the whole case so closely resembling common continued fever, that both the ɛtethoscopist and the non-stethoscopist are apt to be thrown off their guard.”* As a matter of course, he, who avails himself of the aid of auscultation in such a case as this, must have a great advantage over him who neglects, or is ignorant of, it; as the rational or subjective phenomena of the malady are altogether silent as to the presence of any pulmonic distress. There is one symptom, indeed-and it is often a very characteristic and most valuable one-that should always be sought for in doubtful cases; we allude to the pungent heat of the skin over the inflamed portion of the lung; a symptom which usually lasts as long as the inflammation continues in its first or crepitating stage. Pneumonic consolidation of the inferior and anterior portion of the lung may exist, and yet no dulness on percussion be present, in consequence of the inflated state of the stomach or intestines. Under such circumstances, even a well-marked modification of amphoric respiration and metallic tinkling may be heard to a considerable height in the chest, and thus mislead the physician to believe that Pneumo-thorax is present. 10. In the 23rd Proposition, we find Dr. A. giving it as his opinion that "it is very doubtful whether physical examination can, in any instance, determine with certainty the evidence of simple Tubercles in the lungs." True, unless the physical examination is—as it invariably ought to be-associated with minute attention to the subjective or ordinary class of symptoms. Much, very much, may be gained from a sedulous investigation of the history of the case from the first development of the symptoms up to the period when the examination takes place, from observing the general complexion of the patient, from ascertaining the state of health of his parents and the other members of his family, whether he or any of them has been affected with hæmoptysis, &c. &c. Still we must admit that tubercular disease may exist, and to a considerable extent too, in the lungs, without giving rise to any suspicious symptoms. 11. Many will not quite agree with our author when he affirms that "physical examination cannot determine whether Pneumonia, in any of its forms, has, or has not, supervened upon Tubercles; although the prognosis in the two cases would be very different." That pneumonic attacks in phthisical cases are not unfrequently overlooked, in consequence of the comparative mildness of the symptoms, will be acknowledged by every practical physician: but it is equally true that a careful auscultatory examination may generally discover that the murmur of respiration has become feeble and mixed with a fine crepitating sound, when inflammatory action has supervened. The character of the sputa, also, is usually some "It has been only of late years that the attention of physicians has been specially directed to the not unfrequent existence of a latent pulmonic affection in cases of Typhus fever. The subjective' symptoms of this complication are usually not very prominent or striking; and it is therefore only by the aid of the 'objective' phenomena, as disclosed by auscultation, that our diagnosis can be accurately formed."-Schoenlein's Klinische Vorträge, in Medico-Chirurgical Rev. for October 1845. 1847 Dr. Addison on the Fallacies of Physical Diagnosis. 95 what altered from what it was just before the attack; and, in some cases, the increased heat of the skin over the seat of the inflammation may serve as an additional diagnostic symptom. Let us again most strongly urge the reader never to dissociate the auscultatory from the other means of examination, nor to use the one to the exclusion or neglect of the other. 12. There is another point, in which Dr. Addison's experience has led him to a somewhat different conclusion from that generally received. According to him, acute Pneumonia not unfrequently attacks the apex of a lung, quite unconnected with, and independent of, tubercular disease. “I have,” says he, " on several occasions, known hepatization of the apex from acute pneumonia, pronounced to be phthisis by stethoscopists: they have not sufficiently appreciated the difficulty; they have neglected to inquire carefully into the history and progress of the case; and have mistaken the pungent heat of skin of ordinary pneumonia, for that which occurs in phthisis: and which I believe, devertheless, has often the same origin." P. 13. And then the following case is quoted in confirmation of this statement. "Mary B—, aged 19, was admitted, under Dr. Addison. She had always been delicate; and after the whooping-cough and measles, which she had had eight years before, had been subject to attacks of cough and cold, in which she had frequently expectorated blood. "When admitted, she had a troublesome cough, with scanty sputa, slightly tinged with blood. There was dulness on percussion below the left clavicle, with tubular breathing and gurgling, the last extending down nearly to the margin of the ribs, where it became more dry and crepitating. Posteriorly there was dulness on the left side, extending from the apex nearly as low as the angle of the scapula; and tubular breathing and bronchophony to the same extent: slight tubular breathing and bronchophony at the right apex, with large crepi tation. "Under the impression that phthisis was present, she was ordered, Pil. Papav. c Ipecac. bis die sumat. Under this treatment the cough became worse; sputa more copious, fawncoloured, and uniform, except that it contained puriform streaks; the head painful; pulse 120, compressible; cheeks flushed; skin hot and pungent; while the signs afforded by auscultation and percussion continued unaltered. She was then bled twice to eight ounces; and calomel, antimony, and opium were administered. Her mouth was kept sore by the calomel for a few days, when it was discontinued, and nothing given but julep. ammon. acet. Under these remedies the dulness, tubular breathing, bronchophony, and gurgling at the left apex, gradually diminished, and at length entirely disappeared. The tubular breathing and bronchophony at the right apex persisted longer, and caused some alarm; but these also ceased: the expectoration became white and frothy, and then, with the cough, subsided." P. 14. We strongly suspect that tubercular disease did exist in this girl at the period of the pneumonic attack, and that eventually she would die of it. Too often, we never learn the real event of cases in hospital practice. The patients, on being relieved of their more immediate ailments, are discharged as convalescent or cured, only to sink under the more gradual advance of chronic disease. In conclusion, we cannot but express our opinion that, whenever Pneumonia affects the upper and anterior part of the lungs alone, and is unassociated with any trace of the disease in the lower and posterior parts, there is strong reason to suspect the presence of Tubercular disease. 13. The remarks by our author on the Pleurisy that is seated low down in the angle between the ribs and the diaphragm, especially on the anterior part of the chest, are very valuable, as suggesting the necessity of great caution and the most sedulous attention that the disease may not be mistaken, as it is apt to be, for Pleurodynia, Spasm of the diaphragm or thocacic muscles, Hepatitis, &c. In the early stage of the attack, neither auscultation nor percussion can afford us satisfactory'or trustworthy information. Two or three days must elapse, before we can derive any decided assistance in our diagnosis from either. As a matter of course, however, no judicious practitioner will wait for the supervention of the physical signs of pleuritis, before determining upon his line of treatment. In all cases of doubt, where a fixed sharp pain exists, local-if not general— depletion, and the use of nauseant aperients should be had recourse to. "When pleurisy has its seat in the parts alluded to above, it constitutes by far the most painful, and perhaps the most dangerous form, of the acute and sthenic disease. It is the Paraphrenitis of the ancients; a disease which, according to them, consisted simply of inflammation of the diaphragm. This, however, is not correct; for the pleura covering the diaphragm, is often inflamed without giving rise to the dreadful suffering observed in paraphrenitis; whereas, when acute and sthenic inflammation attacks the pleura, where it is reflected from the diaphragm to the ribs at the base of the chest; and thus involves both the diaphragmatic and costal pleuræ at the same time; then it is, that we have such intense suffering, and such an expression of agony in the countenance, as forcibly to remind us of the risus sardonicus of the older writers." P. 20. detec 14. Pleuritic Effusion, when moderate in quantity, and not associated with other morbid states of the thoracic viscera, may entirely escape tion by any means of physical examination. We cannot trust much to percussion, as the fluid does not rise high enough in the cavity of the chest, and any slight dulness of sound is, at the same time, rendered equivocal by the liver on the right, and the inflated stomach on the left, side and even the auscultatory symptoms are only of uncertain value. A case of Bright's disease is mentioned, in which the signs of effusion into the right chest were very unsatisfactory; although, on a post-mortem examination shortly afterwards, it was found to contain a large quantity of serum. 15. When Pleuritic Effusion is very considerable, giving rise to unequivocal bronchophony, tubular respiration, and want of resonance and vocal vibration, physical examination has repeatedly led to a mistaken belief that these signs resulted from pneumonic or other consolidation of the lung. This mistake is more likely to be committed, when the effused fluid is partially retained in the meshes of a fibrinous exudation between the pleural surfaces. It is a fact, too, which the dispassionate stethoscopist must admit, that in some cases it is scarcely possible to distinguish the 1847] Dr. Addison on the Fallacies of Physical Diagnosis. 97 pleuritic rub or friction-sound from some of the sounds developed in the bronchi: they often resemble each other very closely; and both occasionally communicate a distinct vibration to the hand applied to the thoracic parietes. 16. After pointing out several sources of fallacy in the diagnosis of Pericarditis and of some Diseases of the Heart, we come to proposition 36, which stands thus:: "36. A sound closely resembling a valvular murmur appears not unfrequently to be produced by the stroke of the heart against a portion of lung, interposed between it and the parietes of the chest. Under such circumstances, auscultation may lead, and I believe often has led, to the erroneous conclusion, that the heart is diseased, when it is perfectly normal in every respect. "This sound is most frequently heard at some point in the direction of the edge of the left lung, where it overlaps the heart, to the left of the sternum, from about the second or third to about the fifth rib, and especially somewhere between the second rib and the neighbourhood of the left nipple. Its tone somewhat resembles that of a bruit de rape; but, at the same time, it communicates a sense of dryness and crumpling, different from the rigid squeezing or grating observed in the ordinary bruit de rape. It is also more variable, both in its development and its extent. We find it different at different moments, and during the different movements of the chest; and it may occasionally be made to disappear altogether, by a deep and forcible inspiration, so long as that inspiration is maintained by the individual. On the other hand, its extent or prolongation varies in different cases; or even at different times in the same case; apparently according to the extent or size of the portion of lung which happens to be struck by the heart at each systole of the organ. In a few instances I have found the sound, to a certain extent, double; the second, or that attending the diastole of the heart, being in general, perhaps, more limited and indistinct than the first. I believe this sound, which I have long observed, and now attempt to describe, to be that recently pointed out by my colleague, Dr. Barlow. It may possibly be that also noticed by Dr. Latham as frequently present in phthisis." P. 30. 17. Having cautioned his readers against deciding either hastily or very dogmatically as to the existence of cardiac disease from the presence of certain murmurs over the heart and great blood-vessels, by shewing the difficulty of distinguishing between those from a functional and those from an organic malady, Dr. Addison candidly avows, in Prop. 40, that "in certain diseases of the heart, especially when the organ is enlarged, it is difficult, or impossible, accurately to localise the murmurs, however distinct and obvious these murmurs may be." Let this unmistakeable acknowledgement from an experienced auscultator and able physician like Dr. A., serve to check the fractionally-minute and curiously-elaborate descriptions of some of the younger stethoscopists of the present day. We have again and again enunciated the spirit of the above proposition in reviewing various recent works on Heart-diseases, Auscultation, &c. Before taking our leave of this truly practical paper, we must not omit to state that Dr. Addison has mentioned, in an early part of it, that "great contraction of the right chest after pleurisy almost as certainly draws the heart towards the same, as extensive effusion into the left chest forces it towards the opposite, side." Attention to this fact may be of great importance to the physician in forming a correct diagnosis in some NEW SERIES, NO. IX.-V. H thoracic maladies, when the configuration of the chest has become altered either from congenital or subsequent disease. II. EXAMPLES OF PTOSIS, WITH ILLUSTRATIVE REMARKS. By John F. France. Mr. France is inclined to believe that, in a very great number of cases of ptosis, the cause of the paralytic weakness of the eyelid is pressure on the third pair of nerves within the skull, either from vascular fulness, or, it may be, from sanguineous or serous effusion. In not a few instances, symptoms of cerebral congestion will be found to be present; and the relief of that is often sufficient to effect the removal of the paralytic affection. Mr. F. gives the following ingenious explanation of the much greater liability of the motor oculi to be so affected, than any other of the nerves of the orbit. "This nerve, almost throughout its intra-cranial track, is in the immediate vicinity of those which must be regarded as very dangerous allies: first, hooking round the posterior cerebral artery, to traverse the narrow interval between that vessel and the superior cerebellar; then running forward nearly parallel to the posterior communicating artery, in a degree of proximity, the occasional mischief of which is demonstrated by the necroscopic examination in Case 9; and then crossing the termination of the internal carotid, immediately on its outer side, and closer to it than any other of the nerves contained within the cavernous sinus. "The sixth nerve, it is true, is previously in actual contact with the coats of this vessel; but running along the floor of the sinus, must, in a great degree, be secured from pressure; as, from the upward direction of the current of blood, the horizontal portion of the carotid must be rather raised from, than pressed against, the inferior wall of the sinus upon each contraction of the left ventricle; and, from the same cause, the inferior wall of the artery itself must be, mechanically, the least liable to morbid distention, or rupture. That nerve, however, sometimes suffers like the third." P. 55. That the seat of the pressure on this nerve is situated within the cranium is rendered probable from the circumstance that, being in close apposition with the 6th and the nasal branch of the 5th nerve, it is scarcely possible to conceive that one nerve alone could suffer from the supposed cause and the others escape. The double vision of the drunkard, we may remark en passant, is chiefly owing to a disturbance in the functions of the motores oculorum, produced doubtless by the distended state of the cerebral vessels; the axes of the two eyes no longer converging to the same object. Of 13 cases related by Mr. France in illustration of his subject, No. 9 is perhaps the most interesting; the following is a summary of its chief features. A young woman, stout and plethoric, came under treatment on May 13th for Ptosis on the right side. For a month previously, she had been suffering from headache and giddiness; and, five days before admission, she was suddenly seized with headache over the right eyebrow, accompanied by faintness and vomiting. Next morning, the right upper lid was observed to drop, and vision on the same side was found to be impaired. She was bled, leeched and purged; but without relief to the ophthalmic |