f>: iv;:. L ,.u v«an ivnoiivn sn i 3 10 3 w jo auvbb 11 ivno 11 vn 3 n i 3 1 a sw jo a»v »a 11 1 LHIIA.V OF MEDICINE NATIONAL LIBRARY OF MEDICINE NAT.ONAL LIBRARY OF * = ^ My % 4 3NI3I03W JO ABVH9I1 IVNOIIVN 3 f MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE t hyx i vu /v s F MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE r IVNOIIVN 3N I 3 I 0 1W dO All V Da II IVNOIIVN 3NI3I03W dO AHVDBI1 IVNOIIVN 3 F MEDICINE NATIONAL LIBRARY OF MEDICI NE N A T I O N A L I I B R A R Y O F M E D I C I N E I 5 /V 7s ^ \ IVNOIIVN 3NI3IQ3W dO AHVH9I1 IVNOIIVN INOIQ1W dO AIVIIIUVNOI1 VN r% r^ fer MANUAL FOR THE USE OF THE STETHOSCOPE. A SHORT TREATISE ON THE DIFFERENT METHODS OF INVESTIGATING THE DISEASES OF THE CHEST TRANSLATED FROM THE FRENCH OF M. CffLLIN. BY W. N. RYLAND, M. D. FROM THE THIRD LONDON EDITION ) WITH PLATES, AND AN EXPLANATORY INTRODUCTION, BY A FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY. Ham. Will you play upon this pipe ? Gv.il. My lord, I cannot—I have not the skill.—Shakspeare. V WF I fa? DISTRICT OF MASSACHUSETTS, to wit: DISTRICT CLERK'S OFFICE. Be it remembered, that on the fifteenth day of December, A. D. 1828, in the fifty-third year of the Independence of the United Stales of Ameri- ca, Benjamin Perkins & Co. of the said district, have deposited in this office the title of a book, the right whereof they claim as proprie- tors, in the words following, to wit: "Manual for the use of the Stethoscope. A short treatise on the dif- ferent methods of investigating- the diseases of the Chest. Translated from the French of M. Collin. By W. N. Ryland, M. D. From the third London edition ; with plates, and an explanatory introduction, by a Fellow of the Massachusetts Medical Society. Ham. Will you play upon this pipe? G-uil. My lord, I cannot—I have not the skill.—Shakspeare.'' In conformity to the Act of the Congress of the United States, entitled " An Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned ;" and also to an Act entitled " An Act supplementary to an Act, entitled an Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the au- thors and proprietors of such copies during the times therein mentioned ; and extending the benefits thereof to the arts of designing, engraving, and etching, historical and other prints." JNO. W. DAVIS, \ Chrkf$ the, Di^riet ' ( of Massachuse ts. PRINTED BY PEIRCE AND WILLIAMS. ADVERTISEMENT. In preparing for the American press the English translation of the well known and highly useful work of M. Collin, which translation has passed through three editions in England, the editor thinks he can ren- der it more acceptable by dispensing with the various prefaces and introductory remarks which encumber the last edition ; and by substituting in their place an entirely new introduction, which is intended to em- brace the amount of all that is important in the prefaces alluded to, as well as that which is contained in various abstracts and reviews which have appeared of treatises upon the different methods of investigating thoracic diseases, and in some other works which are not gen- erally before the profession in this country. INTRODUCTION. Auscultation, or investigating diseases by the sound is, an ancient mode of diagnosis. It is treated of by Hippocrates, and is, withal, so simple an idea as must have been very obvious to all observers of disease. But mediate auscultation, that is, hearkening by means of an instrument, was first promulgated as a discovery by ]M. Laennec in his elaborate work, De Vausculta- tion Mediate, in 1819. Before this period, the only idea attached to auscultation as a means of diagnosis, was that of applying the ear as nearly as possible to the seat of the disease. The inconveniences of this method are sufficiently obvious, and from this cause, as well as the uncertainty of the signs to be derived from it, it had fallen into merited neglect. " I was consulted," says M. Laennec,* "in 1816, by a young woman, who presented some general symptoms of dis- ease of the heart, in whose case the application of the hand and percussion gave but slight indications, on account of her corpulency. On account of the age and sex of the patient, the common modes of explo- ration being inapplicable, I was led to recollect a well known acoustic phenomenon, namely, if the ear be applied to one extremity of a beam, a person can, * Traite de l'aus. mid. torn 1. p. 7. VI INTRODUCTION. very distinctly, hear the scratching of a pin at the other end. I imagined this property of bodies might be made use of in the present case. I took a quire of paper which I rolled together as closely as possible, and applied one end to the precordial region ; by placing my ear at the other end, I was agreeably sur- prised at hearing the pulsation of the heart much more clearly and distinctly than I had ever been able to do by the immediate application of the ear. " I henceforward presumed this method might be- come very useful and applicable, not only to the study of the pulsation of the heart, but also to that of all those movements within the cavity of the chest, ac- companied by sound ; and consequently to the ex- ploration of the respiration, of the voice, of rattling, and perhaps even of the fluctuation of a fluid effused in the pleura or pericardium. " In this conviction, I commenced immediately at the hospital Neckar, a course of observations, which have resulted in the discovery of new signs, sure, for the most part obvious, easy to be possessed of, and suitable to render the diagnosis of almost all diseases of the lungs, the pleuras, and the heart, more cer- tain, and perhaps more circumstantial, than even the surgical diagnostic signs established by the aid of the probe or the finger." Medical experience, for the last ten years, has given abundant proof of the utility of the discovery of M. Laennec; and the discoverer has lived just long INTRODUCTION. vii enough to bring to perfection his method of diagnosis, to establish his own claims to the permanent gratitude of the profession, and to enrol his name high among medical philosophers. Although the Stethoscope is well thought of by most practitioners, yet it is intro- duced into practice by a very few only, and igno- rance, and prejudice, and perhaps in some instances, honest doubts have conspired to decry its use. But there never was a discovery of importance which had no objectors, and the negative testimony of all the rest of mankind, who do not apply the test of experiment, cannot outweigh the affirmative testimony of one com- petent witness who does do it. The Stethoscope has not wanted for admirers, and is as much in danger from indiscreet friends, as prejudiced opposers. It is at least so far received that a man may quietly use his Stethoscope as well as his stop-watch, and neither be called a quack or a conjurer, and if it be not so necessary to him as a telescope to the astrono- mer, or a compass to the mariner, yet if he will be at pains to carry it in his pocket and acquire a little readi- ness in its application, he may rest assured that he will obtain assistance in discriminating in many per- plexing cases of a class of diseases the most numer- ous and fatal of all those of a New England climate. " The actions going on in the chest are, the entrance and exit of the air in respiration, the voice, the mo- tion of the blood in the heart, and blood vessels; and so perfectly do all these declare themselves to a per- Vlll INTRODUCTION. son listening through the Stethoscope, that an ear once familiar with the natural and healthy sounds, in- stantly detects certain deviations from them. Hence this instrument becomes a means of ascertaining diseases in the chest almost as effectual as if there were convenient windows for visual inspection ; and when it is considered that a fourth or fifth part of the inhabitants of Europe, die of diseases of the chest, such as inflammations, abscesses, consumptions, drop- sical collections, aneurisms, and various affections of the heart and blood vessels, which require an appro- priate treatment, the importance of such a means may be truly judged of."* The use of the Stethoscope has become familiar to many of the most enlightened and distinguished practitioners of Europe. In England it is ordered to be used generally by the army surgeons, who are re- quired to report their observations; in this country it still remains a novelty. A correct diagnosis of thoracic diseases not only greatly involves the reputation of the practitioner, but in the highest degree, the safety and well-doing of the patient. The symptoms usually described as de- noting Hydrothorax, equally belong to certain forms of pneumonia; and what can be more widely differ- ent than the appropriate treatment of those two dis- eases ? It has been statedf " that no practical er- * Arnott's Elements of Physics, 2d edition, p. 488-9. t Dr. Groves' and Dr. Stokes' Medical Cases, in Meath Hos- pital. Dublin Hosp. Rep. vol. 4. INTRODUCTION. IX ror is of more frequent occurrence than the attributing to Hydrothorax, symptoms which belong to pneumo- nia. Numerous cases have been sent into the me- dical wards of the Meath Hospital, by practitioners who had named and treated them as cases of simple Hydrothorax; but in no instance have we found this diagnosis correct, and more than once have we suc- ceeded in saving the life of such a patient, by the bold use of the lancet, at a period of the disease when a reliance on antidropsical remedies alone would have been of no avail." But the case, the most common to the New England practitioner, which calls for ad- ditional means of discrimination, is that of diseases simulating pulmonary consumption, the scourge of our northern climate. We are called upon by an anxious sufferer to tell him if his disease admit of a remedy, or must be borne without hope. With what indus- try and perseverance then, should we educate our senses to the use of those methods of investigation, laborious and difficult though they be, which promise to enable us satisfactorily to resolve such a question. The following case, taken from a modern work,* is the best answer to one who asks what good is to be derived from the diagnosis of consumptive diseases. " M. Laennec was consulted, in the case of a gentle- man, who was supposed to be dying from Phthisis Pulmonalis, and in a state so desperate that he was * Observations on M. Laennec's Method, &c. &c, by Charles Scudaraore,M.D. F. R. S. 1826. X [INTRODUCTION. not expected by his medical attendant to survive more than two or three days. M. Laennec made his usual investigation, and persuaded himself that the case had been mistaken, and that the alarming symp- toms did not arise from ulceration of the lungs, but from empyema or purulent collection within the pleura. He strongly recommended that the operation for this disease should be performed ; and after a little hesi- tation and delay, his advice was adopted. A large quantity of pus was evacuated, and immediate relief was afforded. The amendment was rapid, and the progress of cure so favorable, that the gentleman re- covered his health in less than three months." It is especially desirable in the diseases of the chest of in- fants, who cannot communicate their sensations by words, that we should employ those means which may make their symptoms obvious to our senses without the aid of language. Auscultation, therefore, may be looked upon as a most desirable mean of investiga- ting these diseases. Percussion and auscultation are intimately con- nected, and should be studied and practised together. Corvisart was the first to introduce into general notice the employment of percussion, by his translation and notice, in 1808, of the writings of Leopold Avenbrug- ger, a native of Graets in Styria, published in 1761. This operation consists in striking upon the walls of the thorax, and the sound returned will of course be modified by the state of the viscera of this cavity, so INTRODUCTION. XI that to a person accustomed to the sounds afforded by percussion of the thorax in a state of health, the deviations produced by disease will be sufficiently ob- vious. The sound is obtained with more distinct- ness, when the lungs are most distended with air, as during inspiration. The best mode of performing percussion is to place the ivory cup, which is annex- ed to the end of the most approved form of Stetho- scope, flat upon the part, and apply a light quick stroke of the fore and middle finger. Every part of the chest may thus be examined, directing the patient to draw in his breath, and retain it while you apply the stroke of percussion. The advantage of the cup is, that you occasion less pain and fix with more cer- tainty the exact spot which yields any unnatural sound. The Stethoscope, as it was first used by Laennec, hardly needs a description. It is a simple cylinder of wood perforated in the middle, and used sometimes with a funnel shaped extremity, and sometimes with- out it; the change being made by putting in or taking out a conical plug, at the end of the instrument which is applied to the chest. It should be made of some fine grained, light wood, such as cedar or maple. The plate at the end of the volume, sufficiently explains the common form of the instrument; the principal ob- jection to which is, that it is too large to be a conven- ient inmate of the coat pocket. A more portable in- strument is one which the editor has found to answer all the purposes of Laennec's first Stethoscope, and is xii INTRODUCTION. little more than half as long, and instead of being cyl- indrical, is trumpet shaped, with a circular rim, or ear piece, to be screwed upon the small end, when the instrument is used. It has also affixed to it a plate of ivory, which is the pleximeter of M. Piorri, (mentioned page 19) and is employed to prevent the pain of the stroke in percussion.* As is to be ex- pected the ear must undergo tuition in practising with the Stethoscope, and the natural phenomena must be studied with great care before the morbid alterations can be perceived. A beginner should, therefore, not give up in despair, because his first trials are abortive. A very skilful observer has asserted that it required two days study for him to perceive the murmur of re- spiration, one of the most obvious of the healthy phe- nomena. In exploring the movements of the heart there are several circumstances which give a great value to the signs derived from auscultation. It is obvious that all the knowledge we obtain from the examina- tion of the pulse at the wrist, is merely as to the mode of action of the left ventricle of the heart, and that in diseases of the heart, the practical value of auscultation, which informs us of the movements of both ventricles and both auricles, must be greatly before that of the ex- amination of the pulse at the wrist. For it is pathogno- mic of some affections, that the action of the heart, and * This form of the Stethoscope may be obtained at the pub- lishers. INTRODUCTION. X11I the fulness and strength of the pulse, are in inverse proportion to each other. It has been proposed to use the Stethoscope for the diagnosis of other diseases than those of the thoracic contents. Laennec proposes its use in investigating the diseases of animals, and Lisfranc has applied it with success to distinguish the crepitus of fractured bones. May it not be resorted to with advantage to ascertain the force of the heart's contraction in cases of severe flooding, and thus assist in deciding upon the disputed question of transfusion? The editor has witnessed a case in which, at a period of danger- ous exhaustion from this cause, the heart's impulse, as perceived by the Stethoscope, was unexpectedly strong and distinct, and essentially contributed to in- spire confidence in a favorable prognosis. The following are rules useful to be observed in the management of the Stethoscope. 1. To procure stillness in the room in which the patient is placed, although to long practised ausculta- tors, this precaution is in part unnecessary. Laennec repeatedly asserted that his organ of hearing was so adjusted to distinguish minute difference of sound, that he could, at the same time, observe the move- ments of the heart—the noises produced during re- spiration by air, mucus, he. in the lungs, and in the stomach and intestines ; the noise of his own, and the patient's movements ; and all this, while his students wore moving and whispering round him. XIV INTRODUCTION. 2. The Stethoscope is to be used without the stop- per, in exploring the phenomena of respiration, and the different rattles; and with it, to examine the cir- culation, and the voice. 3. It is not necessary that the part to which the Stethoscope is applied should be uncovered, but only that the covering be not too thick, be perfectly smooth, and not of a kind to produce a rustling noise, as silk or worsted will do. 4. The instrument must be applied perpendicu- larly, and so retained on the chest as to fit and press equally on every part, and at the same time the ear should be applied to the other extremity so as to ex- clude the external air, the hole of the cylinder being opposite the meatus auditorius. 5. In examining the respiration, the patient should be directed to respire a little more rapidly than natural, without creating a sound more audible than usual at a distance. In examining the voice, he may count aloud, slowly, in a natural tone of voice; and for ex- ploring the different rattles, the patient should be di- rected to cough occasionally. 6. The observer should be careful not to place him- self in a constrained position, and for this purpose it is often convenient to rest upon one knee. Salem, Nov. 1, 1828. CONTENTS. PART I. Chapter i. Page Examination of the movements of the Chest in Respiration, - 1 Respiration in Health, ....... 2 ---------in Disease,........3 Chap. ii. Of Percussion,.........13 ----------- in Health,........14 ----------- in Disease, ....... 19 New Method of Percussion, - -.....19 Chap. hi. Of Auscultation, --------- 23 Natural Phenomena furnished by the Respiration, 28 ------------------------by the Voice, - - - - 31 ------------------------by the Heart, ... - 33 Pathologic Phenomena, ...---- 38 ------------------furnished by the Respiration, - - 38 -------------------------by the Voice, - - - 47 ------------------------- by the Heart, - - 64 Of Mensuration,......- -77 Of Succession,........ 81 XV CONTENTS. PART II. Chapter i. Of Diseases of the Pleura and Lung,.....83 Comparative value of the various modes of examination, - 83 Of Pleurodynia,.........87 — Pulmonary Catarrh,.......88 — Pulmonary Apoplexy, -.......90 — GEdema of the Lung,.......91 — Emphysema of the Lung, .---..-92 — Pneumonia, --......- 95 — Empyema and Hydrothorax, .-..-- 101 — Pleurisy,.........101 — Pulmonary Phthisis,........106 — Gangrene of the Lung,.....- - 110 — Pneumo-thorax, .......-Ill Chap. ii. On the Diseases of the Heart, -.....lit Diseases characterized by the alteration of the shock, - - 124 Hypertrophy,.........124 Hypertrophy of the left Ventricle,......125 ---------------right ventricle,......125 Disease characterized by alteration ofthe Sound, ... 126 Dilatation of the Heart,........126 Diseases characterized by alteration of impulse and sound, - 127 Dilatation with Hypertrophy,.......127 Contraction of the Orifices of the Heart, .... 128 Softening of the Heart,........128 Aneurism of the Aorta, -.....- 129 On the use of the Stethoscope in Internal Aneurism, - - 130 In Pericarditis, and Hydropericardium, - 131 A TREATISE, • &c &c. PART I.—CHAP. I. Examination of the Movements of the Chest in Respiration. Respiration, like digestion, is a function, which, according to the ingenious idea of Professor Chaussier, requires the taking in of a foreign substance, by the action of volun- tary* muscles; it is divided into two acts, inspiration and expiration. Inspiration is the movement by which the thorax, separating its walls, augments its in- terior capacity, allowing the air to enter into * Though correctly translated, the statement ap- pears erroneous ; the muscles of respiration, although sometimes aided by voluntary efforts, performing their office independently of the will, as in sleep, &c. 2 STATE OF RESPIRATION IN the lungs ; expiration is the return of the walls to their former state. These movements are always free and easy, so long as no obstacle exists to their perfect exercise; an affection of the lung, or of the cavity which contains it, will always induce an alteration, generally to be recognized with- out difficulty. These alterations must be known, but it is first better to give an idea of respiration in the healthy state. SECTION I. In a healthy man, unagitated by passion, inspiration and expiration should be perform- ed slowly, without violence and without any muscle seeming to make a painful effort to produce them : they succeed each other with regularity : their rhythm is constant and uni- form ; all the ribs rise, and dilatation and contraction are equally marked on each side, except in case of deformity of the thorax. The succession of the movements is more or less rapid in different individuals ; in general there are from fifteen to twenty respirations in a minute, and of each five DISEASES OF THE CHEST. 3 respirations, one is observed to be stronger than the others. In children, women, and weak individuals, the frequency of respiration is greater. The passions, exertion, or repose, the will, the qualities of the air, cause a variation in it every instant; during sleep it is slower and deeper. Respiration may be effected by the inter- costal and other inspiratory muscles, and is then thoracic, or it may take place by the action of the diaphragm alone, and is then said to be abdominal. Some authors affirm, that during the waking state, it is the dia- phragm which contributes most powerfully to this act, and the intercostals during sleep. SECTION II. In disease, the movements of the thorax may offer many varieties, which we shall re- late in the following divisions. They may be either frequent or rare, quick or slow, regular, or irregular, great or small, equal or unequal, easy or difficult, complete or in- complete ; finally, respiration may be either abdominal or entirely thoracic. 4 PECULIARITIES OF RESPIRATION To observe these different alterations well, the patient should be made to sit, if his strength will allow of it, in order that no- thing may obstruct the muscular motions which assist respiration; the arms should hang freely and the thorax should be un- covered; but usually these precautions are not required. 1st. Considered relatively to the number of inspirations and expirations in a given time, respiration infrequent ox rare; frequent, when, in an adult, more than eighteen or twenty respirations occur in a minute ; rare, when a less number occur. This frequency is natural to children, to women, and persons of a sanguine tempera- ment ; in warm climates; in summer, when the air being more rarefied contains less oxy- gen in a given quantity; and after exercise, or great emotion. It also occurs independent of all thoracic affection, in verminous complaints, in the spasmodic, and all the pyrexial diseases. The respiration is usually observed to be rare only in soporose and hysteric affections, and the latter moments of life. IN DISEASES OF THE CHEST. 5 A pain in the thorax; an obstacle to the free passage of the air through the bronchia ; every alteration which renders a part of the pulmonary tissue unfit for respiration, are the causes of increase of frequency; suspension of the nervous influence, debility of the muscular powers, are the causes of increased rarity. 2d. Respiration may be quick or slow. It is quick when the movements of inspiration are short, rapid, and abrupt; slow, when they are long and gradual. Quick respiration is usually united with frequent respiration ; it is then termed accelerated; this may be carried to panting. Quick respiration is sometimes combined with the rare in robust subjects, in acute diseases, and in the latter moments of life. Vivacity of respiration appears to depend on the same causes as its frequency. Its slow- ness is observed in the same circumstances as its rarity, which it often accompanies and depends on the same lesion. 3d. When the inspirations and expirations follow each other at equal intervals, respira- tion is said to be regular; it is irregular when these intervals are more or less prolonged in *2 6 PECULIARITIES OF RESPIRATION IN relation to each other; intermittent, when one or more inspirations supervene late or not at all; interrupted, when the expiration seems to take place before the inspiration is finished. These different modifications occur in the phlegmasia? of the thoracic and abdominal cav- ities, and particularly in nervous affections. The causes above enumerated may produce them. 4th. Respiration is said to be great in those cases in which an inspiration, either slow or quick, attended with a full expansion of the thorax, succeeds an entire perfect expiration. It is small, when the dilatation is scarcely sensible. We thus see that the respiration is not large when the thorax remains expanded, the in- spiration not being followed by a full expira- tion. So in peripneumony, the respiration is frequent, quick, and small, although the chest is completely expanded; this is called a high respiration. The large and rare respiration constitutes the sublime; it rarely accompanies affections of the air passages; it is more usual in cere- bral fevers, on the approach of phrenitic de- lirium. DISEASES OF THE CHEST. / The smallness of the respiration is more usually indicative of thoracic affection, or lesion of the thoracic parenchyma. M. Landre Beauvais has called that respi- ration great or large, in which much air is inspired, and that small in which little is taken in. As I examine the respiration in relation to the movements of the chest, I have con- sidered it necessary to give the same name to a different phenomenon, but one which fre- quently coexists with that noted by this learned professor. 5th. Respiration is equal, when inspiration, whether great or small, quick or slow, is fol- lowed by a similar expiration; unequal, when one or other of these movements is stronger or more prolonged. Adynamic and ataxic fevers, most spasmodic affections and asth- mas, offer examples of it. This inequality is a constant symptom of pleurisy and acute pneumonia. When the pleura is inflamed, inspiration is quick ; expiration, although short, appears long as compared to inspira- tion ; the seat of the pain in this complaint easily accounts for this phenomenon. 8 PECULIARITIES OF RESPIRATION When the phlegmacy occupies the lung, it is the expiration, on the contrary, which pre- sents this brevity, the affected organ being by this painfully compressed: in this case the thorax seems always raised. The high respiration, which we have al- ready said to be a symptom of this affection, depends on the difficulty of expiration. 6th. Respiration is said to be easy, when the muscles destined to produce expiration (inspiration ?) are sufficient, and execute this movement without difficulty; it is difficult, when the large accessory muscles are called into action, or, when the properly inspira- tory muscles contract with violence, or as if convulsively. Simply inspecting the neck, enables us to recognize this difficulty of respiration; the hard projecting scaleni, im- press shocks on the lateral parts of the neck, easily distinguished. The intercostals exhibit the same in thin persons. This state has different degrees : thus the respiration may be simply difficult or laborious, or it may be suffocating. In the last case, the patient threatened with suffocation cannot keep the horizontal IN DISEASES OF THE CHEST. 9 posture; sitting and bending forwards, he forcibly presses his head upon his raised knees, seeking a firm support for the hands, and thus fixing the upper extremities, forcibly contracts the muscles of respiration, of which every effort is concentred on the thorax to to dilate it fully. To this variety of respiration the name of orthopnea has been given; it is common in paroxisms of asthma, and becomes sometimes habitual in persons affected with emphysema of the lungs. The convulsive respiration, a common symptom in the different diseases comprehended under the term asthma, may be referred to difficult respiration. M. Pas- cali has lately communicated to the Academy of Medicine observations upon the employ- ment and utility of galvanism in those cases. It would appear from his experiments, that this convulsive state of the respiration, de- pends rather on an alteration of the vital powers of the nervous system, distributed to the muscles of the thorax, than on that of the lung itself. The chief part of the thoracic and a great number of abdominal diseases, render the 10 PECULIARITIES OF RESPIRATION respiration difficult. Thus every obstacle to the entrance of air into the lung, or to the dilatation of the thorax, whether existing in the cavity or not, may induce difficulty of respiration. 7th. I call that respiration complete in which the lungs of both sides concur equally; it is characterized by equality of force and extent in the movements of the thorax. I call that incomplete, in which one side remains wholly or in part immoveable, or moves less than the opposite one. This sign is among the most certain and constant of all those furnished by the exam- ination of the movements ; it belongs almost exclusively to diseases of the organs of this cavity: it is sometimes sufficient to point out pleurisy or peripneumony in infants; it will enable us in all cases to dispense with the tedious questions, and fatiguing and useless researches, by pointing out the seat of the disease. It depends at one time on a phlegmacv of the lungs, at another on an effusion; a simple pleurodyne may also produce it. It is not rare to meet individuals who present it al- IN DISEASES OF THE CHEST. 11 though enjoining perfect health, but it is then the result of preceding disease, which has pro- duced numerous and close adhesions between the coats of the pleura. It may depend perhaps as much on the tissue of the lung being imper- meable to the air, as on those adhesions. 8th. We have mentioned that variety of re- spiration, of which the term abdominal alone gives an idea. The belly rises in inspiration, sinks in expiration, and the ribs execute no movement. This phenomenon is observed when both sides of the lungs are become unfitted for respiration ; it is among the worst symptoms, and is usually a forerunner of death. How- ever, the respiration becomes naturally ab- dominal in very old persons, owing to the ossification of the cartilages of the ribs, which opposes the action of their muscles, already weakened by age. 9th. Thoracic respiration, effected by the elevation of the ribs, without the assistance of the diaphragm, is observed in all cases of intense extensive inflammation of the abdo- minal organs, or when this cavity is distended by the produce of conception, or other acci- dental production. 12 PECULIARITIES OF RESPIRATION. Such are the changes that take place in the movements of the thorax in relation to their rhythm, their extent, facility, and simultane- ousness. The other modifications of the respiration relate to the qualities of the air expired, or to the noise it produces, either in entering the thorax, or escaping from it. We shall speak of them elsewhere. CHAP. II. Of Percussion. SECTION I. This mode of investigation, proposed by Avenbrugger, and brought to perfection by Corvisart, was for a long time the only one in practice, and with experienced practition- ers contributed much to the certainty of diagnosis in diseases of the chest. Since the discovery of auscultation, it has lost none of its advantages; and it would be an error to suppose that the assistance of the stetho- scope renders its use unnecessary. The cavity of the thorax, which in the healthy state is almost entirely filled by the lungs, and always more or less distended by air, returns a sound when struck, very simi- lar to that of an empty barrel. (This com- parison, though inexact, is the most correct 3 14 OF PERCUSSION IN I have been able to find.) The word percus- sion has been applied to the means employed to ascertain the nature of this sound. The sound returned by the chest when struck upon, is always proportioned to the capacity of this cavity, and to the thickness and elasticity of its walls, but has not the same character at all points. It varies, 1st, According as the part is covered by thick and fleshy integuments ; 2d, According to the degree of leanness, of fatness, or of infiltra- tion* of the subject; 3d, According to the posture of the patient ; 4th, According to the manner in which percussion is practised. All these varieties should be well known in a healthy subject, to enable us to appre- ciate the changes arising from disease. 1st. According to the Points of the Chest struck upon. A clear sound is obtained when- ever we strike upon a bony part covered by the skin only, or by thin muscles sufficiently stretched to transmit the shock wholly, with- out absorbing any of the sound. The most * The anasarcous state of the integuments of the chest. DISEASES OF THE CHEST. 15 favorable parts are, anteriorly, the clavicles, when they are not too much elevated and raised from the thorax ; the space lying two or three inches below them ; all the surface of the sternum, and the parts nearest the carti- lages of the ribs. In the remaining anterior part of the tho- rax, the mamma in females, the fat which covers over the middle and inferior part of the pectoralis major in many men, the vicinity of the liver on the right, and of the heart on the left, diminish the sonorousness natural to the thorax. Upon the sides we may strike with advan- tage, in the hollow of the axilla, and three inches below it ; but from the fourth and sometimes the third rib downwards, the sound is always less clear on the right, owing to the neighborhood of the liver; while on the left, it is often louder than it ought to be from the proximity of the stomach, particularly when that viscus is much distended by air ; the resonance then becomes something metallic. Behind, the most distinct sound is perceiv- ed along the costal angles. In thin persons we may percuss usefully on the supra and infraspinal hollows of the scapulae, and upon 16 OF PERCUSSION IN the spine of that bone, but we cause no sound in striking upon the fleshy layer of muscles which fills up the vertebral hollows. 2d. According to the Leanness, Fatness, or Infiltration of the Subject. It is evident that, all other things being equal, the chest will be more sonorous in thin subjects than in those overburdened with fat, and that it will return no sound in patients the parietes of whose thorax are anasarcous. „ 3d. According to the Posture of the Patient. The more the thorax is separated from all around, the less will the sound be altered ; we should not then percuss when the chest is covered with clothes, or sunk in a soft bed or pillows. When we examine the anterior part, the patient should be seated with his arms carri- ed backwards. He should raise them above his head when his sides are examined, and cross them over his breast, at the same time arching his back, while we examine that part. These different positions stretch the muscles which cover the thorax. It is not always pos- sible to place patients in those positions : when such is the case we make them lie flat DISEASES OF THE CHEST. 17 upon the back, and raise the arms over the head, while we examine the lateral and ante- rior parts of the thorax; but the results thus obtained are always less striking and less certain. According to M. Laennec, the smallness of the alcove, and the narrowness of the chamber, alter the quality of the sound. 4th. According to the mode of performing Percussion. This operation, apparently so simple, requires a number of precautions to be truly useful. We shall point out the best manner of proceeding. We should close and bring together all the ends of the fingers half bent, or we should form them upon the same line, so that one may not project beyond the other. We should then strike with an equal and moderate force upon similar parts, in the same direction and extent, making the ends of the fingers fall perpendicularly to the plane upon which we strike. Too strong percussion would be painful; an unequal one would give an unsatisfactory result. It would be the same if we struck dissimilar parts, as a rib and an intercostal *3 18 OF PERCUSSION IN space ; if the fingers inclined perpendicularly on the right, obliquely on the left side; on a space double or triple the extent on one side to the other, since each of these variations must necessarily modify the sound. It is also necessary not to examine all the points of one side before passing to the other, because we thus lose the remembrance of the results ob- tained in corresponding points ; it is better to strike first on one side, and then on the other. To fulfil all these conditions, none of which are superfluous, we must strike as much as possible with the same hand, and place it in the same direction relatively to the part struck. Percussion with the hand extended has sometimes advantages, whether we wish to know the sound of a great part of the thorax, or to ascertain that the walls of this cavity are too thick to answer otherwise. But we must not let the air confined between the hand and the thorax, produce a sound capa- ble of masking that of the thorax itself. Further, we should leave the hand applied to the thorax to feel if the trembling motion resultmg from the elasticity of the lungs ex- DISEASES OF THE CHEST* 19 ists, or has ceased to be produced. Slight blows with a stethoscope, or other solid body of convenient form, are often the best means of producing appreciable sounds.* SECTION II. In the state of disease, the sound returned by the thorax is often altered. These alte- rations are four in number. The sound may be dull, obscure, absent, or more clear than natural. The names point out the nature of these alterations ; it remains only to explain their causes. * A new method of percussion has lately been pro- posed by M. Piorri, which consists in making the per- cussion upon a circular piece of wood or ivory, a line in thickness and an inch and a half in diameter, with a small handle to keep it in its place. The advanta- ges of this method are said to be, that by it we obtain a louder sound, insomuch as the operation may be per- formed through the clothes; that we can employ a greater force, and employ a more sonorous body than the fingers; that we can select more accurately the point to be percussed, and protect the parts better from the effects of the blow. Some persons use the stethoscope as a hammer in making percussion ; but it is ill adapted for this use, and is apt to bruise the parts struck. 20 OF PERCUSSION IN Every time the lung loses its elasticity and becomes engorged, without however becom- ing totally impermeable, the sound becomes dull or obscure, according as the engorging of the pulmonary tissue is more or less consider- able. Thus then an intense catarrh*, the first degree of pneumonia, an oedema of the lung, produce this alteration. The sound becomes wanting in two cases ; 1st. When the lung loses its permeability completely, its tissue becoming dense, like the substance of the liver, in consequence of an abundant exhalation of blood into its areolae, and of the combination of this liq- uid with its tissue. 2d. When it is compres- sed, thrust back by some accidental produc- tion, developed in its thickness, or in the cav- ity of the pleura, or when this cavity is filled by some fluid. In either case, a greater or less part of the side affected may be yet sonorous, according as the hepatization, the accidental tumor, or the effusion, are more or less considerable. Finally, the sound will acquire a greater in- * Catarrh has the same meaning in France, as Bron- chitis in England.—Trans]. OF PERCUSSION IN. 21 tensity than in the natural state, when the pulmonary tissue becomes as it were rarefied, or when the cavity of the pleura is occupied by air, or other gaseous body. If I have not spoken of percussion upon the precordial region, in cases of disease of the heart, it is because it is rare to meet cases of hypertrophy considerable enough to deter- mine perfect dulness of sound; and that in cases where the sound is simply obscure, we can conclude nothing from it, from inability to establish a comparison between this part and that of the opposite side. This remark is correct, if we have yet had no opportunity of seeing and percussing the patient; but if we can compare his present with his former state, and thence observe some difference in sono- rousness percussion then offers valuable signs, very useful in the diagnosis. The signs furnished by percussion are of great importance ; we must not however de- pend on them always ; it may happen that the sonorousness of the chest may be altered by causes foreign to the organs of the cavity. Thus every large tumor in the abdomen, pregnancy, ascites, diminish the sonorousness, 22 DISEASES OF THE CHEST. and contract the thoracic cavity, thrusting up the lungs; but no cause, entirely indepen- dent of the pectoral organs, can produce a complete loss of sound. CHAP. III. Of Auscultation. The word auscultation is applied to the examination, by means of the ear, of the dif- ferent sounds produced in the interior of the thoracic cavity, by the circulation of the air, the resounding of the voice, or the palpitation of the heart. It is either mediate or imme- diate. Immediate auscultation, is that in which the ear is applied naked to the different points of the chest. Inconvenient and disa- greeable to the patient, it is besides far from giving the results that it seems to promise. The sounds it yields, have never a perfect clearness; transmitted through the whole surface of the head, which is in contact with the breast, they have too much force to allow us to appreciate justly their shades, and they are all so confounded, that it is difficult to 24 OF AUSCULTATION IN distinguish the parts from which they pro- ceed. It is difficult, besides, for the head to fol- low the different movements of rising and falling of the chest; and the friction of the clothes adds still to confusion. In fine, although it may be good in some cases, it is not applicable to all; the ear can- not be placed upon all parts of the thorax, particularly in women, with whom decency alone would suffice to prohibit this mode. The inconveniences which have prevented us from having recourse to this method, and which have retarded the discovery of a means, simple and easy in its execution, and which M. Laennec has demonstrated to be so fruit- ful in the results, so advantageous, I may say so necessary in the practice of physic, are without doubt numerous. If this learned professor was indebted to a happy chance for his first ideas of it, he soon recognised the immense advantages this means might procure ; he anticipated its im- portance, its utility. To invent an instru- ment, proceed to a long series of researches, collect numerous observations in minute de- DISEASES OF THE CHEST. 25 tail, verify by inspections the diagnosis for- med at the patient's bed-side, arrange facts, seek the most probable explanation of the phenomena daily presenting themselves, pub- lish a work to which the repeated experiments of the numerous partisans of his method can scarcely add a few pages,—was to him a labor of only three years. I shall not here describe the stethoscope ; * it is too well known to require a particular detail. It is sufficient to say, that M. Laen- nec has determined by numerous experiments, that the cylindric form is best; that it is ne- cessary to make use of wood, neither too light nor too dense, in the formation of the cylin- der ; that it should be a foot long, fifteen lines in diameter, and its canal three lines; that one of its ends should be hollowed out in a conical form, and have a stopper adapted to it to be used when necessary. To make use of the stethoscope, it should be held as a writing pen, the ends of the fin- gers closed upon the instrument, so as to feel * From \- >&&-; i l Vf V ^ , „N0.1VN 1NI9I0IW JO AIVIII1 IVNOIIVN INIJIOIW « il»Hll l»NOU»N JN 1 IVNOIIVN 1NI3I01W10 AIVIII1 IVNOIIVN 3N IDI 0 3W 30 A»V * 9 11 1 VN O I 1 V N 3N M,^/ vXlx/ . * V "N i / V * 3FMI0ICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE N. 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