;
7. Extensive extravasation of blood in the cavity of the pleura or pericardium ;
8. Aneurism of the heart.
Comm. Of how many errors, prejudices, and false ex- planations, have these unknown or misunderstood lesions of the thoracic viscera, been the source and subject! Owing to ignorance respecting their real nature, result- ing in the first instance from the neglect of morbid ana- tomy, the attention of physicians has been arrested by the obvious, but uncertain and illusory symptoms of the secondary affections produced by these. The secon- dary affections have been raised to the rank of idiopathic, their history and treatment have been formally described by the gravest authorities, and the truth thereby con- cealed, and falsehood propagated, to the great detriment of the healing art. The case, however, is now different ; and I take some credit to myself for having directed the attention of my brethren to the frequency and multi- plicity of organic diseases. Of the surpassing importance of a knowlege of these no one can doubt ; and when it is considered that percussion — and percussion alone —
D
34 ON PERCUSSION
can make us acquainted with them, we cannot suffi- ciently applaud those men who have enriched this, the most difficult department of medicine, with a kind of knowledge at once so scientific and satisfactory.
Schol. I will now proceed to notice these diseases in order, premising, occasionally, some account of the gene- ral symptoms.
TENTH OBSERVATION.
Of scirrhus of the lungs, and its symptoms. XXXVIII. By scirrhus of the lungs I mean the dege- neration of the natural spongy substance of the organ into an indolent fleshy mass.
Comne. Although we may offer objections to the name used by our author, we must admit the existence of the disease thereby designated. I am ignorant of the precise nature of this affection. I think it is generally formed slowly and insensibly, as in the case of artisans exposed to a dusty atmosphere, or as a sequel of acute disease. Perhaps, also, it may originate spontaneously, and be the result of a very slow latent peripneumony, &c. The term carnification, lately applied to this affection, is inexact, inasmuch as the character of the lung is not at all like muscular flesh, but like liver : on this last account the term hepatization is much more correct and appropriate. — In this variety of morbid structure, what becomes of the blood vessels, bronchia, vesicles, glands, and nerves of the pulmonary organ ?
Schol. A portion of sound lung swims in water, but this carniform degeneration sinks. There is often observed a vast difference in the character of these scirrhi, in respect of hardness, colour, and component parts. Thus, in inflamma- tory diseases of the chest proving fatal on the fifth, seventh.
OF THE CHEST. 35
or ninth day, the lung is very often found so completely gorged with blood, as to resemble liver in every respect, both as to colour and consistence. One appearance deserves to be noticed : the lung is frequently invested with apurulent ad- ventitious membrane, in those instances wherein the fatal pc- ripneumony has succeeded an acute pleurisy. In chronic dis- eases of the lungs the appearances are extremely various. Frequently they are interspersed and as it were marbled with a fatty kind of matter; frequently along with the fleshy appearance, they have the consistence of cartilage; and very often they are found indurated by means of a thickened and black blood. These varieties, doubtless, depend on varieties of the morbific matter.
Comm. In the above Scholium, the author has con- founded under one name different diseases. The sudden effusion of blood which takes place in very intense in- flammations of the lungs (and which is so well described by Avenbrugger) is different from the slow formed scir- rhus properly so called. The term purulent applied to the false membrane of pleurisy, is the phraseology of the author's day.
% There is little doubt that Avenbrugger, in the above
Scholium, has confounded, under the term scirrhus,
different pathological states of the lungs — viz. peripneu-
mony, tubercular degeneration, melanosis, &c. In one
respect, however, he is probably more correct than his
commentator, to wit, in classing together the chronic
induration, and the acute hepatization, of the lungs ;
since it would appear, from the investigations of Laen-
nec, that these two are only varieties of one and the
same process — inflammation. For the only complete
and satisfactory exposition of these and other morbid
states of the lungs, see the invaluable treatise of Laen-
nec. Trans.
d3
36 ON PERCUSSION
XXXIX. The presence of scirrhus of the lungs, in its primary unsoftencd condition, may be suspected from the following signs -.
Together with the diminution or entire loss of the natural sound over the affected part, there is an infre- quent cough without any expectoration, or withonlya scanty excretion of viscid and crude sputa. During a state of quies- cence there is nothing to be observed much amiss, either in the condition of the pulse or respiration; but upon any considerable bodily motion, or after speaking for some time, these persons become speedily exhausted, anxious, and breathless, and complain of a sense of dryness and rough- ness in the throat. At the same time the pulse, which had previously been of moderate frequency, becomes quick and unequal ; the respiration and speech are broken and inter- rupted by sighs; the temporal, sublingual, and jugular veins of the affected side, are more than usually distended ; while it will be observed that this side of the chest is less moveable than the other, during inspiration. Mean- while the natural and animal functions continue to be well performed ; and the patient can lie on either side indiffer- ently.
All the above symptoms are more severe in propor- tion as the scirrhus is more extensive.
Comm. The above description of the symptoms of this affection is most just and admirable, and sufficiently proves the spirit of observation of the author, and the great pains he must have taken in studying diseases. In- stead of being enabled merely to suspect the existence of the disease (as he modestly expressess himself), he might have said with truth, that we can recognise it by the signs pointed out by him. There is a necessity for other signs beside Percussion in this case, as, though this will certainly make us acquainted with the exis-
OP THE CHEST. 37
tence of an obstruction in the chest, it will not inform us of its precise nature. To the foregoing signs of scirrhus I would add the following as invariably present : 1 . progressive emaciation, although sufficient nutriment be taken ; — 2. a low febrile diathesis ; — 3. a feeling of oppression and weight, but without pain, in the affected side. From the manner in which the author terminates his description of this disease, one might be led to imagine that it might remain stationary without neces- sarily abridging life. The truth however is, that it proves fatal more frequently in its indurated than in its suppurated state. When it has reached the height in- dicated by the signs above detailed, it increases rapidly, and its fatal termination is precipitated by additional symptoms* The appetite gradually decreases ; the sleep is lost ; great anxiety prevails ; and the character and temper are entirely changed, the patient(although natu- rally placid) often becoming harsh, violent and irritable, and extremely desponding. There are partial sweats on the breast and neck sometimes warm, more frequently cold, and followed by fainting. There ensue frequent paroxysms of extreme breathlessness. The patients are now confined to bed in a state of complete marasmus. Some can lie on the back; others can bear only a sitting posture ; in the last days of life none can lie down ex- cept on the affected side. Sometimes there is slight de- lirium, sometimes not; sometimes there is oedema of the limbs of the affected side, but more commonly there is none. Before death the pulse becomes small, une~ qual and intermittent.
38 ON PERCUSSION
ELEVENTH OBSERVATION.
Of Vomicae in general,
XL. When an humour, sound or morbid, is deposited from the circulating mass in a solid form, and (together with the extreme vessels) is afterwards, by means of the vital powers softened and converted into matter, and contained in a sort of capsule, I term this collection of matter a Vomica,
Schol. This notion applies to every vomica, whether produced by a vice of the solids or fluids, as is clear from the history of obstruction and inflammation.
Comm. The author extends the meaning of the term vomica, beyond its ordinary application, to a collection of matter in the lungs. It will be recollected that he was the pupil of Van Swieten.
XLI. I have observed two kinds of Vomica — the Ichorous and Purulent. The former occupies the lungs only ; the latter, both the lungs and other thoracic viscera. They are both either close, or communicating with the Trachaea.
Schol. By the term Ichorous Vomica, I mean a sac containing a thin fluid frequently of a reddish yellow colour, frequently of a reddish brown, often of a colour between these, different from pus, and arising from the destruction of a scirrhous lung. By Purulent Vomica, I understand an encysted abscess of the chest, resulting from the conversion of an inflamed spot into a white, thick, glutinous, fatty matter. When these communicate with the Bronchia and discharge any of their contents by expectoration, they are called open; otherwise, close or shut.
OP THE CHEST. 39
Comm. The conversion of scirrhous [hepatized] lung into ichorous or serous matter is correctly stated. It takes place insensibly, and commonly without pain, be- ing the result of a species of decomposition, and not of true inflammation. By " chest" in the above scholium, I think the author means simply the " lungs.91
XLII. 1. Ichorous Vomica. If a scirrhus of the lung, recognised by its proper signs (xxxix.) is converted into matter, it presents the following symptoms : The patient begins to languish and waste away insensibly (although the usual quantity of food is taken), with a quick, contracted, and unequal pulse. The respiration, even during a state of quie- tude, is unnaturally anxious and frequent; and is remarkably interrupted by sighing. The forehead, during the more se- vere attacks, is sometimes covered with a cold sweat. The eyes are dim ; the veins of the cheeks and lips are livid, and the tongue, especially on the affected side, is of a leaden hue. At the same time there is neither pain nor thirst. The diseased side, however, is observed to be less mobile than natural, and the degree of immobility is proportioned to the bulk of the vomica into which the scirrhus has been resolved. The cough is infrequent, interrupted, and dry ; or the expectoration, if any, is dirty or blackish (coenosum autfuscum) .
When things have got to this height, the appetite be- gins to fail, and at length is entirely lost; and whatever is eaten only produces an increase of anxiety during the pro- cess of digestion: this process, however, takes place without any hectic flushing, which always accompanies the purulent vomica.
In some cases, when there is a dissolution of the cen- tral parts of the scirrhus, the abdomen and hypochondres sink in ; in a very few instances, the same parts are slightly swollen, and with an indistinct feeling of fluctuation. The
40 ON PERCUSSION
urine rarely presents any deviation from the natural state ; sometimes, however, it is red, and with a sediment (if any exists) of a cinnabar colour. The stools are of natural character, except under the influence of medicine. The extremities, even when of a livid colour, are never hotter than natural, until a few days before death ; the affected side is, moreover, observed to swell, and the hand and foot in the first place. The patient now suffers from frequent sinkings and faintings ; and from having hitherto been able to lie easily on either side, he is able to remain on the affected side only.
Coram, I have never observed the morbid appearance of the tongue more on the affected side than the other. The anxiety experienced after eating, exclusively of the debility of the stomach, is accounted for by the en- croachment of the distended viscus on the cavity of the chest, by compressing the diaphragm &c. &c. &c. 2. Close Purulent Vomica. The following are the symptoms of this affection : While the abdominal organs still continue to perform their functions well, there is often present a very troublesome, frequent, dry cough, so severe as to irritate the fauces, to render the voice hoarse, and often to excite vomiting. At this time are observed frequent ir- regular chills, followed by heat, and strong flushing of the cheeks and lips, particularly of the affected side. A degree of lassitude is experienced, more remarkable after a full meal ; and at the same time, there is perceived a degree of quickness and straitness of the respiration, sufficient to ex- cite suspicion of some morbid affection of the chest. The pulse is also found to be contracted, frequent, somewhat hard and unequal during the period of digestion ; and even at other times it is never in a perfectly natural state, — more especially, under the influence of bodily motion, laughing, or speaking.
OF THE CHEST 41
If at this time the Vomica has reached a size to be de- tected by percussion, the following additional signs exist ; The patient is not nourished by the food taken, partly be- cause it is, in a greater or less degree, rejected by vomiting, and partly on account of the imperfect assimilation of what is retained. As the disease increases, the whole process of respiration is at length carried on by one lung; an incessant state of anxiety prevails, and the patient remains fixed on the diseased side, through dread of impending suffocation if he turn on the other. The face, hands, feet, and the affected side are cedematous ; while the opposite part of the body, from deficient assimilation, hectic heat, and nocturnal perspirations, is extenuated. The urine now becomes scanty, red, turbid, with a copious branny sediment, and soon pu- trefies ; and the scene is finally closed, with short and asth- matic brcathlessness, lividity of the cheeks, lips, and nails, &c.
Comm. The remark respecting lying on the af- fected side is not always correct. To the above, I would add one invariable symptom, viz. an incessant thirst. Towards the close of the disease there is likewise com- monly a colliquative diarrhaea, alternating with the night sweats ; but this is not constant.
3. Purulent Vomica communicating with the Tra- chea. When a Vomica of considerable size, discoverable by percussion, bursts into the Trachea, or rather Bronchia, by a large opening, it produces instant suffocation ; if, by a small aperture, it is recognised by the following marks : By means of a violent cough, pus is expectorated, which is, in different cases, white, yellow, saffron, green, brown, bloody ; which sinks in water, and, when thrown on hot coals, emits a stinking nidorous smell. If at this time, while the patient is coughing and spitting, the palm of the hand be placed over the site of the vomica, i. e. over the place where its ex^
42 ON PERCUSSION
istence had been detected by percussion, — the noise of fluid within the chest will be sufficiently manifest. This kind of expectoration will cease for some days, with relief to the patient ; but it speedily returns, and is always preceded, for four and twenty hours, by an increase of the febrile state. During this state of things, and before the return of the ex- pectoration, if percussion is applied over the site of the vomica a sound exactly like that from a fleshy limb is obtained; but if this is delayed until the evacuation of the accumulated pus, then there is perceived a distinct, though obtuse sound. The slow fever which invariably accom- panies this condition, is encreased after eating, and is still higher during the night ; and at these times, the forehead, neck, and chest, are covered with perspiration. With the in- crease of these symptoms, and the continuation of the pu- rulent expectoration, the breath becomes tainted, insomuch as to be extremely disagreeable both to the patient and the attendants. The thirst continues great, but the appe- tite is lost, even for the greatest delicacies, which, however sparingly taken, produce, in place of refreshment, langour and anxiety. [The case is very different with them whose sputa are inodorous, the appetite in many being even great]. The urine is uniformly frothy, grows speedily putrid, and deposits a viscid, tenacious, white sediment. The patient now daily grows more emaciated : the bones almost pierce the skin, — the hair falls off', — the nails become curved, — the legs swell ; at length a colliquative diarrhsea supervening first lessens, and then suppresses the expec- toration, and the sufferer finally dies suddenly, on the third day after that on which he began to remain obstinately fixed on his back, with his legs drawn under him.
Comm, On inspecting the chest after deah, in these cases, we find the vomica contained within the substance of the lung, and this more or less compressed &c. accord-
OF THE CHEST. 43
ing as the vomica has been of greater or less extent. It fre- quently happens, however, that there is no alteration in the remaining portion of the lung; and in all cases it is to be observed, that the vomica, properly so called, oc- casions much less disorganisation of the viscus, than an abscess which is not confined by a cyst. In this latter case, we find the pulmonary substance softened and des- troyed, irregularly excavated, with the vessels laid bare, and the whole more or less dissolved into a filthy-look- ing fetid mass.
In comparing the various kinds of the purulent vo- mica, with the solid scirrhus of the lungs, or the icho- rous vomica, we find a vast difference as well in the symptoms and nature of each, as in the constitution of the subjects in which they are found. In fact, the pu- rulent vomica is always the result of an inflammation, more or less acute, of the lung ; and hence we have reason to expect in it a train of symptoms very opposite to those that occur in the ichorous Vomica : for exam- ple, in the former we have marked fever, with great in- ternal heat, thirst, flushing of the face, constant anx- iety, contracted, hard and frequent pulse, great emacia- tion, and a rapid progress to a fatal termination. The victims of this affection, accordingly, are persons in youth or adult age, of a strong and sanguine tempera- ment, leading an active life, and exposed to the ordi- nary causes of inflammation.
XL1II. Empyema, When a vomica (xxxvn.), as- certained by percussion, discharges its contents into the ca- vity of the pleura, and upon the diaphragm, Empyema is produced.
Schol. I premise this definition to prevent the affec- tion now in question from being confounded with a vomica that has discharged its contents into the trachaea.
44 ON PERCUSSION
XLIV. If a large vomica, whose superficial and cen- tral extent is supposed to have been recognized by the marks pointed out (obs. third, xv. xvi. xvii.), shall have burst as above mentioned (xliii.), it may be recognised by the following signs: —
The patient who had usually lain on the affected side, starts up with a sudden pain (as if nearly suffocated), and begs to be held in the erect posture.
If percussion is now applied, it will be found that the natural sound, which had been nearly lost in the site of the vomica, has in some degree been restored in that place ; while it is more or less destroyed (according to the quantity of pus effused) over the posterior and inferior parts of the chest.
There is now a very frequent cough, which is either dry, or with a scanty, frothy and noisy expectoration. The respiration becomes very laborious, with frequent faintings, and a cold sweat bedews the forehead and throat ; the cheeks and lips are of an ominous red, while the nails grow livid, the pupils dilate, and death (which follows in a few hours the rupture of a large vomica) is finally preceded by dimness of sight, &c.
A small vomica, ruptured in the same manner, pro- duces the same symptoms, and is equallv fatal. This issue, however, is of later occurrence, and is preceded by the marks of pleuro-peripneumony.
Coram* On inspecting the chest after death in these cases, if the Empyema is only of recent formation, very little morbid change is observed on the pleura. On the contrary, if a considerable period has elapsed since the rupture of the vomica, the natural character of the mem- brane is much altered, and in a degree proportioned to the duration of the disease. Sometimes the membrane is thickened, indurated, of a white colour, and some-
OF THE CHEST 45
times even cartilaginous ; at other times it is softened, corroded, and foliated.
Most commonly the morbid alteration of the mem- brane is confined to the place of the effusion ; sometimes however, it involves the whole pleura. Very often there are adhesions between the pleura of the lungs and ribs or diaphragm, of old date, or resulting from the inflam- mation excited by the empyema. Frequently these ad- hesions form pouches or sacs, in which the effused pus is lodged, in whole or in part. In these cases it occasion- ally happens that the contents of the ruptured vomica do not reach the diaphragm, which consequently remains sound. In this case, the affection is not an Empyema strictly so called.
TWELFTH OBSERVATION.
Of Dropsy of the Chest. Comm. Great mistakes have been made respecting the diagnosis of this disease, partly from the real diffi- culty of recognising its presence in certain cases, but much more from assigning to it as pathognomonic symp- toms, signs which in fact belong to other affections, of which this is merely the consequence. I should have thought that our author would have avoided this almost general error, from his experience in pectoral diseases, his superior diagnosis of them (by means of percussion) in the living subject, and his opportunities of distin- guishing the secondary from the primary affections, by examinations after death. It cannot be doubted, how- ever, that he has fallen into the prevailing error, and has comprised in his description of hydrothorax as an idiopathic and primary affection, a great many symp- toms which are very foreign to it, and belong clearly to
4G ON PERCUSSION
organic lesions of the heart and large vessels. In my commentaries on the respective signs detailed by him, I shall point out these mistakes.
XLV. When water is collected in the cavity of the chest, between the pleura [costalis] and the lungs, the di- sease is called dropsy of the chest ; and this is said to be of two kinds, namely, according as the fluid occupies one, or both sides.
Schol. This is ascertained by percussion in the living subject ; and is demonstrated by anatomical examination after death. The general symptoms of this disease are chiefly the following' :
1. Difficult and laborious respiration;
2. A cough at intervals, which is dry, or only attended by sputa of a thin watery nature, or occasionally somewhat viscid ;
3. A pulse contracted, somewhat hard, frequent, une- qual, and often intermitting;
4. A sense of breathlessness and suffocation on the slightest motion ;
5. An incipient dislike of Warm food ;
6*. Perpetual anxiety about the scrobiculus cordis ;
7. Great pressure on the chest, and distension of the stomach during the period of digestion ;
8. A murmuring noise about the hypochondres, and frequent eructation of flatus, with momentary relief;
9. Scarcely any thirst ;
10. Urine very scanty, and rarely made, red, with a lateritious sediment ;
11. Swelling of the abdomen, more especially in the Epigastrium, and particularly in that point on which the
ncumbent water gravitates ;
12. A sub-livid swelling of the extremities, especially of the feet, which are moreover cold to the touch ;
OF THE CHEST Aj
] 3. (Edematous tumescence of the inferior palpebrae ;
14. A pallid, or, according to the nature of the affec- tion, a sublivid discoloration of the cheeks, lips, and tongue ;
15. Inability to lie down; anxious distressing nights, with heaviness, yet frequently sleepless.
All these symptoms vary in a wonderful manner ac- cording to the disease.
First Kind. — Dropsy of one side of the Chest. Be- side the general signs of this disease above enumerated, the affected side, if completely filled with water, is enfeebled (effceminatum) , and appears less moveable during inspira- tion. In this case, also, the affected side yields no where the natural sound on percussion. If the chest is only half- filled, a louder sound will be obtained over the parts to which the fluid does not extend ; and, in this case, the resonance will be found to vary according to the position of the pa- tient, and the consequent level which the liquid attains. The Hypochondre of the affected side is also unusually tu- mid, and more resisting to pressure than the rest of the ab- domen. The palpebra, hand, and foot of the affected side are slightly cedematous. It is a remarkable fact, that the re- clining posture [decubitus declivis] is easily borne when the chest is entirely full ; while the contrary is the case, when there remains space for the fluctuation of the water.
Second Kind. — Dropsy of both sides of the Chest. If fluid is contained in both sides of the chest, the following specific signs, in addition to the general symptoms, exist : The natural sound is destroyed over the space occupied by the water in either side. The patients uniformly become asthmatic ; and resemble, in many respects, those labouring under Ascites, only that the former have their inferior palpebrae and hands swollen. They cannot lie in an hori- zontal posture, and are equally threatened with suffocation on
48 ON PERCUSSION
whichever side they turn ; on which account, they are forced to remain sitting, day and night, to prevent the pressure of the fluid from being felt on the upper parts of the chest (which would be the case on lying down), in the same de- gree on which it now gravitates on the abdomen. The effect of this state of things might lead to the suspicion of Ascites, only that we find, on examining the patient in the erect position, that the hypochondriac regions are more swollen than the inferior parts, which is not the case in Ascites.
All these subjects die as if from peripneumony, that is to say, — the pulse fails, the whole body, except the chest and head, grows cold, the cheeks and extremities become livid, the respiration is at first laborious, then interrupted, and finally ceases altogether.
Coram, The author's distinction of hydrothorax ac- cording as one or both sides are affected, although use- ful and proper, and easily known by means of percussion, is merely a difference of quantity, and would, I think, be better expressed by the terms partial and complete. But the essential grounds for different species of dropsy is a difference in their nature and causes ; and hence the grand natural division of these must be into Primary and Symptomatic, Without this distinction there will always be the greatest confusion in characterising them by any signs or symptoms.
[I shall now remark, in order, on the various symp- toms enumerated by the author, and shall repeat the no- tation and titles employed in the text, for the sake of easy reference.]
1. Difficult respiration. The respiration, strictly speaking, is not difficult or laborious except on exer- tion ; it is short and confined, yet performed with suffi- cient calmness. The cause of the short breathing is ob-
OF THE CHEST. 49
vlous. — But even if the respiration were laborious, this \yould still be but a very equivocal symptom, as it exists in many other affections, e. g. in all the diseases of the heart, large vessels, or lungs; in true asthma; &c.
2. CoughSfc. The intervals between the fits of cough- ing are long, and the cough itself is generally inconsider- able and without any violent paroxysms.
3. The pulse. The characters of the pulse in the idiopathic hydrothorax, are absolutely the reverse of those given by our author, — it being, most commonly, full, somewhat soft, slow, quiet, regular, — feebler and more frequent according as the complaint increases, but always remarkable for regularity. These, at least, are the qua- lities of pulse which I have observed in similar cases, and I have had occasion to witness a great many, consider- ing the infrequency of this disease in its state of sim- plicity.
In organic diseases of the heart and great vessels, however, one of the principal symptoms is the deranged condition of the circulation, — the pulse being,at different times, hard, full, vibrating, frequent, irregular, greatly intermitting, undulating, in short, varying extremely. It would appear, then, from this statement, that in the cases of hydrothorax, wherein Avenbrugger had ob- served the kind of pulse mentioned by him, — there ex- isted some primary organic lesion of the heart or large vessels, of which the hydrothorax was merely a conse- quence ; — as it is known to be one of the most common.
4. Breathlessness on motion. This symptom is al- ways present, and is easily explained on mechanical prin- ciples. It is, however, a very equivocal sign of hydro- thorax, since it is found in all other diseases which pro- duce a proportionate impediment to the introduction of
50 ON PERCUSSION
the necessary quantity of air into the lungs, — such, for instance, as a scirrhus or vomica of the lungs, empyema, aneurism, &c.
5. Nausea Sfc. I consider this sign as insignificant.
6. Precordial anxiety. This symptom is not usually present in idiopathic hydrothorax, but commonly attends the cases resulting from disease of the heart. It is, therefore, an equivocal mark of simple hydrothorax.
7. Oppression of the chest after eating. This is readily explained by the pressure of the enlarged sto- mach on the diaphragm.
% I wonder that the commentator does not remark the equivocal character of this symptom also, since it exists in almost all diseases of the heart and pericar- dium. Trans.
8. Flatulence. The discharge of this gives momen- tary relief in hydrothorax, on the same principle that the retention of it occasions uneasiness : it cannot, however, be properly reckoned as a symptom of this disease in particular.
9. Thirst. I consider (with the author) this to be very rare in the idiopathic affection, but not so in the symptomatic.
10. The Urine. The state of this excretion described by the author is common to every species of dropsy.
il. Epigastric tumour. Explained on mechanical principles.
1 2. Livid cedema of the extremities. This symptom rarely exists in primary hydrothorax, and is rather to be considered as a sign of organic disease of the heart.
IS. CEdema of the eyelids. This symptom is certainly common in primary hydrothorax, but exists also in many other affections.
Ik. Paleness or Lividity of Countenance. In hy-
OF THE CHEST. 51
drothorax the face rs generally pale, wasted, anxious, and not swollen ; the lips pale and thin ; the tongue neither pale nor livid. All the symptoms of lividity de- pend on an affection of the heart or great vessels.
15. Anxiety, inability to lie dow?i, fyc. I would say that none of the symptoms here enumerated belong to simple hydrothorax, which is a disease of comparative tranquil- lity and sameness. In the same affection, however, re- sulting from diseased heart, all the symptoms enume- rated exist in a high degree.
Dropsy of one side. In such cases, as one side of the chest is only partly filled, the effect of the water in pro- ducing tumour of the hypochondrium is at once illus- trated and detected by causing the patient to assume the horizontal posture, when the tumefaction in a great measure disappears.
Dropsy of both sides. The observation respect- ing the total inability to lie down, is often not true in the simple hydrothorax; but is invariably so in that de- pending on diseased heart. The death of Pneumonias ie, doubtless, that of subjects whose disease is sympto- matic of organic lesion of the heart or lungs, but not of those whose disease is a simple primary dropsy.
After these special remarks on the various symptoms mentioned by our author, I shall sum up this commen- tary by a brief description of the disease, such as it has presented itself to me when unaccompanied by organic lesion, as was ascertained on dissection. In this state of simplicity it is however extremely rare.
In recognising this affection, it is important to study its causes and the previous history of the individual. When idiopathic, its attack is generally sudden, and suc- ceeds to cold drinks — the suppression of accustomed evacuations, — the measles, &c. &c. When any of these
E2
$2 ON PERCUSSION
causes has preceded the disease, and none of the symp- toms peculiar to organic lesions of the lungs, heart, or great vessels have done so, — there exists already much probability of the uncomplicated nature of the dropsy.
The patient at first complains of a sense of weight, uneasiness and weakness, of anxiety and pressure at the prascordia, and a difficulty of breathing, at first perceived only in the act of ascending, or on using considerable exercise. The appetite decreases, the thirst augments, the urine is somewhat more scanty, commonly natural in colour, sometimes red, and when depositing a sedi- ment (which is rare) this is commonly lateritious. There is an occasional cough, usually dry, or with slight mu- cous expectoration. In the progress of the disease, the countenance gets daily more pale, withered and anxious, but without oedema; the eyes are dull and heavy, and gradually lose their natural expresssion ; and the lips pallid and thin. If the effusion is confined to one side, this is observed to become more rounded, and the inter- costal spaces larger, as the water accumulates : This is followed by oec'ema of the same side of the chest, and sometimes of the arm of the same side, — a local affection unconnected with the oedema of the lower extremities, which afterwards comes on. At this period, percussion gives certain indications of the quantity of the fluid. During almost the whole course of this disease the pati- ent can lie horizontally, on either side, or on the back; in the very last stage of it, he frequently lies ob- stinately on the affected side, if the effusion is par- tial, or keeps the sitting posture if both cavities are full. There is never any palpitation of the heart, its action being observed to be feeble, tranquil, and regular. In accordance with this state of the heart, the pulse is often full, soft, slow and regular: as the disease ap-
OF THE CHEST. 53
proaches towards its final close, it becomes more feeble and frequent, but still remains regular. At this time the urine becomes scanty and thick. The disease re- tains a sameness of course, and the termination has no- thing remarkable, being generally without much suffer- ing, and with the senses and mental faculties still pre- served.
After this exact description* of primary simple hydro- thorax, it is easy to convince ourselves how illusory and false are all those histories of this disease given by almost every author, in which we find recorded as decisive in- dications of the affection — starting Jrom sleep, — pal- pitation— precordial distress — inability to lie down — unequal, irregular, intermitting pulse, fyc. Sfc. — symp- toms which clearly belong to an anterior organic disease of the heart or great vessels, — as is, indeed, demon- strated, in such cases, by examination after death. On inspecting the chest after death in the idiopathic disease, if it has arisen slowly and without inflammation we find the pleura almost in a natural state, or only, at most, a lit- tle thicker, denser and whiter than usual. If the effusion has existed on one side only, and in great quantity, the pleura is evidently thickened, and the lung wasted and pressed against the mediastinum. The heart is rather diminished than increased in size, pale, empty, and un- changed in structure.
% For a further account of the symptoms of the idio- pathic Hydrothorax, and an admirable contrast of these, seriatim, with those indicative of organic affection of the heart, see the Commentator's Treatise on diseases of the heart, p. 446. 3d. edit. See also Laennec, torn. 1. p. 409, who considers death from the idiopathic disease
* So termed by the Commentator. Trans*
54 ON PERCUSSION
of as rare occurrence as one in two thousand. The two varieties of this disease are very generally confounded by English writers in their descriptions. See Dr. Maclean's Treatise on Hydrothorax, Dr. Blackall on Dropsy, &c.
Trans. XLVI. Dropsy of the Pericardium, When the liquor pericardii is morbidly encreased, so as to be capa- ble of disturbing the natural action of the heart, the dis- ease is called Dropsy of the Pericardium : of this there are two species, as the fluid is purulent or serous.
Comm, The author here comprehends, under the same name, two different affections, viz* a collection of turbid, milky, sero-purulent fluid, the consequence of inflammation of the pericardium ; and the morbid accu- mulation of the natural fluid. It is only to the latter species, that I consider the name of dropsy as at all ap- plicable.
Schol. The fluid naturally present in the pericardium accumulates in still greater quantity in those who suffer a long protracted mortal agony, as we find on examination after their death. But it is not to this accumulation, originating in the relaxation of death, but to that produced by obstruc- tion during life, that I apply the term dropsy. I have ven- tured to divide the affection into two species, because I have often witnessed both of them. In the first variety, the heart is rough, and as it were shagged, with a coating of the pu- rulent matter ; while in the latter, the organ is only of a paler colour than natural. Many may be of opinion that the purulent dropsy would be better classed under the head of Empyema ; but I shall never quarrel about words, when there are appearances to instruct us.
Comm, The author does well to distinguish the accu- mulation that takes place in the last moments of life, — and which may take place in any disease, — from the
OF THE CHEST. 55
true dropsy occuring, from morbid causes, during life. By obstruction he means any causes which impede the due absorption of the fluid that exists naturally in all serous cavities. The principal causes of this obstruc- tion in the present case are — disease of the heart'; in- flammation of the mediastinum, lungs or pleura ; also other effusions, such as hydrothorax and anasarca : il very rarely happens that a local morbid affection of the pericardium itself is the sole and immediate cause of this effusion. From the nature of the causes just stated, it will be perceived that dropsy of the pericardium must be very rarely idiopathic : in fact, there are very few well authenticated instances of it in a state of simplicity, without some concomitant morbid condition of one or other of the thoracic viscera. Although it be very true, as Avenbrugger says, that it is foolish to quarrel about words, when we have facts before us, still when it is pro- posed, as in the present case, to comprehend two very different diseases under one name, it becomes of conse- quence to point out the impropriety of the designation. Under the title of the Purulent Dropsy of the pericar- dium, the author describes well the morbid appearances of both the acute and chronic pericarditis, — diseases en- tirely dissimilar to Hydropericardium, in their origin, symptoms, progress, and termination. For a full ac- count of pericarditis, acute and chronic, see my Treatise on the Heart.
Signs of Hydropericardiurn. Almost all the symp- toms which have already been enumerated as accompanying dropsy of the chest generally, accompany this species also : in addition to these, however, I have observed the following specific signs of the dropsy of the pericardium : —
The sound in the cardiac region, which I have al- ready stated (in. 2. 3.) to be naturally more obscure than
56 ON PERCUSSION
in the other parts of the chest, is now as completely dead- ened as if the percussion were applied to a fleshy limb. A swelling is perceived in the preecordia, which can readily be distinguished, by its superior resistance, from the stomach distend ed by flatus.
The patients fall asleep, while sitting, the body being inclined forwards ; but they soon are roused by the uncon- scious dropping of the head. On this account, they com- plain to all around them of the distressing propensity to sleep which they experience. At the same time they suffer from faintings (accompanied by a pulse frequently unequal in respect both of its rythm and volume), and, indeed, con- tinue to undergo, to the end of their wretched life, and in every position of body, the greatest distress. A few days before death, in many cases, the neck is swollen, and the eyes become extremely red, as if from crying. This state of things is sometimes terminated suddenly by a stroke of apoplexy, or more slowly by leipothymia.
The same signs are furnished by percussion in the pu- rulent, as in the proper dropsy of the pericardium ; but in the former, the other symptoms are precisely the same as those which exist in the close purulent vomica. In the pu- rulent dropsy, the fluid commonly resembles turbid whey, — the thicker portions of it [quod purulentum est\ being found adhering to the heart like fringes.
Comm. As the author refers to the enumeration of the general symptoms of hydrothorax, I beg to refer to the strictures made by me on that enumeration. As in the case of that disease, the author in this also, confounds the secondary with the primary affection. In judging from the results of percussion, it will be necessary to re- collect the observations made on the natural sound of the cardiac region in a former part of this work (m. and Comm,) ; moreover, it must be observed, that although
OF THE CHEST. 57
in hydropericardium, the region of the heart, and indeed often the whole sternum, yields only the fleshy sound described ; — and although the probability is, that, when this result is obtained by percussion, the disease is the one now under consideration ; it does not follow that this is either necessarily or even certainly the case; — since any other morbid cause existing in the same situ- ation, in the lungs or mediastinum, and producing equal obstruction or displacement, will occasion a like change in the natural sound. When the pericardium con- tains much fluid (and I have found in it seven or eight pints) the swelling of the praecordia mentioned by our author is very evident in the place of the hollow naturally there. It is hard and resisting, and is caused by the fluid of the pericardium depressing the diaphragm below the end of the sternum. I do not think it so easy as the author says, to distinguish this tumour from the dis- tended stomach.
If I am rather disposed to attribute the precordial tumour to the left lobe of the liver thrust forwards and downward by the depressed diaphragm. This was certainly the case in the two instances of purulent
dropsy of the pericardium (Cases of Mr. N n,
and Miss H. P.) given in the present work; and I am the more disposed to adopt this opinion, as well from considering the very frequent morbid enlarge- ment of the liver found in cases of diseased heart, as from observing in other cases, how very often this viscus extends naturally not merely into the epigastric, but into the left hypochondriac region, — occasionally as far as the spleen, often so as to rest on the pyloric half of the sto- mach. In these cases I am disposed to adopt the opi- nion of the original author, in preference to that of his commentator, that the prsecordial tumor may readily be
58 ON TERCUSSION
distinguished, by its superior degree of resistance, from the distended stomach. Trans.
The description of the snatches of sleep in the sitting posture,constantly and suddenly broken, and unrefreshing, is very correct, as is also that of the patient's anxiety, and bitter complaints. Indeed nothing can exceed the distressing condition, both physical and moral, of these persons. They cannot enjoyeven a few moments of sound sleep in any one posture, — while at the same time, borne down by watching, fatigue, and debility, they are con- stantly impelled, even in spite of themselves, to yield to a momentary repose which is sure to be broken by a sudden start. It is proper to observe, however, that this state of anxiety, distress, and irresistible propensity to sleep, belongs less to the simple hydropericardium, than to that which is either caused or accompanied by an orga- nic lesion of the heart. The greater part of the distress of these patients arises from their inability to assume the horizontal posture ; and this inability is well known to be a certain consequence of an organic affection of the heart. The attacks of syncope, which, in the progress of the disease, become more or less frequent, are owing to the impediments that exist to the natural action of the heart : this connexion is further evinced by the state of the pulse, which becomes then feeble, frequent, con- tracted, intermittent and irregular. At this time pal- pitations, properly so called, are seldom observed : but on applying the hand to the heart, we can readily dis- cover, in its obscure and tumultuous movements, that this organ is acting as if surrounded by a fluid, and swim- ming in it. These local causes of the irregularity of the heart's action are still further strengthened by the effect of the irregular circulation existing in the brain, which irregularity, although itself a consequence of the disease
OF THE CHEST. 59
of the hearty eventually hecomes a powerful agent in augmenting the unnatural movements of this organ.
The suhjects of hydropericardium habitually have the face of a violet hue, and the lips dark and livid, and in the last days of their existence, the swelling of the throat and redness of the eyes, mentioned by the author, are pre- sent. I would, however, observe that these symptoms are seldom so strongly marked as stated, when the disease is idiopathic. I have never seen this disease terminated by apoplexy, and very rarely by syncope, — the final scene of suffering being in general long, most distressing, and yet difficult to be described.
I cannot assent to the correctness of the statement that the symptoms of the purulent dropsy of the pericar- dium (i. e. pericarditis) are precisely similar to those of the close vomica. On the contrary, whether the inflam- mation be acute, subacute, or chronic and latent, it is al- ways attended with symptoms peculiar to itself. (See my Treat, on Dis. of Heart.) In the acute variety, the disease is very rapid in its progress, proving fatal on the 4th. 5th. or 6th. day : there are frequent fainting-fits, and a burning pain in the region of the heart. The counte- nance is extremely pinched, and has a mixed expression of profound depression, irritation, agitation, inexpressible and perpetual anxiety. The respiration is laborious and broken, with slight palpitations and imperfect faint- ings ; and the pulse is small, frequent, hard, contracted and often irregular. Towards the close of the disease, viz. on the third, fourth, or fifth day, the facies Hippocratica is exquisitely marked ; and the pain is succeeded by shiverings, prolonged by incomplete faintings, sense of suffocation, and insupportable anxiety. General anasarca now comes on, and the patient usually dies suddenly and unexpectedly while making some trifling exertion.
CO ON PERCUSSION
The subacute variety is less obscure in its signs, prin- pally because one has time to study its various phenome- na more perfectly.
The diagnosis of the chronic variety is certainly diffi- cult, and the more so because it is generally complicated with other affections ; it has, nevertheless, some charac- teristic signs. In it there is general anasarca, the counte- nance is swollen, the lips violet, the praecordia painful, and there is almost constantly a troublesome convulsive cough ; there are frequent imperfect fits of syncope; the respiration is short, quick, oppressed, and attended by a sense of weight about the lower end of the sternum.
The condition of the circulation varies much : the action of the heart being sometimes regular, and some- times indicated rather by an obscure sort of vibration or hruissement ; the pulse, always frequent, is sometimes regular, sometimes irregular, and occasionally intermit- tent.
Besides these radical marksof the pericardiac affection, there are often other symptoms depending on morbid complications ; — for example, palpitations, sudden stag- ings from sleep, &c. when there is disease of the heart ; — pain in various parts of the chest, dyspnoea, cough, &c. when the lungs, pleura, or mediastinum is inflamed.
The appearances of the fluid on dissection are cor- rectly described; but these vary according to the degree of rapidity of the disease. When the inflammation has been acute and of short duration, the fluid is more tur- bid, more flaky, redder and more truly purulent than in the chronic disease.
The fringy matter mentioned by Avenbrugger as found adhering to the heart in these cases, is a well- known secretion peculiar to the inflammation of serous membranes.
OF THE CHEST. 61
In bringing these observations to a conclusion, I must observe that the author, in his account of Pericardiac Dropsy, has been much less correct than in his account of the preceding diseases. Indeed, almost all that he has said on this subject is either vague, or obscure, or insig- nificant, or even false. These defects are, doubtless, owing to his having had too slight experience of this particular disease.
THIRTEENTH OBSERVATION.
Of the symptoms of a copious extravasation of Blood, XLVII. The causes of a large extravasation of blood into the cavity of the chest have been noticed in the Scho- lium of xxxi. The following are the symptoms of this affection.
Schol. There is incessant and indiscribable anxiety and oppression at the praecordia and on the chest, while there is constant jactitation of the body, and complete into- lerance of the horizontal posture. Percussion elicits none of the natural sound over the space occupied by the ex- travasated blood. In all cases the pulse is extremely con- tracted, frequent, and irregular in every way. The respiration is extremely laborious, with a frequent cough, and broken by profound sighing. All the veins become flaccid, and the eyes are at first red but ultimately pale. Cold sweats &c. follow, and the patient dies stertorous.
These are the symptoms when the blood flows into the cavity of the pleura without any accompanying lesion of the lungs : when these are wounded, there is also bloody expec- toration, and a passage of air to and from the wound in the parietes of the chest.
62 ON PERCUSSION
Comm, Thesymptoms accompanying this affectionate faithfully described ; but it i9 very rarely that they ex- hibit so regular and measured a progress as the author's account might lead us to infer.
FOURTEENTH OBSERVATION.
Of Aneurism of the Heart. XLVIII. When the heart becomes so much dis- tended by blood, accumulated in its auricles and ventricles, as to be unequal to propel forward its contents, it frequent- ly becomes thereby enormously dilated. This dilatation has been called Aneurism of the Heart.
Comm. Under the term Aneurism of the Heart, the author describes merely a recent and simple distension of this organ, a transient symptom of other diseases, and not the organic affection of slow growth, usually and properly denominated Aneurism, It would even appear that the author was unacquainted with this class of diseases.
Schol. We frequently observe this state of the heart on dissection, (1.) in sudden and extensive peripneumonies of both lobes at the same time, and (2.) in those fatal inflam- matory diseases which are noticed towards the end of the Scholium on xxu.
The pathognomonic sign of this affection is the com- plete fleshy sound on percussion existing over a considerable space in the region of the heart. Whenever this sound is perceptible in the acute peripneumony it is a sign that the patient will not survive twenty-four hours: in fact, he is already at the last gasp, and is speedily carried off as in apo- plexy, unconscious of his fate.
OF THE CHEST. G3
In the second class of inflammations, the sign is equally fatal, but is attended by different symptoms. In this case, the patients suffer dreadful anxiety, and by the constant jactitation of their limbs, are perpetually uncover- ing themselves. Older persons, indeed, hear more tranquilly their sufferings ; but the younger are pertinaciously restless and violent, struggling and talking, attempting to get out of bed, demanding their clothes, and endeavouring to walk or go about their usual occupations. Meanwhile the eyes become dull, the cheeks livid, and the nails and extremities are tinged with a leaden hue, and death is ushered in by cold sweats, and the gradual extinction of the pulse and respiration.
CEDANT HiEC MISERIS IN SOLATIUM, VERIS AUTEM MEDICINE CULTORIBUS IN INCPEMENTUM ARTIS : QUOD OPTO !
Comm. The observation of the author respecting the recognition of his distension of the heart, holds equally true of the real dilatation or aneurism, which can al- ways be certainly ascertained by this means. It is even possible to detect by percussion not only the species of of aneurism, i. e. whether with thick or thin parietes; — but even, in certain cases, the particular part of the organ that is enlarged. This nicety of diagnosis, how- ever, I must admit not to be of easy acquisition, and to require much practical experience and tact.
The concluding wish and prayer of the author have not been made in vain. This little Treatise, as every candid practitioner may readily convince himself, con- tains most luminous precepts respecting the practice of percussion, and most exact and faithful observations on several diseases which were previously eithei misunder- stood, singularly neglected, or respecting which very er- roneous notions were for the most part entertained :
G4 ON PERCUSSION
Indeed we cannot feel too much gratitude towards a man who consecrated the greater part of his medical life to such painful and minute observation, and who was thereby enabled to make such valuable discoveries. Unquestion- ably, Avenbrugger has neither seen nor said every thing, relating to the subject of his treatise ; there are even some diseases which he has not properly understood; but when we consider at what time (1760) he wrote, and recollect what false notions were then entertained respecting the diseases mentioned by him, — even setting aside his great discovery of Percussion, — we must admit that he has done great things for the improvement of the art, in one of the least advanced departments of practical medicine.
END OF THE TREATISE ON PERCUSSION,.
BEING A BRIEF OUTLINE OF THE METHOD OF DISTINGUISHING
DISEASES OP THE CHEST
BY MEANS OF THE STETHOSCOPE ;
EXTRACTED FROM
THE ORIGINAL TREATISE OF M. LAENNEC,
PUBLISHED IN MDCCCXIX.
Dr. Laennec was indisposed, but his colleague Dr. Cayol pointed out to me several cases where the information gained by the application of the Stetho- scope was useful in ascertaining the nature of the disease. I found that it would require more time than I had to bestow to make myself fully acquainted with the use of this instrument ; but 1 observed enough to convince me that much useful information is to be acquired through the medium of this instrument in distinguishing the diseases of the different viscera of the thorax.
Dr. Recamier, one of the physicians of the Hotel Dieu, informed roe, whilst going round his wards, that he could accurately discover the extent of in- jury in most diseases of the lungs- by means of the cylinder, which he carried" constantly in his hand.
It has been asked in reference to Dr. Laennec*s discovery, what it will avail us to know the exact situation of an ulcer in the lungs, or whether it is a little larger, or smaller, than we believed ? — wliether we shall be better able to cure an organic affection of the heart or large blood vessels, by knowing the particu- lar part affected ? The remark is futile, and has a tendency to check philoso- phic research. To know the nature and extent of a disease is surely the first step hi our progress to the adoption of rational means of cure ; and though the dis- eases particularly alluded to, are, unfortunately, beyond the known powers of medicine, the profession has not assuredly arrived at that degree of perfection to entitle us to pronounce that they will always remain so. But setting aside other advantages, it must surely be highly satisfactory to every ingenuous mind to know the exact nature of the disease under which a patient labours,
even when it is known to be incurable.
Clark. Med. Nettt.
From considerable experience, as great perhaps as that of any body in this country, we have convinced ourselves of the value of the Stethoscope as a means of diagnosis in the diseases of the chest j and the observations we have had op- portunities to make, induce us to place implicit confidence in the finer distinc- tions mentioned by Laennec, which we have not yet acquired skill enough to reach. Any one who will take the trouble to apply the cylinder with tolerable at • tention and adroitness, to the chests of half a dozen patients in an hospital, wilt easily satisfy himself of the great diversity to be observed in the action and rythm of the heart, and in the sounds caused by respiration ; and as these de- pend on the physical state of the organs, the one is a certain indication of the
other.
Duncan. Edin, Journ. July, 182(\
ON MEDIATE AUSCULTATION.
The application to the diagnosis of diseases of the Chest, of Auscultation hy means of an instrument — hence termed Mediate Auscultation — was first made in 1816 by M. Laennec. The full development of this new system of diagnostics is given in the invaluable treatise of that au- thor, and is now well known to many members of the pro- fession in this country, as well in the original, as through the English Translation of it published some years since. As it is very probable, however, that the present volume may come into the hands of many who have not seen the work of M. Laennec, in either form, I have thought it necessary to introduce, in this place, such extracts from it as may, at least, render the subsequent histories intelligible to this class of readers. I beg, however, explicitly to state that the account about to be given of this system, although suf- cient for the purpose mentioned, is inadequate to direct the practical application of it, or even to convey any just notion of its importance. In order to obtain this knowledge, the work of M. Laennec must be consulted.
This method is founded on the well-known property of solid bodies to transmit sound with much greater readi- ness than is done through the air. In the present case, this
F2
68 ON MEDIATE
property is applied to the discovery of the sounds produced in the interior of the chest, by the natural motions of the organs of circulation and respiration. From the modifica- tions of these sounds, in health and disease, a judgement is formed respecting the actual state of the organs.
The instrument used for this purpose is called the Stethoscope. This consists simply of a cylinder of wood,, a foot in length, perforated in its centre longitudinally, by a bore three lines in diameter, and formed so as to come apart in the middle, for the benefit of being more easily car- ried. One extremity of the cylinder is hollowed out into the form of a funnel to the depth of an inch and a half, which cavity can be obliterated at pleasure, by apiece of wood so constructed as to fit it exactly, with the exception of the central bore which is continued through it, so as to render the instrument in all cases, a pervious tube. The complete instrument, — that is, with the funnel -shaped plug infixed, — is used in exploring the signs obtained through the medium of the voice and the action of the heart ; the other modifi- cation, or with the stopper removed, is for examining the sounds communicated by respiration. A solid cylinder, without any perforation, is the best instrument for exploring the action of the heart ; but as this form is not so good for examining the voice and respiration, the perforated cylinder is commonly used for all purposes. On all occasions, the cylinder should be held in the manner of a pen, and the hand of the observer should be placed very close to the body of the patient, to insure the correct application of the instru- ment.
The end which is applied to the patient, — that, namely, which contains the stopper or plug, — ought to be slightly concave to insure its greater stability in application ; and when there is much emaciation, it is sometimes necessary to insert between the ribs a piece of lint or cotton, or a leaf
AUSCULTATION. 69
of paper, on which the instrument is to be placed, as, other- wise, the results might be affected by the imperfect appli- cation of the cylinder. The same precaution is necessary in the examination of the circulation in cases where the sternum, at its lower extremity, is drawn backwards, as frequently happens with shoemakers, and some other ar- tizans.
There are three kinds of exploration by the stetho- scope, viz. that of the Voice — the Respiration — and the Circulation.
I. The Voice. When a person in health speaks or sings, his voice excites in the whole parietes of the thorax a sort of vibration, which is easily perceived on applying the hand to the chest. This phenomenon is no longer observ- able when, through disease, the lungs have ceased to be per- meable to the air, or are removed from the contact of the parietes of the chest by an effused fluid. This sign is of inferior value, since a great many causes occasion varieties in the intensity of the vibration, or completely destroy it. For instance, it is little sensible in fat persons, in those whose integuments are considerably flaccid, and in those who have a sharp and weak voice.- Anasarca of the chest completely destroys it, even when the lungs are quite sound. In any case it is only very perceptible at the anterior and superior part of the chest, on the sides, and in the middle of the back. From these and other causes, we can derive little practical benefit from attending to this particular circum- stance.
On making use of the cylinder with the view of further investigating this phenomenon, it was soon found, as indeed might have been expected, that it conveyed the peculiar vi- bration much less distinctly than the bare hand. It was also ascertained that the degree of intensity of the vibration varied in different points of the thorax. The places where it is
70 ON MEDIATE
most distinct are the axilla, the back — between the spine and the edge of the scapula, and on the anterior and supe- rior part of the chest near the angle formed by the union of the clavicle with the sternum. When we apply the cy^ linder to these points, the voice appears stronger and nearer to us ; in the others, on the contrary, particularly in the inferior and posterior parts of the thorax, it seems weaker and more remote.
The only diseases to the diagnosis of which the explo- ration of the voice has been applied with success are, Phthisis Pulmonalis, Pleurisy, and Pneumo-Thorax.
If we apply the stethoscope to the larynx or trachea of a person in health when speaking, we hear the voice of the individual as if coming directly from the point on which the instrument rests, and reaching our ear through the ca- nal in it. In the second stage of phthisis, when tubercular excavations exist in the lungs, if the stethoscope be applied to the chest, over the site of one of these, the same trans- mission of voice through the tube is perceived. This phe- nomenon has been named Pectoriloquism : it is the par thognomonic sign of the morbid state just mentioned,
In cases of Pleurisy, with effusion of serous fluid, there is a partial transmission of the voice, somewhat re- sembling pectoriloquism, yet peculiarly modified so as to be easily distinguished from it : this is named Hcegopho?iism, from a supposed resemblance that it bears to the voice of a goat.
In certain cases of tubercular phthisis, and in that par- ticular variety of Pneumo-thorax, where the accompanying empyema communicates with the bronchia by means of a fistulous opening, the exploration of the voice conveys to the ear a peculiar sound, which bears a striking resemblance to that emitted by a cup of metal, glass or porcelain, when gently struck with a pin, or into which a grain of sand is
AUSCULTATION. ?1
dropped. This sound has been named Metallic Tinkling, and is considered pathognomonic of the triple lesion above mentioned,
II. Respiration. On applying the cylinder, with its funnel-shaped cavity open, to the breast of a healthy person, we hear, during inspiration and expiration, a slight but extremely distinct sound, answering to the entrance of the air into, and its expulsion from, the air cells of the lungs. This sound may be compared to that produced by a pair of bellows whose valve makes no noise, or, still better, to that emitted by a person in a deep and placid sleep, who makes now and then a profound inspiration*. Weperceive this sound almost equally distinct in every part of the chest, but more particularly in those points where the lungs, in their dilatation, approach nearest to the thoracic parietes, as, for instance, the anterior-superior, the lateral, and the posterior- inferior regions. The hollow of the axil- la, and the space between the clavicle and superior edge of the trapezius muscle, exhibit the phenomenon in its great- est intensity. It is equally perceptible on the larynx, on the exposed or cervical portion of the trachsea, and, in many persons, through the whole tract of this canal to the bottom of the sternum ; but on the trachsea, and in some degree at the root of the bronchia, the respiratory sound has a pe- culiar character, which evidently indicates the transmission of the air through a larger space than the air cells. In this position, also, it often seems as if the patient, in inspiring, inhales the air through the tube of the stethoscope, and ex- pells it by the same, during expiration.
To judge correctly of the state of respiration by this method, we must not rely on the results of the first mo-
• Its precise character will be best ascertained by applying the naked ear to the chest of a child. 7r«#t&
72 ON MED I A IK
merits of examination. The sort of buzzing sensation often caused by the first application of the instrument, the fear, restraint, and agitation of the patient, which mechanically lessen the force of respiration, the frequently inconvenient posture of the observer, and the great sensation occasionally produced by the action of the heart, — are all causes which may at first prevent us from correctly appreciating, or even from hearing at all, the sound of inspiration and expiration. We must therefore allow some seconds to pass before we attempt to form an opinion.
It need hardly be observed that there must be no noise whatever in the vicinity of the patient. The intervention of clothing, even when of considerable thickness, does not greatly diminish the sound of respiration ; but we must be careful that there is no friction between this and the instru- ment, as this circumstance, especially if the clothes are of silk, or of a fine hard stuff, may mislead us by exciting a sen- sation analogous to that produced by respiration. Fatness, even when excessive, and anasarca of the chest, seem to have no notable effect in diminishing the peculiar sound. The sound is more distinct in proportion as the respiration is more frequent. A very deep inspiration made very slowly v/ill sometimes be scarcely audible, while an imperfect in- spiration, such, for instance, as hardly at all elevates the chest, — provided it be made quickly, may produce a very loud sound. On this account, when examining a patient, more especially if we have had but slight practice with the instrument, we should desire the respiration to be performed rather quickly. This is, however, a very unnecessary pre- caution in most diseases of the chest, as the frequent pre- sence of dyspnoea necessarily renders the respiration quick. The same is true of fever, and the agitation caused by ner- vous affections.
Many other causes, and especially the age of the indir yidual, alter the intensity of the sound. In children, respi-
AUSCULTATION. 73
ration is very sonorous, even noisy, and can be heard easily through very thick clothing. In them the close and forcible application of the instrument, to prevent the fric- tion of the garments, is unnecessary, as any noise that might arise from this cause is lost in the intensity of the other. The respiration of children differs, also, from that of adults in other respects besides its intensity. It is impossible to describe this peculiarity, but it will easily be understood by comparative trials. It appears as if, in children, we could distinctly hear the dilatation of all the air cells to their full extent ; whilst, in adults, these seem as if, from their stiff- ness, they could only bear a partial dilatation. This differ- ence of sound is much less marked in expiration than in- spiration. The dilatation of the chest in inspiration is also greater in the child, and both these peculiarities are more remarkable as the child is young ; they continue, in a greater or less degree, to the period of puberty or a little beyond it. Ti.e sound produced by respiration varies, also, very much in its intensity in different adults. In some men it is scarcely perceptible unless they make a very deep inspira- tion, and even then, although sufficiently distinct, it is not one half so audible as in the majority of persons. These in- dividuals have generally a rather slow respiration, and are little subject to dyspnoea, or breathlessness, from any cause. Others, however, have the respiration very sensible even during a common inspiration, without being, on this ac- count, at all more subject to shortness of breath than the former. Some few individuals, again, preserve through life a state of respiration resembling that of children, and which is therefore denominated puerile, in whatever age it may be perceptible. An adult cannot, by any effort, give to his respiration the sonorous character of childhood; but in some morbid states, the respiration spontaneously acquires it, without being, at the time, performed more forcibly than usual. This is particularly the case when one whole lungx
74 ON MEDIATE
or a considerable portion of both lungs, is rendered im- permeable to air through disease, especially acute disease. In the sound portion of the lungs, in these cases, the respi- ration is perfectly similar to that of children. The same thing is observeable throughout the whole extent of the lungs in some cases of fever, and in certain nervous diseases.
When we can distinctly perceive, and with a uniform intensity, the respiratory murmur in every part of the chest, we may be assured that there exists neither effusion into the cavity of the pleura, nor any species of engorgement in the substance of the lungs. On the other hand, when we find the respiration is not to be distinguished in any particular point, we may safely conclude that the corresponding portion of the lungs within, is become impermeable to the air from some cause or other. This sign is as easy to be perceived as the presence or absence of the sound, in the percussion of Avenbrugger, and affords precisely the same indications. With the exception of some peculiar cases, in which the si- multaneous employment of the two different methods gives us signs which are completely pathognomonic, — we may state it as a general fact, that the absence of the sound on percussion coincides uniformly with the absence of respira- tion, as ascertained by the stethoscope. Accordingly, this failure of respiration, existing in a greater or less degree, and over a greater or less extent of surface, is found to be a principal distinctive sign of Peripneumony, Pleurisy, Hy- drothorax, and all other diseases, which in any way obstruct or impede the natural action of the lungs.
The natural sound of respiration is further modified by being combined with other sounds, in certain morbid states of the lungs. These various modifications have been denominated the Rattle, and consist of four principal varieties.
1. The Crepitous Rattle. This bears some resem- blance to the crepitation of salt in a heated vessel, or to the sound emitted by healthy lung when compressed in the
AUSCULTATION. 7 5
hand, only stronger. This variety is the pathognomonic sign of peripneumony, in the first degree ; it exists also in oede- ma of the lungs, and sometimes in haemoptysis.
2. The Mucous Rattle. The dead Rattles of the vulgar is the extreme degree of this variety. It is produced by the transmission of the breath through fluids accu- mulated in the trachea or bronchia. It furnishes important indications in pulmonary catarrh, phthisis pulmonalis, haemoptysis, &c.
3. The Sonorous Rattle, This is more variable in its characters than the former species. In this, the sound, more or less deep, is sometimes extremely loud, resembling at different times, the snoring of a person asleep, the bass note of a musical instrument, or the cooing of the wood-pigeon. This variety is of inferior value as a diagnostic : it is usually produced by the partial obstruction or narrowing of a bron- chial tube.
4. The Sibilous Rattle, This is also varied in its cha- racter. Sometimes it is like a prolonged whisper of various intonation ; sometimes it is very momentary, and resembles the chirping of birds, the sound emitted by suddenly sepa- rating two portions of smooth oiled stone, or by the motion of a small valve. These different kinds often exist together in different parts of the lungs, or successively in the same part. The peculiar nature of the sound, and the appearances on dissection, prove the sibilous rattle to be owing to mi- nute portions of very viscid mucus obstructing, more or less completely, the small bronchial ramifications.
III. The Circulation, The action of the heart, as explored by the Stethoscope, is studied under three differ- ent relations, viz. of the Sound, Impulse, and Rythm.
1. Of the Sound, The alternate contraction of the different parts of the heart produces a peculiar sound, of which the individual is himself sometimes sensible during palpitation and in fever. In certain states of disease it can
76 ON MEDIATE
be heard at some distance from the patient ; but this is a very rare case.
In ordinary circumstances the stethoscope, applied between the cartilages of the fifth and sixth ribs, at the end of the sternum, &c., conveys to the ear a distinct sound, even where the pulse is very feeble, or imper- ceptible. This, in the healthy body, is double, and each beat of the arterial pulse corresponds to this double sound, in other words, to two sounds. One of these is clear and rapid, and somewhat resembles the sound produced by the valve of a pair of bellows : this corresponds to the systole of the auricles. The other is more dull and prolonged, co- inciding with the beat of the pulse and with the shock or impulse communicated to the parietes of the chest by the motion of the heart: — it indicates the contraction of the ventricles. The sounds heard at the end of the sternum are produced by the action of the right side of the heart; those between the cartilages of the ribs by the left cavities. In the state of health the sound produced by the contrac- tions of each side is the same.
The sound is the only phenomenon connected with the motion of the heart, usually observable in any other part of the chest beside the precordial; the impulse of its action being confined to that part.
The sound produced by the action of the heart is great in proportion as the parietes of the ventricles are thin and their impulse feeble : consequently, it cannot be attributed to the percussion of this organ against the side. In a mo- derate degree of hvpertrophia, the contraction of the ven tri- fles yields only a dull sound, like the murmur of inspira- tion, and the auricle, in like manner, a much less noise than in the uatural state. In a high degree of hvpertrophia, the contraction of the ventricles produces merely a shock with- out any sound, and the sound of the auricles is scarcely au- dible. On the other hand, when the ventricular parietes are
AUSCULTATION. 77
thin, the noise produced by their contraction is clear and loud, approaching to that of the auricles ; and if there be a marked dilatation of the ventricles, the sound becomes very smiliar to, and almost as strong as that of the auricles.
In the state of health the sound of the contractions of the heart is no where heard so strongly as in the cardiac re- gion : in certain states of disease it may be heard more dis- tinctly in other places.
The softening of the substance of the heart deadens the sound of its contractions ; as does also any impedi- ment of the circulation, whether caused by too much blood, or by an obstacle in the auriculo-ventricular orifices. This latter state, further, gives rise to a dull rustling sound, very like the noise of bellows, or (when stronger) like that produced by the action of a rile on wood. The particular orifice affected is, in this case, indicated by the place and time in which the sound is observed. When the orifice is on the left side, we can sometimes feel with the hand a sort of vibratory sensation like that produced by the purring of a cat. In this case, the noise produced by the contraction of the cavity having the obstructed orifice is not only dul- ler, but much more prolonged than in the natural state 5 insomuch, that the contraction of the auricles is sometimes three or four times slower than that of the ventricles, if the obstruction is in the auriculo-ventricular orifice. This phe- nomenon may be somewhat diminished in intensity by bleeding, &c. but cannot be altogether removed.
In a healthy person, of moderate fulness, and whose heart is well-proportioned, the sound of this organ is only perceived in the cardiac region, that is, in the space comprised between the cartilages of the fifth and seventh ribs, and under the lower end of the sternum. In thin persons, in the narrow-chested, and also in children, the sound is more extended; being perceptible over the lower third, or even three-fourths, of the sternum, and
7$ ON MEDIATE
sometimes even over the whole of this bone : also at the superior part of the left side, as high as the clavicle, and sometimes, though feebly, under the right clavicle.
When the sounds are confined to the places above mentioned, in subjects of the kind noticed, and when they are much weaker below the clavicles than in the region of the heart, we may conclude that this viscus is well proportioned.
When the sound of the heart becomes more ex- tended, it is heard successively in the following places : — 1st, the whole left side of the chest, from the axilla to the stomach; — 2nd, the whole of the right side; — 3rd, the pos- terior part of the left side of the chest ; and, 4th, the poste- rior part of the right side. This last is rare. In these cases the intensity of the sound is progressively less in the suc- cession mentioned.
When the pulsation of the heart is heard over a greater extent than what is above stated to be the range of sound of a well-proportioned organ, the individual rarely en- joys good health. If he has not formal dyspnoea, he has, at least, shorter respiration than usual, is put more easily out of breath, and is more subject to palpitation. This state, however, which is that of many asthmatics, may re- main stationary many years, and does not always prevent the attainment of an advanced age.
It may be taken as a general fact, that the extent of sound is in the direct ratio of the thinness and weakness of the heart, and, consequently, inversely as its thickness and strength. The size of the organ must also be consi- dered as affecting the extent of the sound.
When the sound extends over all the places above mentioned, we may presume that the heart is increased be- yond its natural size, and that this increase is owing to the dilatation of one or both ventricles. This presumption will be strengthened, if the sound is as great under the clavi- cles or in the axilla, as in the region of the Jieart. If
AUSCULTATION. *J9
it is perceived neither in the back nor right side, but only in the other points mentioned, and if its intensity is nearly equal in all these, we may conclude that the ventri- cles are moderately dilatated, and that the parietes of the heart are naturally thin. On the contrary, when there is a very strong impulse in the region of the heart, and very little or no sound under the clavicle, we may be assured (if the patient has other general symptoms of diseased heart) that the dis- ease is hypertrophia of the ventricles ; while, if he has never experienced any marked disorder of the circulatory organs, we may be certain that the parietes of the left ven- tricle, although very thick and firm, are still not sufficiently so to constitute disease. In these cases, of course a decided opinion will not be formed without considering all the other circumstances.
2. Of the Impulse. The degree of impulse commu- nicated by the cylinder to the ear, is, in general, inversely as the extent of the pulsation of the heart, and directly as the thickness of the walls of the ventricles. In a person whose organs of circulation are well proportioned, this impulse is very little perceptible, often quite imperceptible, especially if the individual is rather fat. When the parietes of the heart are unnaturally thick, the impulse is usually so great as very sensibly to elevate the head of the observer, and sometimes to give a disagreeable shock to the ear. The more intense the hypertrophia, the longer time the impulse is perceptible. When the disease exists in a high degree, we feel as if the heart, in dilating, first comes in contact with the thoracic parietes in one point only, and then with its whole surface, and that it contracts and falls back all at once. The im- pulse of the heart is only felt during the systole of the ven- tricles 5 or if, in some rare cases, an analogous phenomenon accompanies the contraction of the auricles, this is easily distinguished from the former. In fact, when the systole of the auricles is attended by any sensible impulse, this is
80 ON MEDIATE
perceived to have its seat much deeper ; and most commonly it consists merely of a sort of vibration^ In any case, it is very little marked as compared with the sensation produced by the contraction of the ventricles, when these are of a good degree of thickness.
When the parietes of the heart are thinner than usual, no impulse is communicated, even when the sound is the greatest ; and, in this case, the alternate contraction of its cavities is only distinguished by the sound these produce. A strong impulse, therefore, must be regarded as the chief sign of hypertrophia ; and the absence of all impulse as the characteristic of dilatation of the heart.
The impulse of the heart's action is usually perceptible only over the region of the heart, or, at most, over the infe- rior half of the sternum. When very great, it extends to the epigastrium in cases where the sternum is short. In simple hypertrophia it is usually perceived in no other part; but when this is conjoined with a certain degree of dilata- tion, it is sometimes distinctly perceived under the clavicles, and in the right side of the chest. The impulse of the heart's action is, of course, diminished by whatever debili- tates the general strength of the system.
3. Of the Bythm. By this term is meant the or- der of the contractions of the different parts of the heart, and the relative succession and duration of these, as per- ceived by means of the stethoscope. In a healthy and well proportioned heart, these are as follows :
At the moment of the arterial pulse, the ear is slightly elevated by an isochronous motion of the heart, which is accompanied by a somewhat dull, though distinct sound. This is the contraction of the ventricles. Immediately after, and without any interval, a noise resembling that of a valve, or a whip, or the lapping of a dog, announces the contrac- tion of the auricles. This noise is accompanied by no mo- tion perceptible by the ear, and is separated by no interval
AUSCULTATION 81
of repose from the duller sound and motion indicative of the contraction of the ventricles, which it seems, as it were, to interrupt ahruptly. The duration of this sound, and conse- quently the period of contraction of the auricles, is less than that of the ventricles. Immediately after the systole of the auricles, there is a very short, yet well marked interval of re- pose, subsequently to which we feel the ventricles swell anew, with the dull sound and gradual progression which characterise their action ; then follows the quick and sono- rous contraction of the auricles, and again the renewed but momentary immobility of the heart.
Hypertrophia of the ventricles, when in a moderate degree, presents in some respects, only an augmentation of the natural actions of the heart. The contraction of the ventricles becomes less noisy, and more readily dis- tinguishable from that of the auricles. After the latter, the interval of quiescence is well-marked, and contrasts very sensibly with the sound that precedes, and the motion which follows it. But in hypertrophia carried to a very high degree, the rythm of the heart is singularly changed. In this case, the contraction of the ventricles is greatly prolonged. This at first is perceived as a profound and ob- scure motion, which gradually augments, elevates the ap- plied ear, and then terminates in producing the impulse or shock. This contraction is unaccompanied by any noise, or, if this exists, it is merely a sort of murmur like that of respiration. The interval of repose no longer exists, or is lost in the commencing contraction of the ventricles. The con- traction of the auricles is extremely short, and almost, or al- together, without sound; and in some cases the systole of the ventricles seems scarcely over before they begin to swell afresh. In extreme cases there is no sound distinguishable but the murmur abovementioned, and we merely recognise an elevation of the heart corresponding to each beat of the
a
$2 ON AUSCULTATION.
pulse. In these cases the increased brevity of the auricular contraction is not the consequence of their diminished con- tractibility merely, but, also, of their contraction commenc- ing before that of the ventricles has entirely ceased.
When the walls of the left ventricle are naturally thin, or have become so from dilatation, the rythm of the heart's actions is quite different. In this case, the interval of re- pose after the contraction of the auricles is no longer per- ceptible. The contraction of the ventricles is more sono- rous, more resembling that of the auricles, and more ap- proaching the latter in duration. In this condition of the heart, there is, as already observed, a less degree of impulse during the contraction of the ventricles, and a greater ex- tent in the pulsation of the heart. This condition of the organ of circulation is congenital in many cases. It does not necessarily abridge life, but is usually conjoined with a de- licate constitution.
Actual dilatation of the heart produces merely an in- crease of all the characters which indicate a heart with thin parietes. The contraction of the ventricles becomes as short and noisy as that of the auricles ; the pulse, consequently, becomes very frequent ; and the isochronism of the arterial pulse and the contraction of the ventricles becomes quite undistinguishable. In addition to these signs we must add — the absence of any sensible impulse; the extension of the sound of the heart's pulsation over the whole or greater part of the chest; and the existence of this in as great force under the clavicles and the axilla as in the region of the heart itself. This last character, particularly, may be re- garded as pathognomonic, if the patient is not phthisical and pectoriloquous in the places mentioned.
END OF THK OUTLINE.
©age*,
WITH DISSECTIONS AND REMARKS;
ILLUSTRATING THE APPLICATION OF
THE STETHOSCOPE AND PERCUSSION
TO THE DIAGNOSIS OF
DISEASES OP THE CHEST.
La science du diagnostic tient le premier rang entre toutes les parties de l'art , et en est la plus utile et la plus difficile. Le discerneraent du caractere propre de chaque genre de maladie et de ses differentes especes , est la source des indications curatives : sans un diagnostic exact et precis , la theorie est toujours en defaut , et la pratique souvent infidele. Louis.
Nous ne cesserons de le redire : dans le diagnostic consiste toute la mede- cine ; sans lui il ne peut y avoir qu'erreur et que confusion. C'est la plus im- portante de toutes les connaissances mddicales. Toutes les observations n'aboutissent en derniere analyse qu'au diagnostic ; de lui seul decoulent les in- dications curatives fondees sur la raison. Sans lui l'humanit6 est en proie a l'empirisme aveugle, au hasaxd destructeur. Host an.
Si on ne les connait pas [les maladies du cocur] , on prononcera tem6raire- ment sur une infinite de cas ; on fatiguera les malades par des remedes nuisibles ou inutiles ; on hatera la mort en traitant de tels maux de meme que ceux qui sont entierement difFerens ; on sera expos6 a etre dementi honteusement par les ouvertures de cadavres ; enfin , le danger sera pressant quand on croira qu'il est £loigne. Senac.
Le but desirable cependant , l'unique but meme de la medecine pratique , doit etre , non pas de rechercher, par une sterile curiosity , ce que les cadavres peuvent offrir de singulier , mais de s'efForcer a reconuaitre ces maladies a de» signes certains , a des symptOmes constans. Corvisart.
CASES, WITH DISSECTIONS AND REMARKS.
CASE I.
Hypertrophia with Dilatation of the Heart. — Diseased Valves. — Dilatation of the Aorta. — Pt ripneumony.
Chichester Dispensary, May 24th, 1822. George Rogers, aetat. 30, Blacksmith, formerly hostler in an Inn. Has been ill about five months, the principal symp- toms being pain in the praecordia, indigestion, dyspnoea, palpitation of the heart, incapacity of lying in the horizon- tal posture, very bad and disturbed sleep, and (for the last month) much cough with mucous expectoration. He is extremely pale, and his whole surface leucophlegmatic. There is a very perceptible fulness and preternatural hard- ness in the praecordia. The pulse is extremely full, strong, and vibrating, and much fuller and stronger in the left arm than the right. The action of the heart is very great, and occasions a very obvious tremor of the head. [Hepatitis } Hypertrophia of the Heart? — V. S. Mercurial cathartics.]
28th. Examined very slightly and imperfectly with the Stethoscope. Action of the heart perceptible over the whole anterior part of the chest : the impulse very great, and the sound very loud and peculiar. [Evident Hypertrophia with enlargement of the Ventricles.] Has been bled twice with relief. Blood not at all inflamed. CEdema of the legs, [Laxatives. Infus. Digital.]
June 4th. Has been again bled, with slight relief, and has continued the Digitalis. Has been suffering greatly
86 BISEASES OF
from paroxysms of most violent pain, in the cardiac and pre- cordial regions, coming on suddenly and lasting some time. Has not been able to obtain any sleep for many nights. [Omit Digitalis. — Opium.]
24th. Anasarca extends over the lower limbs and abdomen. Cardiac symptoms as before. [Blue Pill. Squill. Potassae Supert.]
July 9th. Dispersion of anasarca under diuresis ; ptyalism.
16th. Pain in the region of the heart less, and palpita- tion less violent. Is gone into the country.
August 11th, and 15th. Examined with the Stetho- scope more particularly. Impulse of the heart's action is very great in the region of the heart, and is very percepti- ble, though in a less degree, to a considerable distance be- yond, viz. under the right clavicle, and over the greater part of the anterior of the chest : the sound of the heart's action is very loud in the region of the heart, and is very distinctly perceptible over the whole chest, before and behind, except on the lower part of the right side ; it is, however, much louder over part of the right side, especially under the clavicle and along the whole extent of the ster- num, than either in the region of the heart, or over the left side. The sound is much more perceptible when the stop- per of the instrument is removed ; it is thus heard to be ex- tremely loud under the right clavicle, and at the top of the sternum, and resembling the grating noise of a saw with fine teeth, or that produced by the forcible action of the piston in a large empty syringe.* It is much louder under the right clavicle than the left \ and it is also heard very dis-
* I noted down these comparisons at the time (as well as every other state- ment in*the case), but in summing up my diagnosis, it will be seen that I neg- lected to draw from them some very obvious conclusions, respecting the state of the valves of the heart,
THK HEART. S7
tinctly above the clavicles. In the action of the heart, as studied by the stethoscope, the sonorous contraction of the ventricles seems to occupy by far the greatest part of the whole space of time, — the contraction of the auricles, and the subsequent interval of repose, being extremely brief,. The impulse or shock of the heart's action is not synchro- nous with the pulse of the radial arteries. I am not sure that there is either swelling or pulsation of the jugulars; but there is a very perceptible tremulous motion of the whole throat, connected with the pulsatile tremor of the head for- merly noticed. Applied over the carotids, the stethoscope conveys a very loud sound, especially on the right side, on which the pulsation is much stronger, and accompanied by a jarring vibratory sensation scarcely perceptible on the other. The whole thorax in the region of the heart is very painful on pressure.
The sound of respiration is very indistinct over the whole chest, being drowned, probably, by the very loud sound of the heart. Percussion elicits a very dull sound in the region of the heart, and to some distance around; but over the rest of the chest the sound is natural. Pulse 100, regular, full and strong, but less strong than formerly.
The swelling in the praecordia is equable, and conveys the idea of a large solid body, like the liver, being suspended there, and hanging down nearly as low as the umbilicus : it seems to extend as far on the left side as the right, and is painful on pressure.
Diagnosis. Great dilatation of the right ventricle with slight hypertrophia ; and moderate dilatation of the left ventricle with very considerable hypertrophia : In other words : — Dilatation of both ventricles, — greatest of the right ; Hypertrophia of both ventricles, — greatest of the left. Dilatation of the Aorta ? Great enlargement of the left lobe of the liver.
88 DISEASES OF
Prognosis. Death.
From the date of this examination until his death, which took place on the 15th of October, this poor man suffered all the horrors attendant on an aggravated and in- curable disease of the heart. Totally incapable of bearing the horizontal posture, he remained, day and night, seated, generally in his chair, sometimes on his bed ; with the con- stant sense of the most distressing uneasiness, and occasion- ally of the most acute pain, in the region of the heart, — al- most entirely deprived of sleep, not daring to move for fear of inducing a paroxysm of pain and palpitation, — and anasar- cous over the greater part of the body. His only relief was from blood-letting ; and this was very frequently repeated. He took a variety of medicines, partly in hopes of relieving the original disease of the heart and liver, partly with the intention of removing some of the consequences of this, — the anasarca, the pain, and sleeplessness ; but with very little benefit, except from blood-letting.
At many different times during the course of the dis- ease, Rogers was affected with a very severe cough, with tri- fling expectoration, which would come and go, leaving him free from it for many weeks. In the end of September and beginning of October, this again became very troublesome, and the sputa were very viscid, and, for the first time, tinged with blood. About the same time, he was also attacked with a severe dysenteric affection, attended with a considerable discharge of blood by stool.
The last bleeding was on the 10th September, and the blood then drawn (16 oz.) like that of every preceding ope- ration, showed no sign of inflammation.
The body was examined 16 hours after death, by Mr. Wm. Guy, one of the surgeons of the Dispensary, and Mr. Dodds, his assistant, in the presence of Dr. Conolly, Mr. Tully, and myself. Before the dissection took place, J
THE HEART. 89
read to these gentlemen, from my case-book, the note of the Diagnosis transcribed above.
Dissection. The whole body extremely pale and moderately anasarcous.
Thorax. Pericardium of natural character, in every respect except size, and without any mark of inflammation, externally or internally; it contained hardly an ounce of se- rum. On laying it open, the heart presented itself of an immense size. To our judgment it appeared to be certainly more than double the natural size ; but it retained nearly the natural shape. From the apex to the root of the pul- monary artery it measured 7l> and was 13| inches in cir- cumference, near the origin of that artery and the aorta. The anterior part of the right ventricle was externally of a very pale colour, as if a thin layer of fat were interposed be- tween the muscular substance and its proper tunic. The veins and arteries of the heart were large, especially the for- mer, but quite sound. The muscular substance was through- out of the natural colour, and very firm. The parietes of the right ventricle were from § of an inch to \ an inch in thickness, and uniformly so. The cavity of the ventricle was