REVIEW X.

The Physical Examination of the Chest in Pulmonary Consumption and its Intercurrent Diseases. By SOMERVILLE SCOTT ALISON, M.D. Edin., Physician to the Hospital for Consumption and Diseases of the Chest, Brompton.-1861. pp. 447.

ON turning from the great work of Laennec to the treatise the title of which stands at the head of this article, we are at once made aware of the great extension of knowledge as to the phenomena to be elicited by the arts subservient to physical diagnosis, which has taken place during the forty years that separate their publication. The only signs of incipient pulmonary consumption recognised by Laennec are summed up in a few lines; they may be referred to the two heads of diminished resonance on percussion and diffuse broncophony. Dr. Alison devotes to their consideration more than a hundred pages of a closelyprinted octavo volume, and we are not aware that to one of the more salient characters he describes is a place now denied amongst the generally admitted signs of the disease. We do not entirely acquit the author of a fondness for over-refinement, or of occasional reiteration. Some will consider the latter scarcely a fault; in the present case, the former may, we think, be readily excused. The science in which Dr. Alison has rendered himself a proficient is one in which, within certain limits, advance and refinement are synonymous. However it may be desirable for the learner that the varying gradations of sound which arise within diseased tissues should be epitomized under a few comprehensive formulæ, we must believe that an exact recognition of the morbid conditions on which such phenomena depend is not to be obtained by loose generalization. This treatise would be out of place in the hands of the mere student, but by the careful and painstaking physician, whose aim it is to increase his power of detecting disease by every hint which experience can afford, and by every means which ingenuity can suggest, Dr. Alison's labours will be fully appreciated. Although on some points we may be at variance with the author, we would at the outset most willingly accord to his work the praise due to a most complete, comprehensive, and elaborate treatise on the signs of tubercular disease of the lungs.

The question, whether greater weight is to be attributed to physical signs or to symptoms in forming a judgment as to the existence of early phthisis, is discussed in the first chapter of the work. The author balances the evidence furnished by 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, against that to be derived from the alteration of the percussion-note, the harsh or quasi-tubular, perhaps divided inspiration, 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 one or both sides, the strong vocal resonance and fremitus, and the systolic bruit of the

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pulmonary and subclavian arteries, occurring together with healthy vesicular breathing heard over other parts of the chest, and a normal character of the cardiac sounds, and decides unhesitatingly in favour of the latter. Placing the two sets of phenomena thus in juxtaposition, we cordially agree with him; but the question immediately presents itself: Are there no cases of undoubted phthisis in which in the incipient stage, although marked by a general deterioration of health, one or more-nay, even the whole category of physical signs, have been unrecognisable? The affirmative is virtually ceded by the admission "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 period of the first stage present themselves without our being able to detect physical evidence that can be held to be decisive." But it is precisely in these cases that correct diagnosis is most necessary, because treatment is then most effectual. The lung through which miliary tubercles are sparingly scattered will yield no information to the percussion-stroke; difference in the vesicular murmur heard over the healthy and unhealthy apices, may be no greater than that variation which is known to be consistent with a perfectly healthy state; the expiratory sound, in place of being prolonged, may (we state it on the authority of Skoda) be altogether inaudible, whilst the other signs enumerated may be but feebly pronounced or absolutely wanting; and yet the real nature of the case shall be indicated by some loss of strength and flesh, by slight cough and shortness of breath, by a quickened state of the circulation-in fact, by the usual symptoms of approaching decline. If in such an instance the history should show that the attack had not originated with ordinary catarrhal coryza, and if in addition the existence of hereditary predisposition be established, we believe that a diagnosis of incipient phthisis would be better founded than were it made in the case of an individual in ordinary health, in whom, nevertheless, the respiratory murmur failed to accord with a preconceived standard, and even other physical indications of an abnormal variation might be noticed. Neither should we distrust our opinion in the former case, although, in consequence of appropriate regimen and remedial measures, the patient progressed towards recovery, and the auscultator were denied the peculiar (but surely melancholy) "satisfaction" which Dr. Alison describes as being experienced when a doubtful diagnosis is confirmed by the supervention of the moist crepitation of the second stage. The truth is, that in actual practice, little real importance will attach to the question. The aid of the physician is invariably sought, because certain symptoms exist which are considered to be of moment by the patient or his friends. This class of indications, therefore, furnish the ground for further investigation, and are probably never dismissed from the mind in the subsequent examination of the case. As far as they may be present, both sets of phenomena are potentially within the ken of the practitioner; and in a condition confessedly so difficult to be discriminated as early phthisis, due importance must be allowed

to the information which each is capable of affording, would he practise with advantage to his patients, or, we may add, to himself.

In the preface to the work two objects are proposed; one is to give a detailed account of the leading physical signs of the chest, &c., in pulmonary consumption; the other, to afford "some practical directions for the examination of the sufferer, and to offer a full account of the instruments employed in exploration, of the principles of their construction, and of their mode of operation." The prominence given by the author to the employment of certain mechanical aids to diagnosis not in general use, induces us to refer to the portion of the work dedicated to the latter object first, as by so doing we shall avoid the necessity of interpolating explanations in our notice of the former and more important section.

We pass over the practical directions for the examination of the chest, not because they possess but little value, but because the more important of them are to be found in most standard works on auscultation. We also shall not recapitulate the various instruments described and commented on with more or less of approval. Taken together, they would go far to constitute an armamentarium medici rivalling in proportions the chirurgical collections of the seventeenth century. Of the instruments contrived by the author, two appear to be of really practical value. One is the chest-goniometer for measuring the angles and estimating the curves or flatness of portions of thoracic surface; the other is the differential stethoscope, an invention which may prove a valuable auxiliary in the detection of differences in respiratory sound over different pulmonary areas. The mechanism of this instrument is partly borrowed from the double stethoscope invented by Dr. Camman of New York. The purposes which the two instruments are intended to fulfil are, however, entirely different. Dr. Camman's, like other bin-aural stethoscopes, is only meant to intensify the sound produced in one portion of the thorax by conveying it simultaneously to both the ears of the auscultator. By the differential stethoscope each ear is employed at the same moment in receiving sound from a different region. The latter consists simply of two hearing-tubes or stethoscopes, composed partly of metal, partly of flexible material, each provided at one end with a cup for the collection of sound; at the other, which is curved inwards to meet the ear, with a knob for introduction into the external meatus. The tubes are connected by a jointed bar, which is calculated to prevent the transmission of sound from one tube to the other, and by an indiarubber band, which by its elasticity obviates the necessity for using effort to keep the ear-knobs steadily applied. The instrument so constructed may be used in two different ways, and in each it is capable of affording important information. It may be employed for "the consecutive observation of the sounds of two parts of the chest by the two different ears." This is done by first applying one of the cups over the region to be examined, and, having completed the observation, by removing it and immediately applying the other cup over the area selected for comparison. Variations in force, duration, and quality

of sound are thus easily estimated. The other mode of use is by the simultaneous application of the sound-receiving cups over the two areas chosen. We shall best make our readers acquainted with the very remarkable results obtained from this method of examination by transcribing the author's own words :

"The differential stethoscope proves of value not only in taking consecutive observations; it affords, as has been discovered in practice, without, if not contrary to expectation, most valuable information when observations are made upon two different parts of the thorax at the same moment. It has been proven, by this instrument, that slight differences in the intensity of the same sounds conveyed separately to the two ears produce remarkable and very striking results. The same sound conveyed to one ear a little stronger, and the same sound conveyed a little weaker to the other ear, is, or seems to be, heard through that ear only which has the major sound, and not at all through that ear having the minor sound. It is to be borne in mind that the conveyance of sounds to the two ears must be simultaneous. Not only does the sound appear to be heard in or through the ear favoured with the major sound, and not at all in or through the ear supplied with the minor sound, but the parts from which the sound proceeds, according as they are connected with the ear more or less favoured, are sounding or silent. To be more explicit : a body which sounds in one ear is rendered sensorially silent when the other ear is connected with that body in such a manner or in such a place as to receive rather more sound, the favoured ear seeming to be the only medium or organ through which the sound is perceived, and the place so connected with this ear being the only one which is sounding. Further, lest the idea which we desire to enforce should not be understood, let it be added, that a sound audible in or through one ear is rendered inaudible in or through it the moment the same sound is conveyed in greater force to the opposite ear; sound quoad the first ear being taken away, and transferred sensorially, so to speak, to the second." (p. 326.)

Facts illustrative of the principle here enunciated form a principal feature of the work. Some of them will be adduced as we proceed. The only practical objection we have seen to the employment of the differential stethoscope depends, not on any imperfection in the instrument itself, but on the frequency of sensorial defects in those who may use it. It is a well-known fact that in many individuals there is a natural, and in many auscultators, an acquired difference in the auditory power of the two ears. Some of the most skilful investigators are the subjects of this peculiarity. Before, therefore, the practitioner can venture to rely upon the more delicate indications derived from the use of Dr. Alison's instrument, it is absolutely necessary that he should assure himself by repeated comparative experiments that his sensibility to sound on the two sides is equally acute. As the ingenious instrument contrived by the author for measuring the thoracic movements in respiration by the rise and fall of water in a graduated tube (hydrostatic pneumatoscope) is not likely ever to come into extended use as a means of investigating the phthisical condition, we must pass over it with bare mention. We would only notice that the same instrument slightly modified (sphygmoscope) affords a delicate means of estimating the amount of cardiac impulse. By the ingenuity of Dr. Upham, who has connected with the sphygmoscope an electro-magnetic machine

with a bell attached to it, that instrument has been converted into an acoustic appliance. An account of this latter invention is to be found in the brochure by the well-known M. Groux, on Fissura Sterni,' which, along with the instrument, was described in No. liii. of this Review, p. 276. The physical signs of the first stage of phthisis which are enumerated under the head of auscultation are those dependent on alterations in the character of the vesicular and expiratory murmurs, different varieties of bronchial breathing termed by the author "bronchnoa sounds," and alterations in the thoracic voice sound. The first modification of the vesicular murmur is generally allowed to be the acquirement of harshness and increased loudness, which soon becomes accompanied by deficiency in duration. A change of an opposite character is, however, not infrequently observed, although Dr. Alison believes that it occurs at a later stage than harsh respiration sound, and that it depends on an increased deposit of tubercle, which annihilates vesicular movement. The inspiratory murmur has become more feeble, and but little audible. The author applies to this modification of the vesicular breath-sound Skoda's favourite epithet "indeterminate." The weak inspiratory murmur of the first stage of phthisis is liable to be confounded, on the one hand, with the scarcely audible respiration sound which is sometimes observed in individuals advanced in life, and in persons of calm temperament and slow respiration and circulation; and on the other hand, with the very deficient inspiration-sound of dry old cavities. In the first class of cases, Dr. Alison would rest his diagnosis on "the detection of an inspiratory bruit, normal in length, although ill-pronounced in pitch and intensity," and on the character of the respiratory sound "being general over both sides of the chest, which is not the case in the feeble respiration of phthisis." It must be admitted, however, that cases may occur in which these grounds of discrimination will prove insufficient; for the duration of the vesicular murmur is not only always diminished in advancing age, but it is liable to variations within the limits of health. Moreover, the character of the inspiratory sound is not always the same over the whole chest ; in some instances, it is louder on one side over the supra- and infra- clavicular regions than on the other, and the normal murmur is readily supposed defective when it is compared with a louder or harsher breathsound heard over another area. It is precisely in such cases that we should not hesitate to prefer the general symptoms present as the basis of diagnosis, to the necessarily uncertain revelations of the stethoscope. The mistake of confounding the feeble respiration of early phthisis with the very deficient sound of dry old caverns, Dr. Alison believes to be a common error. In such cases, the differential stethoscope will generally furnish correct information.

"The respiration of many cavities which are dry, of no great size, whichhave free bronchial communication, both intra and extra, with little or no mucus at the openings of the bronchi to produce bubbling or clicking, free from distinct cavernous pectoriloquy, approaches the character of feeble vesicular respiration. The approach to feeble, ill-formed vesicular respiration sound is such, that it may be, and often is confounded even by practical stethoscopists with