LIST OF ILLUSTRATIONS AND DIAGRAMS. Page FRONTISPIECE.-The first two figures represent the flattening and depres- Diagram representing comparative degrees of loudness of Respiration Diagram representing heard Respiration Sounds with exaggerated Expiration on unhealthy side, and eclipsed Respiration on the healthy side of the Chest . Diagram representing Oscillating or Alternating Respiration Sounds. — The Inspiration Sound is heard on Healthy Side, while it is eclipsed upon the Unhealthy Side.—The Expiration Sound, loud and prolonged, is heard on the Unhealthy Side, while the Expiration Sound of the Healthy Side is eclipsed 7 14 18 24 26 26 Diagram representing Healthy Respiration Sounds of both sides of the Chest 27 Diagram representing the Sounds of the Healthy Side, and the Sounds of the Diseased Side in the Second Stage Diagram representing the Thoracic Voice at healthy base, and its absence at the base in the Second Stage, the Differential Stethoscope being employed Diagram representing strong Thoracic Voice on Diseased Side, and ab- Diagram representing the reverse of the above 133 139 143 143 173 173 Diagram representing unheard Respiratory Sounds and heard Voice Sounds on Cavity Side, and heard Respiratory Sounds and unheard Voice Sounds on the Healthy Side. . Diagram representing unheard Respiration Sounds on Healthy Side, and 174 174 175 Diagram representing unheard Thoracic Voice on Cavity Side, and heard 202 Diagram representing the loud Respiration Sounds of diseased base, and the Heart's eclipsed Sounds at fifth interspace Percussion Hammer Piorry's Pleximeter Aldis', Dr., Echometer Sibson's, Dr., Pleximeter Wooden Stethoscopes Flexible Stethoscope Camman's, Dr., Double Stethoscope Diagram representing heard Respiration Sounds and eclipsed Voice Sound on Healthy Side, and the reverse on the Cavity Side The Author's Differential Stethoscope, or Stethophone . The Author's Hydrophone Dr. Sibson's Chest Measurer Dr. Quain's Stethometer The Author's Pneumatoscope The Author's Sphygmoscopes The Author's Chest Goniometer Coxeter's, Mr., Spirometer The Exploring Needle Tongue Depressors Posterior View of the Pharynx, Glottis, &c., after Erasmus Wilson Illuminated Speculum for Larynx, after Avery The Laryngoscope, after Czermack and Türck. Page 222 . 223 311 311 312 313 316 321 324 330 331 335 EXAMINATION OF THE CHEST &c. IN PULMONARY CONSUMPTION. PART I. CHAPTER I. Symptomatic and Physical Evidence compared. - Disorder of Organs denoted by disordered Functions. - Products of the Lungs not known to be altered in Disease. Disorder of minor Functions.-Physical Properties of Organs aid in Diagnosis.—The acoustic Properties of Lung.-Form and Movements of the Chest. If the question were proposed to me, whether, in the case of a patient supposed to suffer from pulmonary consumption, I would be disposed to regard as the more decisive of the question, evidence afforded by symptoms, or that given by the physical signs ascertained by the examination of his chest, I would reply, that I should much prefer the physical signs as the grounds upon which to form my judgment. The symptoms of pulmonary consumption are much more the symptoms of other diseases, than the physical signs of pulmonary consumption are those of other maladies. The short cough, the frothy scanty sputum, the slight shortness and quickness of breath, the quickened pulse, the debility and languor, and the loss of weight, which are the symptoms of pulmonary, consumption in its first stage, are not uncommonly the symptoms of other diseases, such as bronchitis, bronchial or tracheal or laryngeal irritation, dependent upon, or connected with gastric, hepatic, or even uterine irritation, and general decline of health. On the other hand, B the dullness, or flatness, or shortness of the percussion note; its loss of symmetry, so to speak; the harsh or quasi-tubular inspiration, perhaps divided, with its dry crack and click under the clavicles; the coarse prolonged expiration, with or without its fine crumpling bruit; the defective elevation or expansion of the upper and front part of the thoracic cone, on both sides, or what is stronger, on one side; the strong vocal resonance and fremitus deprived of its relative proportion of one degree more on the right than on the left side; and the systolic bruit of the pulmonary and subclavian arteries, at the same time that other parts of the chest evince the usual characteristics of healthy vesicular breathing, and the heart is free from morbid sounds, are seldom present without tubercular deposit in the lung. The symptoms of pulmonary consumption are more variable in their accession, than the physical signs; some, or even many of them may be nearly or altogether absent, during the whole course of the disease. They may escape the attention of the patient, or from motives of interest, or from self-deception, he may deny their presence. Though once experienced, they may absent themselves, and leave no trace behind. It is different with physical signs; they are very regular in the order of their succession; they are generally all found to lend confirmation and strength to each other; they cannot be denied by the patient, and they are little liable to vanish, or if they do disappear, they are succeeded by other signs well known to be their successors, and still more demonstrative of the nature of the disease. The worst symptoms of advanced phthisis often present themselves unpreceded by scarcely a symptom which has attracted notice; but we know of no cases of this disease marked by advanced signs unpreceded by the preliminary ones just noted. If such be the comparative value of the symptoms and the physical signs of phthisis in its first stage, what shall we not say of the greater value of the signs in the latter stages of the disease? The cough, emaciation, sweatings, and quick respiration, the hæmoptysis of advanced phthisis, are simply as suspicions to the modern physician, compared with the moist crepitation, the dull percussion, the gurgling, the cavernous respiration and cavernous voice, which are as so many certain proofs. When the wasted, coughing, panting patient is seen by the physician, he desires at once to examine the chest before deciding upon the nature of the disease. He is far more desirous to learn the physical signs in such a case than he would be in another case to acquire the symptoms, when he has already learned that the physical signs above noted are present. When the physical signs are manifested to his senses, the symptoms, so far as the nature of the case is concerned, are now of little value, however truly important they may be in respect of the relief of the patient. Yet it must be admitted, that in a large number of cases of phthisis, at an early period of the first stage, there is much reason to confess that physical signs are little developed. Numerous examples of phthisis, at an early part of the first stage, present themselves without our being able to detect physical evidence that can be held to be decisive. Even in examples of the disease of some months' standing, occurring in my own practice, physical signs have been so ill-marked as to have justified suspended judgment, and it has been only by means of subsequent evidence, that a decided conviction could be arrived at, that the disease was all along pulmonary consumption. It is at the early part of the first stage chiefly, that the defective development of physical signs is thus found to render diagnosis difficult. When an injury has been inflicted upon an organ, when its action has been disordered, or when in the simplest inanimate machine a disturbing force or injury is in operation, the fact is revealed, or tends to be, by some disorder in the office discharged by the organ or the machine. The disordered action in either case may be great, and easily recognised, or it may be so very slight as to prove difficult of appreciation to our senses. If the suffering organ be an internal one, and the extent of the disordered action be small, to the ordinary inquirer the indications of suffering in the affected organ may be with difficulty observed, or may be altogether unappreciated; and this may be the case although the general health is manifestly declining. In the case of secreting organs, if a disturbing cause be in operation, we naturally look for some departure in the secretion from its normal state. This departure may be one of quantity, or it may be one of quality. In disordered conditions of the liver and kidney, we find disordered states of the bile and urine. In diseased states of muscles and of their motor nerves, their conditions are revealed by excess, irregularity, partial or total loss of motion, and other events. relating to the functions of the parts. If however we endeavour to apply to incipient tubercular disease of the lungs this method of inquiry, i. e. if we seek to discover some alteration in the ultimate function of the organ, we altogether fail, not perhaps because the inquiry is absolutely |