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utero; and it becomes equally difficult when the living child is first expelled to detect the presence of its blighted twin. These cases are fortunately, however, of rare occurrence.
• REVIEWS. DR WALSHE. On Diseases of the Lungs and Ileart. 2d Edition
1854. Small 8vo, pp. 797. Dr Hughes Clinical Introduction to the Practice of Auscultation,
etc. 2d Edition. 1854. Small 8vo, pp. 302. DR WEBER. On Auscultation and Percussion. Translated by Dr
Cockle. 1854. 8vo, pp. 137. DR HERBERT Davies Lectures on the Physical Diagnosis of the
Diseases of the Lungs and Ileart, etc. 2d Ed. 1854. Small 8vo, pp. 364. Dr Hughes BENNETT's Introduction to Clinical Medicine. 2d
Ed. Foolscap 8vo, pp. 134.
An extraordinary impulse has been given of recent years to that branch of physical diagnosis which has for its object the detection of internal thoracic and abdominal diseases. No medical subject has of late been more extensively handled by our contemporaries. The list of works at the head of this article serves to illustrate this statement, and yet it seems only yesterday since physicians in high places positively ignored the stethoscope, stamped it as an improper novelty, and treated its revelations as untrue, and useless, and superfluous. Now, however, it has come to pass that we are disputing, not about the use of auscultation, not fighting to give the thing a local standing and a name in the domain of medical science, but disputing upon some of the finer shades and phases of one particular item in the long catalogue of facts which are included under the head of auscultation !
Yes! men are disputing, and auscultation has its schools! We are told of a German, and we hear of a French school ; Laennec rules here, and his commentator Skoda there. The collision of opinions has taken place, and we cannot doubt that the end of the conflict will be more perfect methods in this branch of physical diagnosis, and clearer conceptions of the real value of physical signs.
This history of the stethoscope, had we time to indulge in a moment of reflection, might teach us a few useful lessons, which could, perchance, find their application at the present hour. When shall we learn to acknowledge, to a purpose, that dogmatism in
NEW SERIES.—NO. I. JANUARY 1855.
medicine—the practice of which is of necessity mostly empirical—is impossible, in a philosophic sense ? When shall we learn to calculate coolly the quantity of those words, “I am convinced," “ I am sure," etc., and reducing to their true value the facts, for instance, resulting from physical diagnosis, make the analysis of them purely scientific, and free them from all imaginary and preconceived admixtures ?
Certainly, we may say, that if any one will cast a glance over the past and present history of the stethoscope and its revelations, he will, if he is a wise man, be careful for the future, at least, not to indulge in any extreme opinions affecting the matter of auscultation in all its bearings; he will be cautious in the reception of facts; he will be most cautious in his interpretation of the value of those facts, and cautious even in the practical application of his remedial art as guided by those facts. Ilow many particulars are there concerning which “ we have no earthly doubt," whereon observers, equally as learned and capable as ourselves, doubt very considerably?
The number of works on the subject of auscultation, which have of late issued from the press, both in this country and on the continent (the supply indicating the demand), shows that medical observers generally are becoming daily more alive to the value of the subject; and the differences of opinion expressed in them proves how much of it yet remains doubtful and difficult. On this head we will just suggest to our readers, that perhaps that side of the matter which is most worthy of it has hitherto received the smallest degree of attention--we mean the valuation of the signs obtained, their actual worth and interpretation as exponents of disease, and as guides to treatment. It may be very useful for us to know the physical causes which produce bronchophony, but surely when we stand as physicians at the bedside of the patient it is of far greater import for us to know the diseased conditions on which, for instance, those fine crackling bubbles depend—whether they indicate bronchitis, or ædema, or pneumonia – whether the bronchophony heard depends upon pneumonia or results from pleurisy-than to be well informed as to the ins and outs of consonance, unison, resonance, and such like theories. It is of far greater value to know the meaning of a sound than to be disputing about its mode of formation, especially when we know that such sound may be possibly the indicator of very different conditions.
We have occasion to say but little respecting the works named above. Of Dr Walshe's we need do no more than announce the fact of the appearance of a second edition of it, one which he tells us, “has been carefully revised and much enlarged.” We can have no hesitation in saying that it contains the most complete and philosophic summary of the subject of physical diagnosis of diseases of the thorax which we possess in this country.
It is not so fitted for the hand of the student who is coinmencing the study of auscultation as the works of Dr H. Bennett and Di Hughes; in these, the student will find himself more at home, and
we should certainly advise him to pick up all the information they can afford him before he betakes himself to the wide work of Dr Walshe, and dips into the sea of controversy it opens to him.
There is much plain and excellent advice given to the student in Dr Hughes' work, advice which we value much, for the reason that authors generally overlook too much the points which it is concerned about. As illustrative of this, we cannot forbear referring to one particular, and shall extract the passage where it occurs, as especially worthy of the practitioner's attention, and as giving a good idea of the clear head and good practical sense of its writer :
"It cannot be too forcibly impressed on the mind of the student, and it may, therefore, be here again brought to his recollection, that there are few, very few, single signs, if, indeed, there be any, which are purely characteristic or pathognomonic of any particular disease. The more he observes for himself, and the more attentively he studies the products of disease, the more convinced will he become of this truth. Auscultation and its handmaid arts, often enable us, with almost perfect certainty, to predict various morbid changes, but of the exact nature, or rather of the cause of those changes, they tell us little or nothing. Physical signs merely indicate certain physical conditions, which may be produced by two, or by a variety of causes. The physical condition of the organs may be very generally detected by auscultation, and the other different modes of exploration treated of in this work; but information in respect to the morbid process by which it has been produced, must be sought for in other channels, and be determined by other means, as by the general symptoms of disease or by the history of the respective cases. Let the student ever recollect, and excuse us for repeating again and again the axiom which we are so anxious to impress upon his mind, that physical signs are indicative only of certain physical conditions, and not of particular diseases." --P. 130.
There are some matters in Dr Hughes' work which we must recommend to his further consideration Will Dr Hughes give us his proof of the statement that “in simple venous congestion of the lung, ... dulness on percussion exists,” etc. ? Has he one single fact which warrants such an assertion? Evidently the demonstration of it during life is almost, if not altogether, impossible ; and, after death, has Dr Hughes ever met with a case of simple venous congestion where the percussion sound has been thereby altered ? We refer to this matter because it is one of daily and practical import, and because we know it to be a very common belief with physicians, that simple congestion of a lung will produce dulness on percussion. Now we venture to deny the correctness of such an opinion, and for the reason that we cannot discover any alteration produced in the percussion sound of a lung after death, however congested the lung may be. If our position be correct, then the corollary which results from it is this, viz., we are not to conclude because the percussion over a lung is unchanged that the lung is not very highly congested, and, moreover, if the percussion of a luny be altered, then may we be certain that the change it has undergone indicates something more than that of simple congestion.
We also trust that our author will, on some future occasion,
reconsider the question of pectoriloquy and bronchophony, as her stated by him. “We think, if he will carefully re-read what he has written on this point, he will admit that he has left the subject in a most complete embroglio. Is he not very hard in the following passage on the “recusant” who has the misfortune to differ from him, and does he think that such a statement as this is a lucid summary and clear exposition of facts ?
“It must not, however, be supposed that there exists any defined line of demarcation between each, so that it can be said here ends pectoriloquy and here begins bronchophony. They all gradually merge into each other; they are not distinct species, but merely varieties of sound. So that what one abs cultator may call imperfect pectoriloquy, another may denominate broncho phony. But to deny the distinction between well-marked pectoriloquy and bronchophony (I speak not of the indications afforded by them, but of the sounds themselves) appears to me tantamount on the part of the recusant to the acknowledgment that he has a bad ear, or is an indifferent auscultator." -P. 127.
Well, here, if Dr Hughes is correct, we must confess to a bad ear, and to a bad understanding, for we do deny the distinction Dr Hughes refers to, and perhaps we don't exactly understand his larguage; if Dr Hughes means to say that the sounds have no special indications, he evidently gives up the whole gist of the position—it he means that well-marked pectoriloquy is not characteristic, for instance, of a cavern (and he seems to do so), then it appears to us that all these distinctions become mere jeux de mots, and that pectoriloquy and bronchophony are but examples of the same sound, the sound being louder or weaker-and, if so, then certainly th: sooner we get rid of one of these words the better. It has indera been suggested, if we ever arrive at that degree of philosophic modesty which is contented not violently to strain conclusions oc: of facts, and but to receive just so much as, and no more than, such facts simply express, that pectoriloquy would be a more proper word than bronchophony to express the thing indicated thereby, viz., the voice sounding in the thorax; and there appears much reason in the suggestion, inasmuch as pectoriloquy merely indicates the fact. whereas bronchophony prejudges it, leading the mind naturally en the conclusion that its origin is necessarily in a bronchial tube. whereas it might be in a cavity. But we cannot here pursue this subject further; only this we will add, that it is just one of the many questions which, in the subject of auscultation, requires more complete elucidation, for however quietly practitioners in gener! submit to these words as indicators of certain conditions, according to the prescription of Laennec, it is certain that they are productive of the most complete confusion in the minds of the majority of us, if Laennec's views in this particular should turn out incorrect?
On the subject of percussion, we must linger for a moment. We wish we could say that the scientific side of this matter had been by some one of our authors laid down clearly, and practically applied to the art of auscultation. It is one which still demands elucida
tion; the principles of it are yet to be defined ; its indications to be truly interpreted. Why, it does not appear as though men agreed even as to the source of the sound elicited by percussion ! whether the sounds arise from the vibrations of the thoracic walls, or from those of the air within the thorax! That the study is full of difficulty we readily admit, but we believe (and the justification of such belief is founded on general observation), that modern scientific researches have placed at the service of the physician certain particulars respecting percussion, which have not as yet been made available in the ordinary practice of this particular inethod of diagnosis, as fully as they profitably might be. And if certain particulars here referred to have been correctly stated, be really founded on facts, then it would seem to follow that some of the standard opinions of the day concerning the phenomena of percussion must undergo considerable modifications, and that some of them are indeed erroneous; and if so, then necessarily result these important conclusions, viz.: that our diagnosis of disease, as derived through its aid, does not rest upon the secure basis it is generally assumed to stand upon; and that observers, in short, do frequently deduce from the physical phenomena obtained by percussion of the body, conclusions which, measured by such new tests of experience, cannot be considered legitimate.
Whatever errors of this kind may have arisen, may be perhaps in part ascribed to this, that the practice of percussion, as a manual art, has been much too lightly esteemed; that its difficulties have not been sufficiently impressed upon the minds of the student; and that its phenomena have been laid down in much too exclusive, narrow, and dogmatic a manner.
Now, if any observer will place "aside for a time the particular notions on percussion which he may have derived from his students' books, and will apply himself simply to a consideration of the signs or sounds produced by percussion of the body, which present themselves to his senses at the bedside of the patient; and will compare them with the sounds obtained by percussion of the organs taken from the body after death, and which lay beneath the part percussed during life, and will carefully bring the diagnosis he had made during life into connection with the actual post-mortem condition of the organs which were the subjects of his consideration; such observer will, we believe, admit the justice of the above conclusions; he will find also, that percussion, as an art, is a much more difficult and complicated affair than it is generally supposed to be, that very considerable dexterity is required for its effective practice, and especially so in those fine manœuvres from which signs result, whose correct or incorrect appreciation affords important information, or leads to grave error.
If we consider for a moment a little closely the manual operation itself, we shall soon discover why it cannot be of that simplicity and facile execution, which an observer, who witnessed the matter-of