the beautiful reflections that ought to afford consolation to all parents for the early loss of promising children- Honourable age is not that which standeth in length of time, nor that is measured by number of years. But wisdom is the grey hair unto men, and an unspotted life is old age. Being made perfect in a short time, he fulfilled a long time. Thus the righteous that is dead condemneth the ungodly that are living; and youth that is soon perfected, the many years and old age of the unrighteous."

ART. IV.-On the Diagnosis of Diseases of the Chest; based upon a Comparison of their Physical and General Signs. By W. W. GERHARD, M. D., Fellow of the Philadelphia College of Physicians; Member of the Société Médicale d'Observation, and of the Société Anatomique of Paris, &c. &c.

ALTHOUGH the advantages of auscultation are now so clearly established that few can be found hardy enough altogether to deny its utility, still there are undoubtedly many physicians who are very far from appreciating its vast importance. Nevertheless, without a resort to this mode of exploration, the practitioner will find it in most instances very difficult, and sometimes impossible, to determine either the nature or extent of any disease of the chest which he may be called upon to investigate, and consequently to adopt with promptness and confidence the course of treatment best adapted to its alleviation or cure. But the advantages of auscultation do not stop here-it has far higher claims upon our attention, since it has been principally through its means that many new and interesting facts have been added to our science, and also that the general history of pulmonary diseases has been brought to a degree of perfection so far beyond what had been previously attained.

That the discovery of auscultation has been of the greatest utility in advancing our knowledge of diseases of the chest, no one can doubt who will take the trouble to examine their history as at present established, and compare it with the accounts of the older writers. He will find that there is no disease in relation to which we have not now a much more accurate and full detail of the symptoms than formerly, and also a far more correct estimate of their value in diagnosis and prognosis, as well as of their relations to the pathological conditions of the different tissues and organs.

It has been not unfrequently asserted that those who practised auscultation were in the habit of depreciating the importance of the functional and general symptoms of diseases of the chest. Whatever foundation there may have been for this remark in individual instances, as a general rule it is undoubtedly incorrect. To be convinced of this, we need only to look into the works of the most experienced auscultators since the time of Laennec. Let any one

peruse the work of Louis on Phthisis, and he cannot fail to be struck with the unwonted attention which the author has given to the examination of the functional symptoms of the disease, and also with the great importance which he attaches to a proper consideration of them in the formation of an accurate diagnosis. It will be found that the condition of the digestive apparatus, of the nervous system, as well as of the muscular and cellular tissues, &c., has been investigated most minutely-that still greater attention has been paid to the examination of the character and seat of the pain, the kind of cough and nature of the expectoration, the alteration and loss of voice, the discharge of blood from the lungs, the modifications which pleuritic inflammation undergoes when occurring in a tuberculous subject, the connexion of pneumothorax with the same complaint, together with the dependence of chronic peritonitis upon the same general cause. These and a number of other circumstances attendant upon the disease, have been described with the greatest clearness and precision, and (which particularly concerns our present argument) most of them have been brought out in bold relief as diagnostic signs, and their importance as such established upon the firm basis of observation. The same general remarks will apply to the history of almost every other disease of the chest, as will appear by referring to the works of Andral, Bouillard, and others. In fact, were the practice of auscultation from this moment abandoned, medicine would still remain greatly the gainer by the discovery of this means of exploration, on account of the many new facts with which that science has directly or indirectly been enriched through its means.

But, whilst admiring the general beneficial influence which the discovery of auscultation has exerted upon the progress of medical science, we must not omit to impress upon the physician the importance of a practical acquaintance with it at the bedside of his patients. Indeed, no one can now be held excusable who omits to acquire this knowledge so far as circumstances will permit. As his acquaintance with the subject increases, he will find that diseases of the thoracic cavity present themselves to his mind under a new aspect-that many of the doubts and difficulties which he had formerly laboured under with regard to the diagnosis of these diseases will vanishthat he will be able in individual cases to follow the disease from stage to stage, and appreciate, with a certainty which he could not previously have thought possible, the various changes which the pulmonary tissue undergoes from day to day in its progress towards a favourable or unfavourable result.

The importance of diagnosis is generally very much undervalued, partly perhaps owing, so far as regards inflammatory diseases, to the attaching too exclusive an importance to the study of the nature, symptoms, and treatment of inflammation in general, without

sufficiently considering the important modifications which it undergoes in many respects, according as it is seated in one or other of the organs or tissues of which the body is composed. All the knowledge which we possess of the general doctrine of inflammation, and of the functions and properties of the different organs and tissues, would never enable us to determine, à priori, most if any of the modifications above alluded to; an acquaintance with which, in fact, can only be acquired by a patient and careful investigation of all the phenomena which accompany each separate lesion. In confirmation of the above remarks, let us look for a moment at a few of the prominent features of two of the most important acute inflammations occurring within the thoracic cavity, viz. pleurisy and pneumonia. The former, when attacking an adult not very far advanced in life, and who at the time of invasion is free from any chronic disease of the chest, is an affection of no very grave character, and which will almost necessarily terminate favourably, without the employment of any active treatment, by a simple attention to diet and regimen. To secure the most rapid and favourable termination possible, it is only necessary in addition to this to make use of moderate depletion, combined with the eternal application to the side affected of such substances as are calculated to favour the absorption of the liquid effused into the cavity of the pleura. Reasoning à priori, we should have come to an exactly opposite conclusion, and classed simple pleurisy among the most violent and fatal diseases, because the inflammation of serous membranes generally possesses this character. Pneumonia, on the contrary, is a disease of the most serious importance-is frequently characterised by the most violent symptoms, especially in its latter stages, when the cerebral functions are much impaired-and demands the most energetic treatment. Perhaps there is not in the whole catalogue of diseases to which we are liable, one in which it is so important to make use of large and frequently repeated bleedings, and that too in the very early stage of the complaint. Now, it is absolutely impossible in a considerable proportion of the cases of pneumonia, that the treatment so important to the welfare of the patient can be confidently pursued unless auscultation and percussion be employed as a means of diagnosis; for the inflammatory condition of the lungs constituting pneumonia is sometimes accompanied with such slight functional disturbance of those organs, that without the aid of the physical signs the practitioner would remain ignorant of the nature of the disease until revealed to him by a post-mortem examination. Many other cases also occur in which, without the same assistance, it would be difficult, not to say impossible, to arrive at a certain diagnosis during the early stage of the disorder, the moment of all others when it is of the greatest consequence to employ with promptness and energy the most active

remedial means. Moreover, the treatment generally requisite is one which would be entirely unjustifiable, were the inflammation confined to the pleuræ or the bronchial mucous membrane.

The object of Dr. Gerhard in the work, the title of which we have placed at the head of this article, is to lay before the reader a concise view of the most prominent symptoms of each one of the numerous diseases of the chest-to give a more detailed account of their physical signs, and to indicate the several conditions of the thoracic viscera with which these are inseparably connected, thereby presenting the data by a careful comparison, between which the diagnosis is to be determined.

In the introductory chapter, which is devoted to a few remarks upon the relative importance of the physical and functional signs, the author makes the following observation:-" Diseases of the lungs. may be recognised tolerably well by the rational signs alone; but it is as unwise in a physician to reject the aid of auscultation, as it would be in a surgeon to despise the use of the sound”

We entirely assent to the truth of the above proposition in the greater portion of cases; but, at the same time, we believe that very few are able so to recognise them in most instances, unless they have acquired that precise knowledge of the rational signs which is only to be obtained by a careful study of these diseases with the aid of auscultation and percussion.

In the second chapter, we have a short account of the conformation of the chest, and of the mode in which ocular examination should be performed. The morbid changes which take place in the external conformation of the chest are very various, and frequently afford very important assistance in the diagnosis of its diseases, and for this end it is necessary that they should be examined with the most scrupulous accuracy. The author's account of this subject is chiefly derived from the instruction of Louis, and is particularly worthy of a careful perusal, as it notices several alterations of form, in general but little understood or appreciated.

The four following chapters contain a description of the sounds which auscultation and percussion will enable us to distinguish, and of the mode in which these operations can be best performed. As this description, except in one particular, does not essentially differ from that usually given, we shall dismiss its consideration with a few remarks upon the part alluded to.

It has been known for some time to several auscultators, that the respiratory murmur was, under ordinary circumstances, more harsh and blowing under the right clavicle than under the left. A knowledge of this difference is of great importance in the examination of an individual in whom the existence of tubercles at a very early stage is suspected, otherwise we might sometimes be led to suppose that there was a small deposit of these bodies at the summit of the right

lung, when in fact it was perfectly healthy. Of the causes of the difference alluded to, we think that the author has given a very satisfactory account. Starting from the well known anatomical fact, that the right bronchus is shorter, more horizontal, and of much larger diameter than the left, he has pointed out a circumstance familiar perhaps to few except professed anatomists, viz. that the bronchial tubes distributed to the right superior lobe are, even after they have penetrated some distance into its substance, of considerably greater diameter than the corresponding ones on the left side. This circumstance, taken in connexion with the fact that the former have a much more direct communication with the trachea, owing to the horizontal course of the right bronchus, is, he thinks, entirely sufficient to account for the difference of sound under the two clavicles. The explanation is novel and ingenious.

The history of the bronchial respiration is very clear and full. He has divided it into three kinds, viz. the rude, the bronchial, and the tubal. The rude respiration was first noticed by Louis, and differs from the true bronchial; the vesicular murmur being still present, though in a slight degree, in the former. This mode of respiration is particularly observable in the early stages of phthisis. The tubal respiration does not essentially differ from the bronchial, but is merely an exaggerated form of it, and we doubt the necessity of treating of it separately.

The remainder of the work is chiefly occupied with the consideration of the different diseases of the chest. In tracing the history of emphysema of the lungs, the author remarks that

"The conformation of the chest is altered; the distension of the lung, which is increased by the efforts made by the patient in the act of respiration, gives rise to permanent enlargement of the thorax. The dilatation is of two kinds-one is the rounded form given to the thorax of emphy. sematous patients by the strong efforts of respiration. This general dilatation is not confined to a portion of the chest near the enlarged vesicles, and is, therefore, probably owing to the strong efforts of inspiration, and to the imperfect expiration characterising the disease."

We very much doubt the truth of this opinion, because a general dilatation, strictly speaking, is very rare in this disease; and, in fact, in the immense majority of cases, the enlargement is confined to a portion of one side only. It is stated by Dr. Louis, that "of forty-five cases of emphysema in which he had studied the configuration of the chest with care, one only presented a general change of form; and that in all the others the dilatation of the thorax was partial, and was confined to one side of the chest, except in four

cases.

As regards the situation of this dilatation, Dr. G. contents himself by stating that it is generally found over the anterior margin of the lung, on each side of the sternum. This is hardly sufficiently