Part 1

TRANSCRIBER’S NOTE

Italic text is denoted by _underscores_.

Some minor changes to the text are noted at the end of the book.

The superscript re is denoted by 1^{re}.

OBSERVATIONS,

_&c. &c._

OBSERVATIONS

ON

M. LAENNEC’S

METHOD OF FORMING A DIAGNOSIS

OF THE

DISEASES OF THE CHEST

BY MEANS OF

THE STETHOSCOPE,

AND OF

PERCUSSION;

AND UPON SOME POINTS OF

THE FRENCH PRACTICE OF MEDICINE.

BY

CHARLES SCUDAMORE, M.D. F.R.S.

Member of the College of Physicians in London; Honorary Member of Trinity College, Dublin; of the Medico-Chirurgical Society of Edinburgh; and of the Medical Society of Paris; Member of the Medico-Chirurgical Society of London; Physician in Ordinary to His Royal Highness the Prince Leopold of Saxe Coburg, &c. &c.

London: PRINTED FOR THE AUTHOR, By Joseph Mallett, 59, Wardour Street, Soho;

AND PUBLISHED BY LONGMAN, REES, ORME, BROWN, AND GREEN, PATERNOSTER ROW.

1826.

TO Sir HENRY HALFORD, Bart. K.H. F.R.S. PRESIDENT OF THE COLLEGE OF PHYSICIANS, PHYSICIAN TO THE KING, &c. &c. &c.

MY DEAR SIR,

In requesting the honour of dedicating to you the following pages, I am actuated by the feelings of respect and personal regard, which I entertain equally for your public and for your private character.

It is also with more than ordinary interest that I address my observations to you, as the President of the College; an office which, it may with truth be said, you fill with no less dignity to yourself, than with benefit to the whole profession.

In becoming an advocate for the employment of the stethoscope, I disclaim adopting principles in the practice of physic, which might with any justice be called mechanical.

It cannot however be denied, that with all the improvements which the art of medicine has received, it still must, on many occasions, depend greatly on conjecture.

Some of the diseases of the chest are attended with such obscurity, that the detection of their precise nature bids defiance to the most acute penetration. What prudent physician, then, will disdain to avail himself of the means which this simple but philosophical instrument affords, of obtaining a more faithful diagnosis?

It is not intended that its use should supersede those established principles of our art, which early and regular education, as well as experience, have pointed out to us; but that it should serve as an auxiliary in the investigation of obscure disease.

For my own part, I have no apprehension that the judicious employment of the stethoscope can, in any degree, tend to make us negligent in observing the symptoms of diseases, or indifferent to the study of the usual means of diagnosis.

In the hope, that the general opinions which I have offered in this volume, may receive the high sanction of your approval,

I have the honour to remain, DEAR SIR, Your most obliged, faithful, And obedient Servant,

CHARLES SCUDAMORE.

Wimpole Street, April 14th, 1826.

PREFACE.

Having expressed my opinion generally on the merits of the stethoscope, in the course of the following Essay, I have little to say in the form of a preface.

Although the credit of the invention is due to the ingenuity of M. Laennec alone, and the volume which he has presented to us abounds with valuable pathology, it is of no small importance that the sentiments and the experience of others should also be collected and recorded.

Before any new method in the practice of medicine can be firmly established, or even deserve to be regarded in the light of fixed authority, it is incumbent upon us to examine all the collateral evidence which can be produced in its favour; and he who, with this view, contributes to the general stock of information, may claim the merit of usefulness, although he be not entitled to the more brilliant distinction awarded to genius.

It appears to me, that whoever adopts the use of the stethoscope, must study it for himself, and consider, that all which is offered to his attention by the industry and observations of others, is calculated to serve his purpose only as an introductory lesson.

The skilful employment of this instrument must be the result of practice. Every case which occurs, presents new and distinct matter for investigation. It is peculiarly necessary to be accurate in marking with nicety the nature of the impressions which are made upon the ear, and to reflect upon the phenomena with all the skill and care of the physiologist, the anatomist, and the physician. Nothing must be left to the imagination; for, if this creative faculty be exercised, the judgment may be misled, rather than informed and assisted.

I have purposely confined myself to a limited sketch of the general subjects which I have embraced; so that if the following pages should not appear to possess the merit of great novelty, they will, I hope, at least escape the imputation of being tedious and devoid of interest.

OBSERVATIONS,

_&c. &c._

In a late visit to Paris, I availed myself of the opportunity of attending the principal hospitals; of inquiring into the general practice of French medicine; and of studying, at the hospital of La Charité, the method brought to so much perfection by M. Laennec, of investigating the diseases of the chest; in regard to which, I had also the advantage of receiving every kind attention and personal instruction from this distinguished physician.

The method of which I now purpose to offer a brief account, embraces the use of percussion and of the stethoscope.

It appears that percussion was first practised by Avenbrugger in Germany, who published a treatise on the subject in the year 1761, which was translated into French by the celebrated Corvisart, with commentaries, in 1808. This author, in his Treatise on the Diseases of the Heart, constantly founds much of his diagnosis on the indications afforded by percussion.

The method consists in striking the respective parts of the chest, which return a hollow kind of sound, when the contents of this cavity are in a healthy state; but give a duller sound, when, from any cause, there is impediment to the free entrance of air into the cells of the lungs. When the obstruction is considerable, the perception is very much the same as when you strike upon the thigh. The sound is flat instead of hollow.

Simple as it may appear, there is a considerable tact in the mode of percussing; and it is of importance to practise it in aid of the information derived from the stethoscope.

The linen covering over the chest may remain, but thick dress should be removed, and the surface also ought to be smooth. The integuments should be rendered rather tense by the favourable position of the arms. The four fingers being held close, bent, and a little curved, the chest is to be struck rather sharply and in quick succession; and when the indication of obstruction is manifest by the dulness of sound, the corresponding part on the opposite side, is to be struck with equal force; nice care being observed that all circumstances are equal; as for example, the kind and strength of percussion, the quantity of covering on the part, and the position of the patient. At small points of examination, it will sometimes be convenient to use, in the same manner, only two fingers; or, now and then, on a broad surface, the flat hand, percussing rather slowly and gently.

M. Laennec displays no less skill and accuracy in his mode of percussion than in the use of his stethoscope; and he attaches great importance to it as an auxiliary source of information.

Through the industry and ability of Dr. Forbes of Chichester, who translated the work of Laennec in 1821, and who has also lately published an original volume of great merit on the subject; and through the medium of our medical journals, more especially the excellent quarterly works published at Edinburgh by Dr. Duncan, jun., and in London by Dr. James Johnson, the professional public has been made acquainted with the nature and uses of the stethoscope; but up to the present time, it is so much a novelty in medical practice, as well as with the public at large, that I trust no apology is necessary for presenting an abridgment of the opinions of M. Laennec, with a few reflections on the subject derived from my own observation and practice.

As with percussion, the use of the stethoscope is founded upon a simple philosophical principle; that of ascertaining whether the cells of the lungs are healthy, and fitted for the free reception of air in the function of respiration; or whether the membranes of the chest, or the vessels, valves, and cavities of the heart, are obstructed by any disordered action, or by any permanent disease.

The instrument which has received the name of _stethoscope_ (derived from στῆθος, pectus, and σκοπέω, speculor or exploro), was invented by M. Laennec; and the idea of it occurred to him from reflecting on the well-known fact in acoustics, that the impression of sound is augmented, 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. In examining a disease of the heart, he first made use of a quire of paper rolled into a cylindrical form, and, satisfied with the result, he soon proceeded to investigate the various phenomena afforded by the vibrations of air within the chest, through the medium of the stethoscope; which he constructed from the suggestion already mentioned.

After making various experiments as to the form of the instrument, and the kind of material, he found most success in using a wood of medium density, as cedar. This proves very favourable for conveying the delicate vibrations caused by respiration, from the walls of the chest to the ear. For the information of those who have never seen the instrument, I may observe, that it is of cylindrical form, shorter in length, but larger in diameter, than the common flute. It has a cylindrical perforation throughout its whole length, and is divided into two parts for the convenience of using the whole or half length, according to the situation of the patient in bed. The end of each part terminates in a funnel-shaped cavity, the one to receive the separate half of the instrument, and the other to receive the part acting as a stopper, which latter has a short pipe, made of brass or silver to enter the bore of the cylinder.

The instrument is used without the stopper, when employed to ascertain the state of respiration; and with it, either to examine the action of the heart, or the signs afforded by the voice, in certain states of disease affecting the lungs, or the pleural membrane.

In using the stethoscope, care is to be taken that it is kept perfectly flat upon the part to which it is applied, in order that sound may not escape, nor air be admitted; for which purpose it is convenient to hold it at its lower part, while the other end (with the even surface) should be in close contact with the ear, so that the aperture of the instrument be in direct communication with the internal ear. Silk covering, as causing a creaking sort of noise, and thick dress, as obscuring the sound of respiration, should be removed; but the linen or flannel dress may remain on the person without disadvantage. A beginner will be very apt to fail in his early trials, from inattention to some of these points, and from the difficulty which at first attends the tuition of the ear.

A skilful use of the instrument requires much practice. It is not, as some may imagine, a simple matter of hearing a delicate sound. _Tact_ is necessary, but this will be acquired by perseverance. For two days of my own study, I was frequently at a loss to distinguish the peculiar sound or murmur of respiration, and almost despaired of success. I mention this circumstance, that others beginning with the practice of this instrument, may not be deterred from proceeding, by the awkwardness and disappointment which they at first encounter.

At _La Charité_, the best informed students are great enthusiasts in the practice of this discovery, and regard it as an indispensable source of information in the diagnosis of the diseases of the chest. Such reliance on the stethoscope is very natural, when constant proofs are afforded of the accuracy of opinion formed by M. Laennec, and others, who are competent in using it. The proofs of sure diagnosis are derived from dissection; as, necessarily, the diseases of the lungs and of the heart, allow frequent opportunity of obtaining this test of the physicians’ judgment.

I will relate one instance which came within my immediate knowledge; although equally strong proofs are so numerous, that the regular observer can no more doubt the merits of the stethoscope, than the mathematician can distrust a resolved problem.

In the clinical record of a case of consumption, M. Laennec had stated his opinion, that the upper portion of one lung was the exclusive seat of ulceration. The patient died, and examination was made. The lungs were removed from the chest, and the expected evidence of disease did not appear. M. Laennec, making a closer inspection, discovered that a small part of the upper lobe had been left in the chest, and upon its removal, the ulceration was found exactly as he had predicted.

Some persons assert, that the discovery of the precise situation of an ulceration of the lung is merely a matter of curiosity, as when arising from tubercles, they consider it incurable; but surely this is not a good medical objection. Our art may improve so as to enable us to remedy these evils; and assuredly our chance of success will be increased by a knowledge of the seat of tubercles, their commencement, and their progress. While those persons therefore who have made use of the stethoscope with success, praise it in terms which may seem romantic and beyond the truth; others, and perhaps those chiefly who have never even seen the instrument, speak of it with ridicule, or censure it as a piece of quackery.

It is not just that any one wholly unacquainted with the stethoscope, should assume the right of pronouncing an opinion on its properties. It certainly does not deserve the imputation of quackery; for this opprobrium belongs to the concealment of a remedy; or to some mysterious plan of practice, studiously kept secret for the mere purpose of gain. Candour is most honourable to the educated mind; and to be sensible of our ignorance on any particular subject, is the first step to the acquirement of knowledge.

It has been said that the use of the stethoscope may be injurious, by leading the physician to know too much of the danger in a bad case; to make him despond and resign the patient to his fate too soon. Such an observation scarcely requires refutation. In no instance of dangerous disease can the physician see his way too clearly; and at all times to know the disease, is at least making a considerable approach towards the cure. The judgment, the discretion, and the humanity of the good physician, will be a sure protection to the patient against any abrupt decision, any gloomy opinion, and much more against unkind desertion, in the most hopeless circumstances of disease.

The following case serves to shew the converse proposition, and the happy purpose to which superior knowledge and discernment were applied.

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 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 pleuræ. 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 favourable, that the gentleman recovered his health in less than three months.

In thus rendering my homage to the merits and science of M. Laennec, I do not wish it to be thought, that I consider even his authority as infallible; but it is nothing more than is justly due to the new practice, to admit, that it may become of very great importance; and, that by no other mode can we examine the interior state of the chest, with equal accuracy.

Let it be further remarked, that we are not required to lay aside any of our ordinary methods of investigation: This additional mode comes to our aid in cases of obscurity and difficulty. If the physician of long experience be so confident in his powers of diagnosis, that he rejects this invention as unnecessary for his purpose, it need not follow that he should disapprove of it for others who are less experienced, and are more diffident of their skill and penetration. Most assuredly it is a great help to the judgment; and I am fully persuaded, that, in proportion as it is understood, it will be more generally received, and more highly esteemed.

If the naked ear be applied to any part of the chest, it is made sensible of the entrance of the air into the cells of the lungs; and the beginner in this study will receive the impression more fully and sensibly, than by the medium of the stethoscope, because the vibrations are collected from a larger surface; but it is a less accurate method, and much less analytical. He may with advantage practise with the naked ear occasionally, in order to become familiar with the sounds of respiration; but under many circumstances, such a mode is inconvenient and inapplicable. The listening by the ear only is technically called, immediate auscultation; and by the stethoscope, mediate auscultation.

In examining the chest of a person whose respiration is calm, we should desire that it be made purposely quicker, and stronger; but not so audibly as to cause confusion by that external sound. The perception afforded to the auscultator by healthy lungs, is that of air entering a cavity, as it were with a gentle stream of sound. If the pupil first apply his naked ear to the chest, he will have a clear idea of what he has to expect. As a general rule, in making our investigation of the state of the lungs, the stethoscope should be applied immediately under the clavicle, near the axilla; and the learner will do well to choose the right side, lest he become confused by the action of the heart. In seeking for ordinary respiration, it should not be applied near the trachea, as the stronger action of the air in the bronchial tubes would mislead the ear. To ascertain the state of the posterior part of the lungs, the instrument is to be applied on the scapula, above or below the spinous process.

In my own practice, I have derived the utmost advantage from the use of the stethoscope in cases of pneumonia, with regard to local treatment. When we find a patient ill with severe symptoms arising from inflammation of the lungs, we do not require the aid of auscultation to determine us in employing the lancet as our first and most important remedy; but we may desire immediately to join with the general bleeding, local depletion; and, most commonly, the period arrives when we wish to use local treatment exclusively, by cupping or leeches, and blisters. Under such circumstances, it is of the utmost importance that we should be able to ascertain the exact seat of the inflammation; and when, as commonly happens in pneumonia, the patient cannot direct us by any sensation of pain, but is labouring under a general sense of oppression and suffocation; we resort to the stethoscope as a positive and most valuable source of instruction. Even when it is manifested to us by ordinary indications, that the inflammatory action is prevailing on one side of the chest, it is of great advantage that we can detect, by means of the instrument, the particular part of the lungs most affected. I shall illustrate the truth of these remarks by the recital of a few cases.

A gentleman dangerously ill with inflammation of the lungs, which had supervened on an attack of asthma, experienced, in the evening, a renewal of the feelings of suffocation, which, in the morning had been relieved by copious bleeding from the arm. In the middle of the upper part of the chest, he had a severe sensation of tightness, but was not conscious that the lungs were affected more on one side than the other. His cough was most urgent. The stethoscope, applied to the lower part of the right side, conveyed to the ear a strong sonorous rattle, both on inspiration and expiration, much resembling the sounds of loud snoring. These sounds could not be detected in any other part of the chest. In addition, therefore, to a fresh bleeding from the arm, cupping was used very freely at this part, and with evident good effect. Almost immediately the sounds abated. Two days after, leeches and a large blister were used with further benefit; and the actual relief of the patient perfectly corresponded with the improving indications afforded by the stethoscope. Occasional bleedings from the arm were afterwards required; but the inflammation was finally subdued, and the constitution was restored to its previous state; this gentleman being habitually subject to spasmodic asthma.

A female patient was in a state of most alarming difficulty of breathing from neglected inflammation of the bronchiæ, which had extended to the lungs. The pulse was sharp and frequent, the skin hot, and every urgent symptom of high fever and irritation was present. Her cough was extremely violent, and the expectoration difficult. The expectorated matter was dense and almost puriform in appearance. On applying the stethoscope over the upper part of the right side of the chest, at every point, and also over the whole of the right shoulder blade, I heard acute sounds similar to those produced by air strongly passing through a key-hole. I considered that these sounds indicated active inflammation in the whole ramifications of the bronchiæ of the right lung. A large quantity of blood was drawn from the right arm; and cupping was also freely employed, both on the chest and shoulder blade. A saline draught with tartar emetic and nitre was administered every two hours. I need not detail the exact progress of the case. These principles of treatment being diligently followed up, the patient finally recovered.