A short treatise on the different methods of investigating the diseases of the chest. Tr. from the French of M. Collin

Front matter

MANUAL FOR THE USE OF THE STETHOSCOPE.

SHORT TREATISE

ON THE

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 hj M. L'aennec in his elaborate work, De V auscultation 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 disease 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 exploration 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,

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 surprised 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 become 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, accompanied by sound ; and consequently to the exploration 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 7 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 certain, 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 v

INTRODUCTION. Vll

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 introduced into practice by a very few only, and ignorance, 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 competent 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 astronomer, or a compass to the mariner, yet if he will be at pains to carry it in his pocket and acquire a little readiness in its application, he may rest assured that he will obtain assistance in discriminating in many perplexing cases of a class of diseases the most numerous 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 motion 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, instantly 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, dropsical collections, aneurisms, and various affections of the heart and blood vessels, which require an appropriate 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 required 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 denoting Hydrothorax, equally belong to certain forms of pneumonia ; and what can be more widely different than the appropriate treatment of those two diseases ? 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 Hospital. Dublin Hosp. Rep. vol. 4. ,

INTRODUCTION. IX

ror is of more frequent occurrence than the attributing to Hydrothorax, symptoms which belong to pneumonia. Numerous cases have been sent into the medical 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 succeeded 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 additional 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 industry 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 gentleman, 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 Scudamore,M.D. F. R. S. 1836,

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 symptoms 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 hesitation 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 recovered his health in less than three months." It is especially desirable in the diseases of the chest of infants, 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 investigating these diseases.

Percussion and auscultation are intimately connected, 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 Avenbrugger, a native of Graets in Styria, published in 1761. This operation consists in striking upon the walls of the thorax, and the sound returned wall 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 obvious. The sound is obtained with more distinctness, 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 annexed to the end of the most approved form of Stethoscope, 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 certainty 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 without 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 objection to which is, that it is too large to be a convenient inmate of the coat pocket. A more portable instrument is one which the editor has found to answer all the purposes of Laennec's first Stethoscope, and is

Xll INTRODUCTION.

little more than half as long, and instead of being cylindrical, 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 expected 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 respiration, one of the most obvious of the healthy phenomena.

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 examination 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 examination of the pulse at the w r rist. For it is pathognomic of some affections, that the action of the heart, and

* This form of the Stethoscope may be obtained at the publishers.

INTRODUCTION. Xlll

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 dangerous exhaustion from this cause, the heart's impulse, as perceived by the Stethoscope, was unexpectedly strong and distinct, and essentially contributed to inspire 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 auscultators, 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 movements of the heart — the noises produced during respiration by air, mucus, &c. 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 were moving and whispering round him.

XIV INTRODUCTION.

2. The Stethoscope is to be used without the stopper, in exploring the phenomena of respiration, and the different rattles ; and with it, to examine the circulation, 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 perpendicularly, 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 exclude 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 exploring the different rattles, the patient should be directed to cough occasionally.

6. The observer should be careful not to place himself in a constrained position, and for this purpose it is often convenient to rest upon one knee.

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

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 Succussion, - - - 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

— CEdema 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, 114

Diseases characterized by the alteration of the shock, - - 124-

Hypertrophy, 124

Hypertrophy of the left Ventricle, 125

right ventricle, 1 2.3

Disease characterized by alteration of the 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, 1£8

Aneurism of the Aorta, 129

On the use of the Stethoscope in Internal Aneurism, - - 130

In Pericarditis, and Hydropericardium, 131

A

TREATISE,

&c. fa.

PART L— 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 voluntary* muscles ; it is divided into two acts, inspiration and expiration.

Inspiration is the movement by which the thorax, separating its walls, augments its interior capacity, allowing the air to enter into

* Though correctly translated, the statement appears 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 without 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 performed 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 uniform ; 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 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 intercostal 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 diaphragm 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 relate 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 incomplete ; 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 nothing may obstruct the muscular motions which assist respiration ; the arms should hang freely and the thorax should be uncovered ; but usually these precautions are not required.

1st. Considered relatively to the number of inspirations and expirations in a given time, respiration is frequent 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 temperament ; in warm climates ; in summer, when the air being more rarefied contains less oxygen 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 ; !r every alteration which renders a part of the pulmonary tissue unfit for respiration, are the A 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 m 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 slowness 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, respiration is said to be regular ; it is irregular when these intervals are more or less prolonged in *2 b 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 phlegmasiae of the thoracic and abdominal cavities, 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 inspiration not being followed by a full expiration. 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 cerebral fevers, on the approach of phrenitic delirium.

The smallness of the respiration is more usually indicative of thoracic affection, or lesion of the thoracic parenchyma,

M. Landre Beauvais has called that respiration 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 considered it necessary to give the same name to a different phenomenon, but one which frequently coexists with that noted by this learned professor.

5th. Respiration is equal, when inspiration, whether great or small, quick or slow, is followed 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 asthmas, 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 inspiration ; 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 presents this brevity, the affected organ being by this painfully compressed : in this case the thorax seems always raised.

The high respiration, which we have already 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 inspiratory muscles contract with violence, or as if convulsively. Simply inspecting the neck, enables us to recognize this difficulty of respiration ; the hard projecting scaleni, impress 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. V

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. Pascali has lately communicated to the Academy of Medicine observations upon the employment and utility of galvanism in those cases. It would appear from his experiments, that this convulsive state of the respiration, depends 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 examination 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 phlegmacy 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 produced numerous and close adhesions between the coats of the pleura. It may depend perhaps as much on the tissue of the lung being impermeable to the air, as on those adhesions.

8th. We have mentioned that variety of respiration, 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. However, the respiration becomes naturally abdominal 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 abdominal organs, or when this cavity is distended by the produce of conception, or other accidental 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 simultaneousness.

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 practitioners 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 stethoscope 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 similar to that of an empty barrel. (This comparison, though inexact, is the most correct 3

I have been able to find.) The word percussion 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 infiltration* 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 appreciate the changes arising from disease.

1st. According to the Points of the Chest struck upon. A clear sound is obtained whenever we strike upon a bony part covered by the skin only, or by thin muscles sufficiently stretched to transmit the shock wholly, without absorbing any of the sound. The most