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Week2_Laennec - From an 1821 translation of Laennec's 1819...

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Unformatted text preview: From an 1821 translation of Laennec's 1819 treatise on mediate auscultation. ' 0N me DIAGNOSIS OF DISEASES OF THE CHEST. INTRODUCTION. HOWEVER dangerous diseases of the chest may he,they are, nevertheless, more frequently curable than my other severe internal affection. For this reason medical men, in all ages, have been desirous of ob- tsining a correct diagnosis of them. Hitherto, how- ever, their efl'orts have been attended by little suc- cess,—a circumstance which must necessarily result from their having confined their attention to the observation and study of the deranged functions only. From the continued operation of the same cause, we must even now confess, with Bsglivi, that the diagnosis of the diseases of this cavity is more obscure than that of those of any other internal Mgan. Diseases of the brain, not in themselves numerous, are distinguished, for the most part, by constant and striking symptoms; the sol! and yield- in; parietes of the abdomen allow us to examine, oo 282 mssasas or Tue (211337. through the medium of touch, the organs of that cavity; and thus to judge, in some measure, of the size, position, and degree of sensibility of these, and, also, of the extraneous bodies that may be formed in them. On the other hand, the diseases of the . thoracic viscera are very numerous and diversified, and yet have almost all the same class of symptoms. Of these the most common and prominent are cough, dyspnoea, and, in some, expectoration. These, of course, vary in different diseases; but their varia- tions are by no means of that determinate him! which can enable us to consider them as certain in. dications of known variations in the diseases. The consequence is, that the most skilful physician who trusts to the pulse and general symptoms, is often deceived in regard to the most common and best known complaints of this cavity. Nay, I will go so far as to assert, and without fear of contradiction from those who have been long accustomed to morbid dissections,——that, before the discovery of Avenbrugger, one half of the acute cases of perip- neumony and pleurisy, and almost all the chrome pleurisies, were mistaken by practitioners; and that, in such instancesas the superior tact of a physrcian enabled him to suspect the true nature of the dis- ease, his conviction was rarely sufficiently strong to prompt and justify the application of very powerful remedies. The percussion of the chest, according to the method of Avenbrugger, is one of. the most valuable discoveries ever made in medrcme. By means of it, several diseases, which had hitherto been cognisable by general and equivocal signs only. macuoars. 233 he brought within the immediate sphere of our perceptions, and their diagnosis, consequently, ren- dered both easy and certain. We must still admit, however, that the method of percussion is far from being complete, or generally available. It frequently affords no indication in phthisis; and in no case does it enable us to distin- guish this disease from chronic peripneumony. Even in peripneumony it fails us in a great measure when the inflammation is confined to the centre of the lung, or when both lungs are equally afl'ected, and only in a slight degree. It does not enable us to distinguish the disease just mentioned from pleurisy, hydmthorax, or any other effusion into the cavity of the chest. It completely fails us, or rather cer- tainly misleads us, in the disease called Puma- Thorax. It gives no indication of the diseases of the heart until this organ is greatly enlarged; and itis often before this takes place that the disease proves fatal. It afl'ords no assistance in aneurisms of the aorta and large vessels, until the nature of the disease is appreciable by the sight, or by the touch. In many other respects, also, the indications afforded by percussion are rendered equivocal by peculiarities of formation, by the niceties required in its perfum- ance, and by the circumstances under which it is performed. It is more particularly in diseases of theheart that we regret the insufciency of this lethod, and wish for something more precise. The general symptoms of disease in this organ greatly resemble those produced by many nervous com- Pllints, and by the diseases of other organs. The 284 Diseases or run cuss-r. results afl'orded by the application of the hand to the part, with the view of judging from the tactual sensations communicated, have been found of some use, in doubtful cases; but, as a general method, this is by far too vague and uncertain to be of much benefit. In these cases some physicians have attempted to gain further information by the application of the ear to the precordial region; and, doubtless, such a proceeding will encrease the certainty cf the diag- nosis. Even this, however, is very insufiicient; and there are, besides, many reasons why it cannothe followed, as a general guide, in practice. Neverthe- less, I had been in the habit of using this method for along time, in obscure cases, and where it was practicable; and it was the employment of it which led me to the discovery of one much better. In 1816, I was consulted by a young woman labouring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just men- tioned being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, and fancied, at the same time, that it might be turned to some use on the present occasion. The fact I allude to is the augmented impression of sound when conveyed through certain solid bodies,—as when we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other. Immediately, on thin suggestion, I rolled a quire of paper into a sort 0‘ mammals. 285 cylinder and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased, to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear. From this moment I imagined that the circumstance might furnish means for enabling us to ascertain the character, not only of the action of the heart, but of every species of sound produced by the motion of all the thoracic viscera. With this conviction, I forthwith commenced at the Hospital Necker a series of observations, which has been continued to the present time. The result has been, that I have been enabled to discover a set of new signs of dis- eases of the chest, for the most part certain, simple, and prominent, and calculated, perhaps, to render the diagnosis of the diseases of the lungs, heart and pleura, as decided and circumstantial, as the indica- tions furnished to the surgeon by the introduction of the finger or sound, in the complaints wherein those are used. In prosecuting my enquiries I made trial of in- struments of various composition and construction.— The general result has been that bodies of a mode- ratc density, such as paper, wood, or indian cane, are best suited for the conveyance of the sound, and consequently for my purpose. This result is per- haps contrary to a law of physics ;——-it has, never- theless, appeared to me one which is invariable. I shall now describe the instrument which I use at present, and which has appeared to me preferable 286 msusu or “I cussr. to all others. It consists simply of a cylinder of wood, perforated in its centre longitudinally, by a bore three lines in diameter,‘aud formed so as to come apart in the middle, for the benefit of being more easily carried. One extremity of the cylinder is hollowed out into the form of a funnel to the depth of an inch and half, which cavity can be oh- literated at pleasure by a piece of wood so con- structed as to fit it exactly, with the exception of the central bore which is continued through it, so as to render the instrument in all cases, a pervious tube. The complete instrument,—that is, with the funnel-shaped plug infixed,—is used in exploring the signs obtained through the medium of the voice and the action of the heart; the other modification, or with the stopper removed, is for examining the sounds communicated by respiration. (See Plate VIII.) This instrument I commonly designate simply the Cylinder, sometimes the Stethoscope. In speaking of the different modes of exploration I shall notice the particular positions of the patient, and also of the physician, most favourable to correct observation. At present I shall only observe that, on all occasions, the cylinder should be held in the manner of a pen, and that the hand of the observer should be placed very close to the body of the patient to insure the correct application of the instrument. The end of the instrument which is applied to the patient,—that, namely, which contains the stopper or plug,——ought to be slightly concave to insure its greater stability in application; and when there is nuonosu. 287 much emaciation, it is sometimes necessary to insert between the ribs a piece of lint or cotton, or a leaf of paper, on which the instrument is to be placed, as, otherwise, the results might be affected by the imperfect application of the cylinder. The same precaution is necessary in the examination of the circulation in cases where the sternum, at its lower extremity, is drawn backwards, as frequently hap- pens with shoemakers, and some other artisans. Some of the indications ali'orded by the stetho- scope, or mediate auscultation, are very easily ac- quired, so that it is suflicient to have heard them once to recognise them ever after: such are those which denote ulcers in the lungs, hypertrophia of the heart when existing in a great degree, fistulous commu- nication between the bronchia and cavity of the pleura, 8m. There are others, however, which re- quire much study and practice for their effectual acquisition. ' The employment of this new method must not make us forget that of Avenbrugger; on the contra- ry, the latter acquires quite a fresh degree of value through the simultaneous employment of the former, and becomes applicable in many cases, wherein its solitary employment is either useless or hurtful. It is by this combination of the two methods that we obtain certain indications of emphysema of the lungs, pneumo-thorax, and of the existence of liquid extra- vasations in the cavity of the pleura. The same remark may be extended to some other means, of more partial application, such, for example, as the Hippocratic nit-mission, the wusumlimr of the 288 msmas or ran cassr. thorax, and immediate auscultation; all of which methods, often useless in themselves, become of great value when combined with the results pro- cured through the medium of the stethoscope. In conclusion, I would beg to observe, that it is only in an hospital that we can acquire, completely ' and certainly, the practice and habit of this new art of observation; inasmuch as it is necessary to have occasionally verified, by means of examination after death, the diagnostics established by means of the cylinder, in order that we may acquire confidence in the instrument and in our own observation, and that We may be convinced, by ocular demonstration, of the correctness of the indications obtained. It will be snflicient, however, to study any one disease in two or three subjects, to enable us to recognise it with certainty; and the diseases of the lungs and heart are so common, that a very brief attendance on an hospital will put it in the power of any one to obtain all the knowledge necessary for his guid- ance in this important class of afi'ectiona. There are three classes of application of this instrument, viz. as regards the Voice—the Respiration—and the Circulation; all of which I shall here briefly notice as observable in the healthy subject; referring for the varieties of these, as modified by disease, and {0' the diagnostic indications afforded by them, to the individual affections to be noticed hereafter. I. Tua'Vorcn. When a person in health speak! or sings, his voice excites in the whole parietes of the thorax a sort of vibration, which is easily per- ceived on applying the hand to the chest. Th! nrsonoars. 289 phenomenon is no longer observable when, through disease, the lungs have ceased to be permeable to the air, or are removed from the contact of the pari- etes of the chest by an efi'used fluid. This sign in of inferior value, since a great many causes occasion varieties in the intensity of the vibration, or com pletely destroy it. For instance, it is little sensible in fat persons, in those whose integuments are cone siderably flaccid, and in those who have a sharp and weak voice. Anasarca of the chest completely destroys it, even when the lungs are quite sound. In any case it is only very perceptible at the ante— rior and superior part of the chest, on the sides, and in the middle of the back. From these and other causes we can derive little practical benefit from av tending to this particular circumstance. 0n making use of the cylinder with the view of further investigating this phenomenon, I soon found, as indeed might have been expected, that it conveyed the peculiar vibration much less distinctly than the bare hand. I also ascertained that the degree of intensity of the vibration varied in difi‘erent points of the thorax. The places where it is most distinct are the sails, the back—between the spine and the edge of the scapula, and on the anterior and superior part of the chest near the angle formed by the union of the clavicle with the sternum. When we apply the cylinder to these points, the voice appears stronger and nearer to us; in the others, on the tontrary, particularly in the inferior and poste- rior parts of the thorax, it seems weaker and ”I. reinote. P P 290 nrsaasas or ran caasr. II. Rasmauros. On applying the cylinder, with its funnel-shaped cavity open, to the breast of . healthy person, we hear, .during inspiration and expiration, a slight but extremely distinct murmur, answering to the entrance of the air into, and its expulsion from, the air cells of the lungs. This murmur may be compared to that produced by a pair of bellows whose valve makes no noise, or, still better, to that emitted by a person in a deep and placid sleep, who makes now and then a profound inspiration. We perceive this sound almost equally distinct in every part of the chest, but more parti- cularly in those points where the lungs, in their dilatation, approach nearest to the thoracic parietes, as, for instance, the anterior-superior, the lateral, and the posterior-inferior regions. The hollow of the axilla, and the space between the clavicle and superior edge of the trapezius muscle, exhibit the phenomenon in its greatest intensity. It is equally perceptible on the larynx, on the exposed or cervical portion of the trachea, and, in many persons, through the whole tract of this canal to the bottom of the sternum; but on the trachea, and in some degree at the root of the bronchia, the respiratory murmur has a peculiar character, which evidently indicates the transmission of the air through slugs! space than the air cells. In this position, also, It often seems as if the patient, in inspiring, inhales the air through the tube of the stethoscope, and expel“ it by the same, during expiration. To judge correctly of the state of respiration by this method, we must not rely on the results of tho nuouosrs. 291 first moments ofexamination. The sort of buzzing sensation often caused by the first application of the instrument, the fear, restraint, and agitation of the patient, which mechanically lessen the force of respi- ration, the frequently inconvenient posture of the ob- server, and the great sensation occasionally produced bythe action of the heart,-—are all causes which may at first prevent us from correctly appreciating, or even from hearing at all, the sound of inspiration and expiration. We must, therefore, allow some seconds to pass before we attempt to form an opinion. I need hardly observe that there must be no noise whatever in the vicinity of the patient. The inter- vention of clothing, even when- of considerable thick ness, does not sensibly diminish the sound of respi- ration; but we must be careful that there is no friction between this and the instrument, as this circumstance, especially if the clothes are of silk, or of a fine hard stuff, may mislead us by exciting a sensation analogous to that produced by respiration. Fatness, :even when excessive, and anasarca of the chest, seem to have no notable efi‘ect in diminishing the peculiar sound. The sound is more distinct in proportion as the respiration is more frequent. A very deep inspiration made very slowly will some- times he scarcely audible, while an imperfect inspi- ration, such, for instance, as hardly at all elevates the chem—provided it be made quickly, may pro- duce a very loud sound. On this account, when “mining _a patient, more especially if we have had but slight practice with the instrument, we should ass nrsusas or run cassr. desire the respiration to be performed rather quickly. This is, however, a very unnecessary precaution in most diseases of the chest, 'as the frequent presence of dyspnoea necessarily renders the respiration quick. The same is true of fever, and the agitation caused by nervous afl‘ections. Many other causes, and especially the age of the individual, alter the intensity of the sound. In children, respiration is very sonorous, even noisy, and can be heard easily even through very thick clothing. In them the close and forcible application of the instrument, to prevent the friction of the garments, is unnecessary, as any noise that might arise from this cause is lost in the intensity of the other. The respiration of children differs, also, from that of adults in other respects besides its intensity. It is impossible to describe this peculiarity, but it will easily be understood by comparative trials. It appears as if, in children, we could distinctly hear the dilatation of all the air cells to their full extent; whilst, in adults, these seem as if, from their stiifness. they could only hear a partial dilatation. This dii~ ference of sound is much less marked in expiration than inspiration. The dilatation of the chest in inspiration is also greater in the child, and both these peculiarities are more remarkable as the child is young: they continue, in a greater or less degree. to the period of puberty or a little beyond it. The sound produced by respiration varies, sin. very much in its intensity in different adults. In some men it is scarcely perceptible unless they make a very deep inspiration, and even then, although DIAGNOSIS. 293 sufficiently distinct, it is not one half so audible as in the majority of persons. These individuals have generally a rather slow respiration, and are little subject to dyspntea, or breathlessness, from any cause. Others, however, have the respiration very sensible even during a common inspiration, without being, on this account, at all more subject to short- ness of breath than the former. Some few indivi~ duals, again, preserve through life a state of respi- ration resembling that of children, and which I shall therefore denominate puerile, in whatever age it may be perceptible. Such persons are almost all women, or men of a nervous temperament, and they preserve, in some other respects, the character of childhood. Some of these cannot be said to have any actual disease of the lungs, but they soon get out of breath, even though lean, by exercise. and are very liable to catch cold. Others of this class are affected with a chronic eatarrh, attended by dyspnoea, a condition constituting one of those cases to which the name of Asthma is usually given. With these exceptions, an adult cannot, by any efl‘ort, give to his re...
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