We hold this to be a golden rule, as well in chronic affections of the heart, as in other chronic diseases.

But we must leave this part of the work, to make a few remarks on the method of diagnosis recommended in it. We shall not occupy our reader's time, by inquiring into the causes which have retarded the progress of mediate auscultation. They are much the same which have operated against the introduction of every important discovery connected with the advancement of medical science, from the time of Harvey downwards. We are ready to grant, also, that there are some circumstances which operate against the application of the stethoscope, peculiar to itself; but even these have been greatly magnified, and will be entirely disregarded, as the conviction of its practical utility becomes established.

The application of auscultation to the diagnosis of diseases is surely a philosophical experiment. No good reason can be certainly adduced, why we should not avail onrselves of the information to be obtained through the medium of the sense of hearing, in increasing our powers of detecting the nature of diseases. And if we can show that there is a most important class of diseases, the nature and seat of which it is often impossible to discover by other means, while it is yet of great practical importance to distinguish them, not only from one another, but in their different stages, we think it will be difficult for the opponents of auscultation to adduce satisfactory reasons for rejecting it.

It is notorious, and matter of daily occurrence, that great and important errors are committed in the diagnosis of thoracic diseases; most, if not all, of which might be obviated by means of auscultation.

"I will go so far as to assert," says Laennec, "and without fear of contradiction from those who have been long accustomed to morbid dissectionsthat, before the discovery of Avenbrugger, one half of the acute cases of peripneumony and pleurisy, and almost all the chronic pleurisies, were mistaken by practitioners, and that in such instances as the superior tact of a physician enabled him to suspect the true nature of the disease, his conviction was rarely sufficiently strong to prompt and justify the application of very powerful remedies."*"

Now the greater number of medical practitioners, in this country, are precisely in the same state as the French practitioners were before the time of the justly celebrated Corvisart, who first called the attention of his countrymen to the discovery of Avenbrugger; for percussion is scarcely more frequently employed in England than the stethoscope; and yet it is justly

* Introduct. p. 2.—Trans.

characterised by Laennec as one of the most valuable discoveries ever made in medicine."

"By means of it (he adds) several diseases which had hitherto been cognizable by general and equivocal signs only, are brought within the immediate sphere of our perceptions, and their diagnosis rendered both easy and certain."*

Even in our hospitals, percussion, we believe, is little used, though we will venture to affirm that, before a physician has made trial of it in half a dozen cases, he shall be so satisfied of its practical utility, that he will experience surprise, and it may be, regret, that he had not had recourse to it sooner. But the information to be derived from mediate auscultation is far more extensive and accurate, though, as Laennec justly observes, the combination of the two methods becomes still more useful than either singly.

Too much has been required of the stethoscope by those who were prejudiced against it: if it did not tell every thing, it was considered as doing nothing; and the sins, moreover, of the auscultator have been, not unfrequently, visited upon the instrument. It has been said, too, most incorrectly, that mediate auscultation has been brought forward as a substitute for all other diagnostic signs. M. Laennec never had such an intention; and Dr. Forbes takes particular pains, in his preface, and other parts, to define the value, and limit the reliance to be given to auscultation. In a note on the article phthisis, he ob

serves,

"It is only by combining the practice of auscultation with the faithful observation of symptoms, and by studying the results obtained from both sources, with a reference to the pathology of the disease, that we can hope to attain such a certainty of diagnosis as can satisfy a philosophical mind."

This is the true light in which auscultation should be employed-not as a substitute for, but as an addition to, the means we already possess of discriminating diseases. So far from leading us to relax in our researches, it tends rather to sharpen the intellect, by giving us a new interest in the disease. Having, by means of auscultation, ascertained the precise nature and stage of the disease, we may, by close observation of the morbid phenomena which accompany it, greatly improve our general diagnostic power. Before we know the exact pathological condition of an organ, the general symptoms produce but a vague and feeble impression on our mind, because we know not to what particular lesion they are referable. But this once ascertained, every thing connected with the case acquires a vast increase of value and interest, and every obser

* Introduct. p. “. Trans.

vation we afterwards make forms a step towards a positive knowledge of the symptoms which characterise the disease. We have, thus, in mediate auscultation a new source of power, which, being well applied, may ultimately enable us to dispense with the very means by which we acquired it. It has also been used as an argument against the stethoscope, that the knowledge communicated by it comes too late for useful practical purposes. This has arisen chiefly from mediate auscultation having been too much associated with phthisis, and from its value in other diseases having been estimated by its practical utility in consumption; while, in general, and used alone, it is comparatively of little use in this disease: but the reverse holds true in other diseases, and the great practical utility of auscultation rests on the fact of diseases being discovered by it in their more early stages, when the most observant physician is doubtful of their nature. In the latent periods of disease, auscultation will often convert our bare suspicions into certainty, and enable us to apply our means of cure at a period when they avail the most. In pneumonia, in bronchial diseases, and in some affections of the heart, the disease not unfrequently remains latent during the greater part of its progress, or is only accompanied by symptoms which do not enable the practitioner to detect its nature till it is too late--sometimes not until it is disclosed by the dissecting knife! This is still more strikingly the case in some fevers, accompanied with oppression of the nervous system, in which extensive disease of the lungs occurs, without being accompanied with the usual indications. This is the case in a remarkable degree, also, in that fatal termination of many surgical diseases, by supervening, but masked, peripneumony, as noticed by some of our best surgical writers, Mr. C. Bell, Mr. Guthrie, &c. as referred to by Dr. Forbes in a note, p. 238. In the case of young children, also, where we are deprived of half the information on which we are accustomed to form our opinions, auscultation becomes the only diagnostic measure on which we can safely depend. On examining bodies, carried off apparently by fever, at all ages, extensive inflammation of the lungs is often discovered, though, during the life of the patient, the existence of such an affection was scarcely suspected, and the detection of which, in due time, might have been the means of saving him. Yet this post-mortem examination is of little utility to practitioners in general, because it does not show them how such cases are to be detected on another occasion:-On him, however, who can call auscultation to his aid, the discovery of such a case produces a very different effect. He is not likely to lose another patient VOL. VIII. No. 15.

16

case.

under similar circumstances; or, at least, he will not do so, without being aware of the nature of the fatal disease, if he is not able to prevent its becoming so, which will often be the The stethoscope thus communicates the same certain kind of information which, in too many cases, we obtain only at the dissection table: with this difference, that, in the former case, we have the disease still under our observation, and may turn our knowledge to the advantage of our patient; while, in the latter case, we can only regret that we did not know what the dissecting-knife has disclosed to us, while our patient was yet alive.

The difficulty of acquiring a knowledge of the application of the stethoscope has been urged as a reason against its general employment; but against what part of medical knowledge might not the same argument be used? It is much easier to become acquainted with mediate auscultation, for all useful practical purposes, than it is to become acquainted with the indications afforded by the pulse. The sense of hearing no doubt differs in acuteness in different individuals, just as the other senses do, and there can be no question, that some will, by one week's practice of the stethoscope, acquire more tact in its application, than others will in several weeks, or even months; but we are well assured, that there is scarcely any one whose acoustic organs are so dull, that he may not, in a very short period, acquire sufficient proficiency in its use, to enable him to distinguish the principal diseases of the thoracic viscera from each other, so as to render his practice much more satisfactory to himself, and infinitely more beneficial to his patients. We can speak strongly on this subject from practical experience. Even in a negative point of view, we have felt much indebted to the stethoscope, for setting our mind at ease in some of those nervous affections, which simulate organic disease of the respiratory organs, and, at times, produce such alarming symptoms, as to embarrass the most experienced practitioner. But the greatest enemy to mediate auscultation, after all, we fear, is indolence, which, as Dr. Forbes well remarks, (note, p. 78) " is a potent and prevailing advocate, even with the most active. We readily persuade ourselves, that what is very troublesome to do may be left undone, with little detriment to ourselves or others; and that an easy substitute is an adequate substitute." For our own parts, we are thoroughly convinced, that, in the present state of our knowledge, there is no adequate substitute for auscultation in discriminating the various important diseases to which the thoracic viscera are obnoxious, and which, it is to be feared, too often lead to a fa

tal result, because their nature is misunderstood, or because they are not recognised till the period has gone by at which our art is of much avail.

Deeply impressed with the great advantages which the profession which mankind-may derive from the general introduction of auscultation, (under which term we comprehend percussion, and immediate, as well as mediate, auscultation,*) we think it our duty to urge our professional brethren, and above all those who are at the head of our public medical institutions, to give the measure a fair trial. Those who hold the highly responsible office of instructing the rising members of the profession, should reflect on the mischief they may be doing by neglecting auscultation, even if it might claim only one half the praise which we are satisfied it deserves. All we ask for is a fair trial, and we fear not the decision of every candid and honest mind. Too often, we fear, has the measure been condemned after a trial altogether inadequate, and we readily sympathise in the indignant feelings expressed by Dr. Forbes, on the contemplation of such unphilosophical proceedings.

"When, therefore, we hear," he says, "as we sometimes do, that cer. tain persons have tried the stethoscope, and abandoned it upon finding it useless or deceptive; and when we learn, on inquiry, that the trial has extended only to the hurried examination of a few cases within the period of a few days or weeks; we can only regret that such students should have

* Much of the information afforded by the stethoscope may be obtained more directly by the immediate application of the ear to the chest of the patient; but, independently of various objections to this method, it does not generally afford the same accurate information as the stethoscope, and, in several situations, is not at all applicable. We, therefore, strongly recommend the beginner to commence his observations with the stethoscope; the substitution of the ear is afterwards easy, and often convenient-not so the reverse. Every person desirous of making himself acquainted with the nature, the value, and method of employing auscultation, should read with care M. Laennec's Preliminary Essay on the physical Diagnostics of the Diseases of the Chest, &c. On Percussion, which our author has treated too briefly, the reader is referred to the translation of Avenbrugger by Dr. Forbes, or Corvisart; the former has some interesting cases attached to it, illustrative of the utility of mediate auscultation.

+ In Dublin, where, as it seems to us, medicine is cultivated more as a science, and with greater zeal, especially in their public institutions, mediate auscultation, as might be expected, is in far greater estimation than on this side St. George's Channel. We had occasion to make pretty copious extracts, in our last number, from a valuable paper in the fourth volume of the Dublin Hospital Reports, by Drs. Graves and Stokes, the principal object of which was to" prove the utility of the stethoscope in the diagnosis and treatment of thoracic diseases." The remarks of these gentlemen on hydrothorax we recommend especially to the attention of the opponents of auscul tation.