242 



AUSCULTATION. 



where a portion of the lung a condensed, whether 

 it be by inflammation, or tubercles, or by the infil- 

 tration of a fluid into its substance, a resonance of 

 the voice is transmitted to the ear at the corre- 

 sponding part of the chest, resembling that from 

 tin- bronchial tubes, and thence called bronchophony. 

 When there is an empty cavity in the lungs, the 

 sound is still more remarkable. The voice seems 

 to enter the ear, as if the mouth of the speaker 

 were applied closely to it. This speaking from 

 the chest (pectoriloi/u;/"), when strongly marked, is 

 a very decided characteristic of confirmed con- 

 sumption, and sometimes gives evidence of a hope- 

 less condition of that deceptive disease, long before 

 the symptoms have led the patient to feel any ap- 

 prehension. Dr Williams says of it, " More than 

 once has it occurred to me, that the very words, 

 which in that delusive confidence with which this 

 malady enshrouds its victims, ridiculed my exami- 

 nation of the chest, roundly saying, that nothing 

 ailed them there, have belied their meaning, and, 

 coming from the Dreast, have told a far different 

 tale." A modification of the voice, of a different 

 character, is observed in some states of the chest 

 in pleurisy. The voice comes to the ear through 

 the walls of the chest, not in its clear natural tone, 

 but in a vibrating, thrilling, squeaking sound ; like 

 the bleating- of a goat (hagophony). 



Auscultation is applied to the investigation of 

 the diseases of the heart as well as those of the 

 lungs, although the actions of this organ are more 

 obscure, and the phenomena which attend them 

 are less understood. On applying the ear over the 

 region of the heart, we perceive, in the first place, 

 the impulse of the heart beating against the ribs ; 

 then we hear two distinct sounds, following each 

 other at every pulsation, in regular succession. By 

 habitual practice we learn to distinguish the natural 

 force of the impulse, as well as its natural extent 

 and limits, and the regular cadence or rhythm of 

 the successive sounds, and to appreciate the differ- 

 ence if either is changed by disease. The diagnosis 

 of the particular diseases of the heart and large 

 arteries is still involved in much obscurity. Con- 

 siderable progress has been made in the knowledge 

 of them within the last few years, and much may 

 be hoped from the investigations which are con- 

 stantly going on. As it is, we are in general able 

 to distinguish with confidence between the actual 

 changes of structure in that organ, and the ner- 

 vous, and sometimes imaginary affections, which 

 have often, in past times, been confounded with 

 them. And, in many cases, if not in most, we can 

 ascertain the particular character of the morbid 

 affection, and give a tolerably sure prognostication 

 of its termination. There is here consolation in 

 the fact, that some of these diseases, which were 

 formerly classed together without any other dis- 

 tinction than "diseases of the heart," and regarded 

 alike with terror, as surely fatal, excite very little 

 alarm, now that their true character, and the 

 means of distinguishing them, are better known. 



Enlargements of the heart, or its envelope, are 

 easily detected by the greater extent over which 

 the impulse and the sounds of its action are per- 

 ceived, and by the absence of the sound of respira- 

 tion, in consequence of the encroachment of this 

 organ upon the lungs, as well as by an enlargement 

 of the corresponding part of the chest, and a change 

 in the sound on percussion. But a knowledge of 

 the general fact of an enlargement is not enough. 

 We wish to know, whether it be a simple dilata- 



tion of the cavities of the heart, or the thickening 

 of its muscular substance, or a distention of the 

 pericardium by a fluid. And each of these has its 

 appropriate, characteristic marks, so as to leave 

 little cause of doubt between them. The mem- 

 brane which covers the external surface of the 

 heart, and that which lines its internal cavities, 

 and occasionally also the muscular substance itself, 

 are liable to inflammation ; its numerous valves are 

 exposed to various diseases ; and both its cavities 

 and its orifices are subject to unnatural dilatation 

 or contraction. Most of these changes can be de- 

 tected with a greater or less degree of confidence 

 during life, and some of them are capable of .-nc- 

 cessful treatment. We shall not trouble our read- 

 ers with a description of the diifeient sounds 

 heard in the several diseases, as we have done in 

 regard to the lungs ; partly because these sounds 

 are less fully understood, and partly because we 

 are afraid of wearying them with so many details. 



Let us now see how these two modes of explora- 

 tion, percussion, and auscultation, bear upon each 

 other. We have thus far examined them only in 

 their separate capacities. In their relations to 

 each other, they do much to correct or confirm the 

 results obtained from either separately. In all 

 diseases of the chest, besides the knowledge ob- 

 tained from the symptoms, we have two dis- 

 tinct modes of observation. If the inferences 

 drawn from the sounds on percussion are confirm- 

 ed by applying the ear to the chest, and, in re- 

 gard to the lungs, we have both the respiration 

 and the voice to reveal their secrets to us; and 

 especially if these inferences are in accordance 

 with the symptoms, we may feel an assured con- 

 fidence, that we have come to a just knowledge of 

 the disease. 



A man has pain in the side, with difficulty of 

 breathing, attended by more or less fever. All 

 this may arise either from rheumatism in the mus- 

 cles, or from pleurisy or inflammation of the lung; 

 and the symptoms alone will not always tell which 

 is the disease. If it be rheumatism, we are not 

 likely to find any external sign of if, except per- 

 haps Rome feebleness of respiration, on account 

 of the difficulty of expanding and contracting the 

 chest. If the disease be pleurisy, we shall have 

 flatness on percussion, in the lower part of the 

 side affected, changing its place if the patient changes 

 his position, so as always to keep the lowest part ; 

 absence of all sound of respiration in that part, 

 while the respiratory sound is louder than na- 

 tural in the surrounding parts; and generally hae- 

 gophonic resonance of the voice. If it be inflam- 

 mation of the lung, there is dulness on percussion, 

 increasing, as the disease advances, to flatness, re- 

 taining the same place in all positions, not bounded 

 abruptly by healthy resonance; crepitous rdle in 

 the respiratory sounds, at first, followed by bron- 

 chial respiration and bronchophony. These sev- 

 eral characteristics, however obscure they may 

 seem in the description to many of our readers, 

 to an intelligent and experienced observer will per- 

 fectly designate the character of the disease, so as 

 to leave no doubt whatever in his mind. The dis- 

 ease may, indeed, be complicated, and then the 

 evidences of its nature will be so too; and so will 

 be the treatment that it will require. 



A more interesting case is unhappily also rmirh 

 more frequent. A youth, just ripening into man- 

 hood, gradually loses his ruddy colour and vigor- 

 ous strength ; he loses flesh, and occasionally a 



