The principles and practice of medicine

Front matter

at'f

WixlxMX^ 0f ^ongvr^si.

TOTI'IED STATES OF AMERICA.

Preface To The Second Edition

When this Work first appeared, it had to compete with several long established favourites, and to encounter some deeply-rooted prejudices on the part of men who strongly dissented from Dr. Elliotson's views on certain subjects. In spite of these obstacles, however, its reception has been more flattering than we dared to anticipate. The first impression was rapidly exhausted; it became the favourite class-book in the majority of our Medical Schools; and even those who were formerly strongly prejudiced against it, have since acknowledged the practical information they have derived from its perusal. All this is highly satisfactory; and were any additional proof of its sterling worth required, it would be furnished by the fact that the Germans have published a translation.

In entering on the task of preparing for publication a Second Edition, we have been stimulated by the success of the first to fresh exertions, in order to render it (if possible) still more worthy of the approbation it has received. With a view to the accomplishment of this object, we have ventured on making certain additions and alterations; which, without materially increasing the size of the book, will (as we believe) materially enhance its value. Much care and discrimination were necessary in making these additions,— both as to the materiel to be selected, and the mode of its insertion; otherwise the book would have been injured, rather than improved. We have therefore been careful only to remedy obvious deficiencies, and to make such other additions as more recent researches had rendered necessary. The sources whence this supplementary matter has been taken are various; but we have of course been guided, to a great extent, by public opinion; — making our selections from those works which seemed best entitled to our confidence, for their general accuracy and soundness of doctrine. For the purpose of rendering these additions as useful as possible, it has been deemed advisable to insert them within brackets, in the text; taking care, however, to preserve the continuity of the whole; and to acknowledge, in a foot-note, the source whence each quotation was derived. Some other illustrative extracts, often very interesting in a literary point of view, and all bearing on some medical observations in the text, have been inserted as foot-notes.

The alterations that have been made, though few, are such as have

VI PREFACE TO THE SECOND EDITION.

been dictated by a desire to consult the convenience of the Reader. The subjects have been grouped together, in conformity with Dr. ElUotson's own views; and divided into Parts, Books, Chapters, and Sections. Page-headings and side-titles have been introduced; and, together with a copious Index, will (it is hoped) enable the Reader to refer to any particular passage with perfect ease.

These are the alterations we have deemed it necessary to make. In the performance of our task, we have been actuated (at every step) by a sincere and ardent wish to render the volume worthy of the reputation which Dr. Elliotson has so justly acquired, both as a teacher and Physician. In working out this design, we have received every assistance from the enterprising publisher, who has spared no expense either in the literary or the printing department; — being anxious to raise this distinguished member of his series of Medical Text-Books to a degree of excellence commensurate with the favour it has received. Whatever approbation or censure may be bestowed on our labours as Editors, we feel quite certain that the valuable materials contained in this book, will always meet with the respectful consideration due to genius and industry, when directed to the alleviation of human misery.

PEEMCE OF THE AMERICAN EDITOE.

. In the last London edition of Dr. Elliotson's Lectures, numerous additions have been made, with the view of giving to the work the character of a complete Treatise on the Practice of Medicine, suited to the purposes of a text-book. Most of these have been retained, whilst at the same time the work has been still further enlarged. In particular, it has been thought necessary to give a more extended space to the consideration of Remittent and Yellow Fevers, which, as the reader will observe, are but cursorily treated of by Dr. Elliotson. A separate article, by the American editor, has therefore been devoted to each of these affections. His other additions, with the exception of a few foot notes, are included within brackets, and bear his initials.

T. S.

Philadelphia, October 18, 1843.

Pago

Dedication ........ iii

Preface ....

V

Introduction . . . .

General Pathology ....

Section I. Nature of disease

11. General nosology

III. iEdology

IV. Semeiology .

V. General treatment of diseases

VI. Methodical nosology

.. 69

Chapter I. Inflammation

Section I. General definition

II. Appearances after death

III. Pathology of inflammation

a. Microscopic condition of the capillaries h. Pathological changes in the state of the

IV. Course of common inflammation V. Results of inflammation

VI. Varieties of inflammation VII. Causes of inflammation VIII. Diagnosis and prognosis of inflammation IX. Treatment of inflammation a. Active inflammation h. Atonic and passive inflammation

c. Chronic inflammation

d. Terminations of inflammation

e. Specific inflammation

Chapter II. Haemorrhage

III. Profluvia .....

IV. Dropsy .....

Section I. General pathology of dropsy

II. Acute or febrile dropsy

III. Renal dropsy

a. Morbid appearances of the kidney h. Signs of renal dropsy during life capillar les

71 73

Contents

Page c. Characters of the urine in renal dropsy . . 159 d. Changes in the blood in renal dropsy e. Complications of renal dropsy

Section IV. Cardiac dropsy

V. General treatment of dropsy-

Part II. Universal Diseases

Chapter I. Anaemia . . . . .

II. Chlorosis . . . . .

III. Scurvy . .

IV. Intermittent fever . . . .

Section I. Symptoms and varieties .

II. Complications and effects

III. Causes a. Predisposing causes .

- b. Exciting cause c. Proximate cause

IV. Diagnosis and prognosis .

V. Treatment a. During the paroxysm

b. During the intermission

Chapter V. Continued fever

Section I. Symptoms and prognosis

II. Local complications .

III. Morbid appearances .

IV. Diagnosis and prognosis

V. Causes a. Remote causes b. Contagion c. Proximate cause .

VI. Treatment

Chapter VI. Remittent fever

" " (Dr. Stewardson)

CONTENTS.

XI

Book I.—cutaneous Diseases

Chapter I. Papulse

Section I. Strophulus II. Lichen III. Prurigo Chapter II. Exanthemata Section I. Roseola

II. Erythema

III. Urticaria

IV. Rubeola V. Scarlatina

VI. Erysipelas Chapter III. Squamae .

Section I. Pityriasis II. Lepra III. Psoriasis Chapter IV. Vesiculse .

Section I. Miliaria II. Herpes

III. Eczema

IV. Scabies

Division L Chronic pustular eruptions Section I. Impetigo II. Ecthyma

III. Rupia

IV. Porrigo Division 2. Acute pustular diseases

V. Variola VI. Vaccinia VII. Varicella Division 3. Tubercular eruptions VIII. Acne IX. Sycosis Division 4. Boils .

X. Plague

XI. Malignant Pustule XII. Equinia

a. Appearances and varieties in the lower animals

b. Appearances and varieties in man Chapter VI. Purpura .

VII. Discolorations of the skin .

VIII. Organic diseases of the skin Section I. Lupus

II. Elephantiasis

III. Ichthyosis

IV. Framboesia Chapter IX. Diseases of the appendages of the skin

X. Diseased secretions of the skin

Pagre 363

XU CONTENTS.

BOOK II.— DISEASES OF TEE NERVOUS SYSTEM . Page

Chapter I. Phrenilis

Section I. Symptoms .....

II. Milder forms ....

III. Morbid appearances . . .

IV. Causes .....

V. Diagnosis . ; . . .

VI. Prognosis . . . . .

VII. Treatment . . . . .

Chapter II. Hydrocephalus . . . . .

Section I. Acute hydrocephalus ....

II. Chronic hydrocephalus

Chapter III. Apoplexy

Section I. Symptoms .....

II. Morbid appearances ....

III. Causes a. Predisposing causes h. Exciting causes ....

IV. Treatment .....

Chapter IV. Cerebral affections from remote causes

Section I. Cerebral symptoms from intestinal irritation .

II. Cerebral symptoms from exhaustion .

a. Spurious hydrocephalus . . . , h. Apoplexia exsanguinea . . . .

III. Effects of a shock, mental or physical

IV. Delirium tremens . . . . .

V. Cerebral symptoms from chlorosis, &c.

Chapter V. Tumours in the brain

VI. Atiections of the intellect . . . . .

Section I. Malformations of the brain . . . .

II. Idiocy ......

III. Insanity ......

a. Varieties ......

h. Symptoms and progress . . . .

c. Morbid appearances . . . , d. Causes ......

e. Diagnosis and prognosis . . . .

/. Treatment . . . . .

1. Physical treatmeyit . . . .

2. Moral management . . . .

Chapter I. Bronchocele IL Affections of the mouth and throat

Section I. Parotitis II. Tonsillitis

III. Stricture of the cesophagus

IV. Inflammation of the mouth

a. Pustules in the mouth

b. Jlphthse

c. Stomatitis mercurialis

d. Stomatitis ulcerosa V. Gangrsena oris

VI. Fetid breath .

VII. Ear-ache Chapter III. Diagnosis of pulmonary diseases .

Section I. Examination by sight and touch II. Percussion in. Auscultation .

a. Auscultation of the respiration J). Auscultation of the voice . c. Pleural friction- sound IV. General remarks Chapter IV. Diseases of the larynx and trachea Section I. Acute laryngitis

II. Chronic laryngitis m. Croup

IV. Organic affections of the larynx and trachea V. Catarrh VI. Spasmodic affections of the larynx

a. Laryngismus strididus

b. Nervous affections of the larynx in the adult

XIV

CONTENTS.

Chapter V. Bronchitis .

Section I. Acute bronchitis

II. Asthenic bronchitis

III. Chronic bronchitis

IV. Effects of chronic bronchitis

a. Dilatation of the air-tubes

b. Diminution of the air-tubes

c. Dilatation of the air-cells , Chapter VI. Pneumonia

VII. Gangrene of the lungs VIII. Haemoptysis

Section I. Haemorrhage from the air-passages II. Haemorrhage from the air-cells III. Treatment of haemoptysis Chapter IX. Functional diseases of the lungs Section I. Asthma

II. Hooping-cough Chapter X. Phthisis pulmonalis

Section I. Pathology of phthisis

II. Symptoms and progress of phthisis

III. Diagnosis and prognosis of phthisis

IV. Causes of phthisis V. Treatment of phthisis

Chapter XI. Diseases of the pleura Section I. Acute pleuritis

II. Chronic pleuritis

III. Hydrothorax

IV. Pneumato-thorax V. Hydro-pneumato-thorax

VI. Organic affections of the pleura

Book Iv,— Diseases Of The Heart

Chapter I. Pericarditis ....

II. Disease of the lining membrane of the heart Section I. General inflammation of the membrane II. Diseases of the valves

III. Effects of diseased valves on the circulation

IV. General symptoms of obstructed circulation Chapter III. Disease of the substance of the heart

Section I. Carditis ....

II. Hypertrophy and dilatation

III. Aneurism of the heart

IV. Chronic changes, the result of inflammation V. Rupture of the heart .

VI. Structural diseases of the heart VII. Neuralgia of the heart Vni. Angina pectoris Chapter IV. Diseases of the aorta

Section I. Aortitis ....

II. Aneurism of the aorta

824 831 831

Book V.~diseases Of The Chylopoietic Viscera . 873

Chapter I. Diseases of the periton&um ..... 873 Section I. Peritonitis ...... 873

CONTENTS.

xv

Pa^e Section II. Enlargement of the mesenteric glands . . . 876

III. Ascites ....

IV. Organic diseases of the peritonaeum .

Chapter II. Diseases of the pancreas

III. Diseases of the spleen . • .

IV. Diseases of the liver

Section I. Hepatitis

II. Structural diseases of the liver

III. Jaundice

IV. Biliary calculi

V. Diseases of the gall-bladder .

Chapter V. Pathology of the stomach and intestines

VI. Diseases of the stomach

Section I. Acute gastritis

II. Chronic gastritis a. Ulceration of the stomach b. Rupture of the stomach

III. Structural diseases of the stomach

IV. Haematemesis . .

Chapter VII. Diseases of the intestines .

Section I. Enteritis

II. Colic

III. Paralysis after lead-colic

IV. Intus-susception

V. Dysentery ...

VI. Diarrhoea

VII. Discharge of fatty matters

. 930

A^III. Gastro-intestinal concretions .

Chapter VIIL Cholera

Section I. English cholera

Cholera infantum (Dr. Stewardson)

Epidemic cholera

Chapter IX. Disorders of the digestive organs .

Section I. Symptoms

II. Causes

HI. Treatment

Chapter X. Worms ....

Section I. Ectozoa

II. Entozoa

Book Vi.— Diseases Of The Urinary Organs

Chapter I. Diseases of the kidney Section I. Nephritis II. Haematuria HI. Organic diseases of the kidney Chapter II. Functional disorders of the kidney .

Section I. Ischuria II. Diabetes

HI. Excess of urea in the urine .

IV. Serum, chyle, and fat in the urine Chapter HI. Calculous diseases

Section I. Urinary sediments

a. Amorphous sediments

b. Crystallized sediments

XVI

CONTENTS.

Page

Introduction

The Art of Medicine is to be perfected, I conceive, by improvements in our knowledge of the nature of diseases, by improvements in diagnosis, and by improvements in our acquaintance with remedies and their application.

Anatomy. — Improvements in our knowledge of the nature of diseases must be obtained through the cultivation of Anatomy and Physiology, and of Morbid Anatomy and Morbid Physiology ; or, in other words, from an acquaintance with the derangements that take place in structure and function, it is evident that no one can be acquainted with a disease, unless he is acquainted, more or less, with the part diseased, — -its situation, form and structure ; and the more accurate and minute his acquaintance with these, the greater, casteris paribus, will generally be his knowledge of the nature of its lesions. I say ^^cmteris paribus;^^ iDecause a knowledge of mere Anatomy, however accurate and minute, does not imply a knowledge of disease (its symptoms, history, and causes), or skill in treating it; — any more than a knowledge of the alphabet, and the ability to read, imply a literary character: and nothing can be more absurd than for the public to presume that a man is a good practitioner, merely because he is a good anatomist. An anatomist is not necessarily even a physiologist; and Mery was accustomed to say, — "We anatomists are like the porters of Paris; who are all well acquainted with all its streets, as well as all its lanes and alleys, but know nothing of what passes within the .houses."* The most assiduous examination of only the dead body, can disclose but little of the functions and properties of the living. The structure of the brain would never teach us that it is the organ of feeling and thought; or of the kidney, that it produces a fluid containing lithic acid and urea. The sympathy existing between the nasal membrane and diaphragm, and between the kidneys and surface; the curious phenomena resulting from contagions and malaria; the various morbid actions to which various parts are liable (the innumerable diseases of the nervous system, for instance); the susceptibility of various parts to the operation of various agents during health (such as of the mouth to the operation of mercury, and of the 'stomach to that of ipecacuanha); the peculiar power of certain substances over certain diseases (as of quinina over intermittent fever); — all this would never be suspected at the dissecting-table. And I cannot refrain from remarking, that for any one to pride himself upon his knowledge of established Anatomy, would be exceedingly weak; as it requires no preparatory philosophical education, and no in-

aRees's CyclopiBdia; Article "Mery.'*' VOL. I. — 2 tellectnal exertion; but rtierely the possession of eyes and memory, and a willinsfriess to em ploy them. Dr. M'Culloch, in his powerful, thonah (1 must be pardoned in saying) occasionally extravag'ant, work, apologizes for not arranging liis cases anatomically; on the ground that it would have savoured of pedantry; — "a small pedantry," he says, '-far too common; as if any man could not make himself master of Hutnan Anatomy in a few weeks, as well as of any other tangible and demonstrable substances."'' But if it would be laughable for any one to pride himself on his knowledge of Anatomy, it is culpable in a physician not to be a good anatomist. Oiherwise he cannot comprehend the phenomena of many diseases. He cannot, for example, understand why, in partial paralysis of the head, sometimes only certain muscles cease to obey the will; — wliy loss of sensation sometimes occurs alone, and why to only a certain extent; — why the pain of the neuralgia takes a particular course; — or why, in disease of the heart, unusual varieties of sound and impulse are obseivable in particular portions of the cardiac region. He cannot possess any but the most superficial knowledge of Morbid Anatomy; the cultivation of the far greater and more important part of which is peculiarly the duty of the physician, who treats the chief morbid states of the' most important organs of the body; and not of the surjreon, who does not even witness their symptoms. He will, therefore, either neglect to complete the investigation of his unsuccessful cases, by examination after death, or be unable to appreciate what presents itself, and perhaps be indebted to an active surgeon for information. He cannot otherwise be a good physioloaist; for, although Anatomy alone will seldom teach the operations of an organ, these can manifestly not be known, unless the organ i;self is understood.

Physiology. — The importance of Physiology requires no argument in its support; for, except in obvious structural or mechanical changes, the symptoms of disease are chiefly Morbid Physiology; and therefore, to quote the familiar passage of Galen, — "The magnitude of a disease is proportionate to its deviation from the natural state; and he only knows the extent of the deviation who knows exactly what is the natural state." Et^ oaov yd^ l^ictaiaL ty^? ^vcJecoj sxaatovi si^ tosovto xai fisysOov^ vjxBi. To 8'6gov ^^latatai, yvujvav 6vvat6v fMOvqi ta to xa-ta ^vGiv^ axpijSCoi STiiata/jiiva).^ And again, Mtj 8vvars9av ruva xa'kCj^ Id&aaOat ta vo^rnxata, Ti^lv b'kov to\) (jtO|ita-r'oj iriKSxi'^aaeai f^ •fi^on^.'' Wilhotit a thorough acquaintance with both the natural structure and the functions, a thousand highly interesting deviations will never be recognised in the cases which come daily before us.

Pathology. — If such is the importance of Anatomy and Physiology to every physician, it will not be disputed that, in order to advance our knowdedge of the nature of diseases, these sciences should be improved to the utmost. But however necessary these foundations (Anatomy and Physiology), the grand source of this knowledge is the observation of the phenomena of diseases, — their symptoms, history, and causes (in other words. Pathology), and of their structural lesions (in other words, Morbid Anatomy). No one expresses a doubt respecting the importance of Pathology; — the importance of observing the symptoms, and tracing the history of diseases; and of investigating their pecidiarities, analogies, and causes. Yet, in all this, how liable are we to error! How patient and searching an eye is required to note all the phenomena of a disease; — to perceive what is essential to its existence, and what is only Incidental! How profound a judgment to reason upon these phenomena, and to investigate their causes; — to discern the analogies between alTections which, at first sight, are perfecdy distinct! And, at the same time, how cool should be the judgment duly to appreciate all fanciful analogies, all

a"Mar.sb Fever and Neuralgia;" Volume 2; Page 104.

••"As is the degree of devi<Uion from nature, so is the magnitude at which the disease arrives; but the amount of this derangement can be ascertained only by him who is accurately acquainted with the natural slate." — ^^MeLhodus Medendi ad Glauconem.;^ Liber 1; Caput I.

c "Ii is impossible for any one to cure diseases perfectly, without having previously well examined the constitution of the whole body." — ^'Metkodus Medendi;'^ Liber Ij Caput 1.

hypolhelical suggestions! Exactly the same difficiiUles surround Morbid Anatomy; but in its case they are alleged, by some, as rbjeclions to its prost^cution. But how could any affection beneath the surface of the body have been understood, without an ocular investigation of the parts affected? How could pain in the chest, dyspnosa, cough, and pyrexia, have bren known as signs of inflammation of the kings or their membranes, unless the examination of persons who died under these symptoms, had proved such a lesion to be frequendy their cause? If knowledge can be thus obtained, why not obtain the utmost possible? True it is, that incidental morbid appearances have often been mistaken as necessary and constant; and that some even pretty constant appearances have often been absurdly announced as the essence of the disease, when they were merely its effect, or (at the utmost) only among the number of its piienomena. Equally true it is, that chang-es after dealk have been mistaken for morbid appearances; as was pointed out by Dr. John Davy in the case of redness from imbibition of blood.* But such errors, surely, afford no reason for neglecting careful and extensive examinations of diseased parts, and drawing just inferences as to the connection of the change of colour or structure with the (Hsease; — they supply no reason for not cultivating so ample a field of knowledge scientifically. If a disease be accompanied by a change of structure or appearance ivit/im the body, surely this change, as a fact in the disease, is worthy of notice; — as worthy as visible changes in the skin, the mouth, or the eyes; which changes are always carefully described by these objectors, even when merely secondary effects; though they differ from the Aicts of Morbid Anatomy, only in the accident of bemg coornisable without dissection; while they are not a whit more necessary to a perfect history of a disease, and are much less in number; — owing to the circumstance of nearly all our organs being concealed from view.

After some diseases, indeed, no change of structure or appearance is discernible. But even here, extensive anatomical investigation is important; for it often prevents us from forming groundless hypotheses, as to the seat and nature of such affections. Hydrophobia might be referred to the stomach, were it not that the red patches, which are sometimes seen in this organ after the disease, are frequently not to be detected. Tetanus might be thought always to arise from inflammation of the spinal marrow, were not this part frequently found free from inflammation in tetanic patients. It discloses to us a fact which we might otherwise have doubtetl; — that diseases may be only functional, as well as structural; — that, in the words of one of the most intelligent and industrious cultivators of Pathology and Morbid Anatomy (Dr. Andral), — "it is one of the most serious errors to which the ill-directed study of Morbid Anatomy can lead, to admit no other alteration in the economy, than those which are discoverable by the scalpel."^ We learn, in short, to form a just estimate of Morbid Anatomy; — that it is an important part of the basis, but by no means the ^'main basis" of Pathology.

Diagnosis of Diseases. — But if our art is to be perfected by a better acquaintance with the nature of diseases, it is not less to be perfected by improvements in distinguisliing them; — by improvements in diagnosis. '^ 'I'he diseases of the lungs and their membranes, are as well understood as any of the body; yet the best practitioners continually fail in distinguishing them. They often fail, for instance, to distinguish one form of chronic bronchitis from hydrothorax; the treatment of which diseases may be totally different. So important is diagnosis, that it has become a proverbial saying, — "The knowledge of a disease is half the cure." Diagnosis also

' "Transactions of the Medical and Chinirgical Society of London;" Volume 10; Page 89.

""Clinique Medicale;" Tome 3; Page 510. _ <= On ihis subject we beg to refer the reader to Dr. Marshall Hall's "Treatise on Diagnosis." It is now incorporated with his "Principles of the Theory and Praciice of Medicine.** Dr. Cowan, in his "Bedside Manual of Physical Diagnosis," lias given, in a very portable form, the phy?>ical signs of the diseases which affect the folluwing important parts:— 1. Lungs and Pleura. 2. Pleart and Pericardium. 3. Vascular System. 4. Abdomen, Osseous System, and Auditory Apparatus. The physical signs are chiefly furni.shcd by auscultation and percussion.

is to be improved, not only by a better acquaintance with the symptoms and history of diseases, but by a better acquaintance with Morbid Anatomy; so that the correspondence between symptoms and local lesions may be established, and tlius the affection clearly ascertained. As HealtJiy Anatomy is the foundation of Morbid Anatomy, and Physiology is the foundation of Pathology, the importance of these also to improvements in diagnosis is apparent.

Laennec's Discoveries. — The discoveries made by Laennec with respect to diseases of the heart and lungs,* are great enough to entitle him to all the honours which have ever been acquired in our profession. He has enabled us to judge of diseases, which are otherwise often not distinguishable with certainty, or even at all; and this with an accuracy inconceivable to those who are unacquainted with his investigations. He has enabled us to distinguish diseases of the heart, which were formerly, and are sldl, too often either all expressed by the easy term — "disease of the heart," — without any specification of the part of this complicated organ affected; or are as often passed over entirely; — the case being mistaken for hydrothorax, or some pulmonary affection. He has also enabled us to distinguish diseases of the lungs which, in many cases, could not be pronounced upon with accuracy; and others of which the diagnosis was always uncertain. Moreover, we can point out the very part afTected.

But Laennec's discoveries are objected to on the very ground of their accuracy. We are asked — "C?n bono?'''' ("Of what use are they?") The answer is plain. It is universally allowed that every disease should be described, and its nature ascertained, as accurately as possible. Now, with every advance in accuracy of description, and in knowledge of the source of symptoms, diagnosis imperceptibly and inevitably becomes more accurate. To condemn accurate diagnosis, therefore, is to condemn accurate knowledge^ — to rest satisfied with imperfect information, when industry would give us more; — to admire ignorance, when knowledge is wiihin our reach.

The art of diagnosis ought to be universally cultivated, without reference to its utility ni particular instances. It is part of our science; every part must be cultivated for the perfection of the whole; and what may not be practically useful to-day, may become so to-morrow. How many discoveries in Chemistry and Physics appeared, at first, to be objects of mere curiosity; but have afterwards been applied to the most important purposes! Plato possessed so exalted a feeling for science on its own account, that he considered the applications of geometry to practical purposes, as far inferior to its philosophy;'' and those who may see no reason for being so deeply enamoured of science as that, must allow that there is every reason to remember the words of Jesus, the son of Sirach: — "None may say — 'What is this?' — 'Wherefore is that?' — for, at time convenient, they shall all be sought out."*" In improving diagnosis, it is impossible to discover only what is obviously useful. The research nmst be made generally; and what is at once useful, and what is not, must turn up together. In the diseases of other organs, we always aim at accuracy of diagnosis, without any hope of utility. When a solid tumour exists in the abdomen, we endeavour to ascertain whether it is the liver, the

» See his celebrated Treatise, entitled— "De TAuscultation Mediate; ou Traite du Diagnostic des Maladies des Poumonsetdu Cceur; fonde principalement sur ce Nouveau Moyen d'Exploration." ("Treatise on the Diagnosis of Diseases of the Lungs and Heart; chiefly founded on a New Mode of Investigation,— Mediate Auscultation.") This work is principally known lo the English reader through the medium of Dr. Forbes's Translation; — a work which is enriched with many valuable notes.

vii. ("We must not, therefore, if compelled to eoniemplate, on the one hand, an actual being, say — 'It is fitting;' and if we contemplate, on the one hand, the origin of that being, say — *It is.not fitting;' for they speak as intriguing advocates, who utter all their speeches with a sinister design;— squaring, stretching, adding, and asseverating without scruple; but every scientific pursuit is cultivated for the sake of knowledge.") e "Ecclesiasticus;" Chapter 39; Verse 17, spleen, the pylorus, an ovarium, a new formation, or something else; although the treatment would probably be the same in all.

Auscultation and Percussion.— ^uX therein immediate utility in the discoveries of Avenbrugger* and Laennec. No one will pretend that, in chronic diseases of the chest — with the exception, perhaps, of phthisis — ihe diagnosis is generally satisfactory. Before I adopted auscultation, I frequently discovered disease of the heart after death, where I had not previously suspected it; and frequently found the organ sound, when I had supposed it diseased. When I was correct in expecting to see organic affection of the heart, I was often wrong as to the precise nature of the lesion. Too often has auscultation at once revealed to me disease of the heart, when, by good practitioners, no affection of the heart, or even of the chest, had been suspected; or where the case had been named "nervous palpitation" or "asthma;" — where the lungs had been regarded as the seat of the malady; or where the case had been treated with the most violent remedies for hydrothorax. Repeatedly have I seen chronic bronchitis with extreme congestion in the lungs mistaken for hydrothorax; and this was imavoidable, when percussion and auscultation were omitted; because the symptoms were precisely the same, with the exception of those which percussion and auscultation could alone disclose. Inflammation of the substance of the lungs often takes place during other diseases, without being obvious before death to any but the auscultator and percussor. Without the aid of the ear, who can distinguish emphysema of the lungs, or, in every case, pneumato-thorax?^ Both may be readily mistaken for hydrothorax. The symptoms may be a pallid face, purple lips, orthopnoga, sudden starting from sleep to the waking state, a small and intermitting pulse, cold extremities, and swollen feet. The remedies of hydrothorax may appear indicated; but the ear will discover, on percussion, a hollow sound — far too hollow a sound — in the chest, at its very lowest parts; while there is, in the first case, little respiratory murmur, and in the second none at all, — at the very place where the hollow sound is heard. Nothing but the ear can show the nature of these cases. Nothing but the ear can distinguish them from each other. Without the ear, no case (^an be known with certainty to be one of hydrothorax, — however marked the symptoms.