25 OCTOBER 1845, Page 16

SIIASMUS WILSON ON THE SKIN—DR. H. H. HUGHES ON AUSCULTATION.

Da. COOMBE, about a dozen years ago, in his Physiology applied to Health and Education, first drew the attention of the public to the influence of the skin upon the health, in a manner at once sound, scientific, and popular. His exposition of the subject, though comprehensive and complete so far as it went, was of necessity only a general view; and since that time further discoveries have been made upon the subject, by Continental and British anatomists. Among these Erasmus Wilson oc- cupies a conspicuous place. In his Diseases of the Shin, he gave to the profession the results of the discoveries of others and himself, accom- panied by a new classification of cutaneous diseases, and a treatise upon their diagnosis, pathology, and treatment. In the work before us he has popularized the subject; presenting to the general reader a clear descrip- fion of the anatomy and physiology of the skin, some plain and useful advice for keeping it in order, and a compendious view of its diseases, with suggestions how to treat them, (if it be wise for a person ever to undertake to doctor himself in a disease new to him,) and when recourse should be had to medical advice.

The book is divided by chapters only ; but it may properly be ar- ranged into five beads. The first division is a scientific yet popular ac- count of the skin, illustrated by plates, which are accompanied by full descriptions. The next part embraces the functions of the skin, including the perspiratory system, the oil-glands, and the hairs, that are anato- mically included in the skin. The third and most popularly useful sec- tion contains an exposition of the influence of die; clothing, exercise, ablution and bathing, on the health of the skin, and the body in general, with very sensible directions upon each topic. The fourth division discusses the subject of the cold water cure ; to which Mr. Wilson is favourable under proper regulations and advice. The fifth and most ex- tensive section embraces the diseases of the skin, from St. Anthony's fire down to the simplest rub&gcence, including an account of "human horns," and a disquisition on baldness, grey hairs, and other disorders of the locks.

As a popular exposition of a medical subject, Mr. Wilson's Practical Treatise on Healthy Skin is entitled to praise. The subject, no doubt, was taken because the author has given considerable attention toil: but it is a lucky subject ; for we all have a skin, and our health greatly de- pends upon its health. The treatment only consists of a proper use of water and soap ; which if they fail in keeping it in order, and some sim- ple lotions in restoring it when out of order, something is wrong and ad- vice should be had. But if the subject is an accident the execution is Mr. Wilson's own, and is very judicious and able. Everything is made plain, but therein no attempt to sacrifice soundness to popularity. The ana- tomical account of the skin is clear, to those who will attend to it ; and if more than a general view is required, the plates will enable the reader to study the subject. The physiology is sufficient without minuteness; the principles on which the practice of exercise, ablution, &c., rest, are explained, so as to enable the reader to apply the general advice, without a vain attempt to lay down rules for particular cases ; and in the section on diseases he is warned when to leave off self-prescribing, if he will at- tend to the warning. The style is also clear and neat, and not deficient in animation or ornament.

In presenting examples of Mr. Wilson's book, we shall disregard the abstruser subjects for the popular. His grand hortative is

USE SOAP.

When examined chemically, the scarf-skin is found to be composed of a sub- stance analogous to dried white of egg—in a word, albumen. blow, albumen is soluble in the alkalies, and these are the agents which are commonly employed for purifying the skin. Soap, whatever its specific name is a compound of the alkali soda with oil, the former being in excess. When used for washing, the excess of alkali combines with the oily fluid with which the skin is naturally bedewed, re- moves it in the form of an emulsion, and with it a portion of the dirt. Another portion of the alkali softens and dissolves the superficial stratum &the scarf-skin, and when this is rubbed off the rest of the dirt disappears. So that every wash- ing of the skin with soap removes the old face of the scarf-skin and leaves a new one; and were the process repeated to excess, the latter would become so much attenuated as to render the body sensible to a touch too slight to be felt through its ordinary thickness. On the other hand, where the scarf-skin and the dirt are rarely disturbed by soap, the sensibilities of the skin are necessarily beniunbed. The proper inference to be drawn from the preceding remarks is in favour of soap as a detergent for the skin. On the faces of some women soap acts as an irritant, and patches of red are left after its use These are exceptional cases, and are generally attributed to an unusually delicate and susceptible skin; but the truth is, that the skin is less in fault than the habits or health of the individual. The former are faulty, where soap is not regularly employed, or where the water used in washing is too warm, and exposes the skin as in the winter season, to a violent alternation of temperature; the latter supports a charge of too little exer- cise in the air, late nights, and over-indulgence. Other means than soap for the purification of the skin are highly objectionable, such as the various wash-powders; they are sluttish expedients, half doing their work, and leaving all the corners on- swept. Another and a weightier objection obtains against them: from having no power to remove the superficial lam= of the scarf-skin, these become stained, and then the skin has the appearance of being mottled, with irregular brown or olive-coloured spots. The remedy for these spots is lemon-juice an agent of great utility in removing stains from the skin after the dirt has been completely washed away with soap. Neither can wash-powders follow the innumerable apertures of the skin, nor enter the mouths of the pores otherwise than to obstruct them. A skin cleaned in this manner may always be detected by a certain kind of shining, not to say greasy polish; and the whole complexion looks mellowed into a kind of tone, as we say of pictures, in which dirt and time have softened and chastened the tints. But surely no one would care to put up for the reputation of resembling an old picture, however rich its tints or admirable the art developed in its painting. Soap is accused of being irritative to the skin; but this is an obvious injustice done to soap, for soap never irritates the delicate skin of infants. Depend upon it, that when soap dies cause irritation, the error is in the condition of the com- plainant, and betokens either an improper neglect of its use, or a state of sus- ceptibility of the skin verging on disease of that membrane. If we would have health, we must use soap. If soap act as an irritant, we must train to its use by beginning with a small quantity and increasing it gradually. I may be asked, What is the best soap? I reply, Good white curd soap, without scent, or scented only by its contiguity to odorant substances. The use of soap is certainly cal- culated to preserve the skin in health, to maintain its complexion and tone, and prevent it from falling into wrinkles; and if any unpleasant sensations are felt after its use, they may be immediately removed by rinsing the surface with water slightly acidulated with lemon-juice. That living illustration of Gay's Fable, "the man with many friends," is continually exhorted to drain his land. There is no doubt soundness in the advice, if he had the means ; for see the drainage of the human system. "Taken separately, the little perspiratory tube, with its appended gland, is calculated to awaken in the mind very little idea of the importance of the system to which it belongs; but when the vast numbers of similar organs composing this system are considered, we are led to form some notion, however imperfect, of their probable influence on the health and comfort of the individual. I use the words imperfect notion' advisedly, for the reality surpasses imagination and almost belief. To arrive at something like an estimate of the value of the perspiratory system in relation to the rest of the organism, I courted the perspiratory pores on the palm of the hand, and found 3,528 in a square inch. Now, each of these pores being the aperture of a little tube of about a quarter of an inch long, it follows that in a square inch of skin on the palm of the hand there exists a length of tube equal to 882 inches, or 74 feet. Surely such an amount of drainage as seventy-three feet in every square inch of skin, assuming this to be the average for the whole body, is something wonderful; and the thought naturally intrudes itself, What if this drainage were obstructed? Could we need a stronger argu- ment for enforcing the necessity of attention to the skin? On the pulps of the fingers, where the ridges of the sensitive layer of the true skin are somewhat finer than in the pahn of the hand, the number of pores on a square inch a little ex- ceeded that of the palm; and on the heel, where the ridges are coarser, the num- ber of pores on the square inch was 2,268, and the length of tube 567 inches or 47 feet. To obtain an estimate of the length of tube of the perspiratory system of the whole surface of the body, I think that 2,800 might he taken as a fair ave- rage of the number of pores in the square inch, and 700, consequently, of the number of inches in length. Now, the number of square inches of surface in a man of ordinary height and bulk is 2,500; the number of pores, therefore, 7,000,000, and the number of inches of perspiratory tube 1,750,000, that is,145,883 feet, or 48,600 yards, or nearly twenty-eight miles."

A Clinical Introduction to the Practice of Auscultation. Auscul- tation is the art of discovering morbid conditions of the lungs and heart by listening to the various sounds which they respectively produce, and thence, in conjunction with other symptoms, deducing the character of the disease. We say in conjunction with other symptoms, for few pretend to decide by the sound alone, and practically no one does. A patient does not present himself for auscultation without stating his complaints; and these, with the look and all the other obvious spur toms, contribute to influence the judgment, as the palmister, though examining the lines of the hand, would use all other information he could

get hold of. To make a good auscultator is not an easy thing. It requires, like music, a "good ear" from nature; like horsemanship, pianoforte-playing, and some other pursuits where instinctive dexterity is required, it should be begun early; nor indeed is it easy, amid the limited character of private practice, to find subjects; or, with its struggles, its anxieties, and its de- mands, to gain time and freedom of mind to pursue the study with that patience and practice requisite to attain skill, supposing the natural qualification exists. The first thing to be done is to acquire a perfect knowledge of the various healthy sounds to be heard from the chest, and so to imprint them on the memory as to have a standard by which to recognize their morbid deviations. The next thing is to master these morbid sounds, whether of the region of the heart or the region of the lugs; to mark their variations with the changes of disease; and where it terminates fatally, to compare the appearance after death with the in- ferences drawn from auscultation, making allowances for the alteration which may have been produced by the progress of the disorder, since "experimenting" ceased to be practicable, at least to the humane. To do all this properly,- or to do it at all to any purpose, can only be man- aged in a hospital or an infirmary, where "numbers ofall diseased" are col- lected together, and then only under good tuition. Looking at the number of patients and of pupils, with the comparatively little time the physician can give to each in his runs through the wards, it is possible that only a confident and pushing industry can learn it there. In short, auscultation seems rather an art by itself than the branch of a profession, and, like solo-playing, an art in which only a few gifted and persevering ones excel.

Nor are its conclusions to be implicitly trusted. Even a great auscul- tator may fall into great mistakes, if he is not likewise a sagacious phy- sician, prompt to perceive and skilful to combine the attendant symptoms, natural constitution, or temporary circumstances, which explain, modify, or mask the sounds. Perhaps, too, there is a faintness and obscurity in the earlier stages which forbid a certain diagnosis ; and when the sounds are unmistakenly developed, the certainty is of little use. Still, auscul- tation is a help—more, perhaps, in rejecting than in forming conclu- sions—and in competent hands a valuable help, "to thicken other proofs which do demonstrate thinly." It is therefore a thing to be learned, so far as time, opportunity, and ability permit.

It cannot, however, be learned by precept, any more than pronunci- ation or musical intonation. "The sounds," says Dr. Hughes, speaking of certain minute variations in a disease of the lungs, "must be heard to be appretiated ; no description, however exact and however minute, can render them practically available to the uninitiated. Auscultation cannot be learned by book—except for the purpose of passing an examination. The student must go to the bedside—must go frequently, and stay long. Without this he cannot become a practical auscultator. Without this, he cannot become a skilful practitioner in diseases of the chest." Let us add, that until he acquire some perception of the sounds, and some capacity in distinguishing them, he should not go alone ; as Dr. Hughes intimates in another place. Indeed, if auscultation is to be taught, it is as worthy of being taught separately as botany.

The object of Dr. Hughes's work is not, therefore, to teach ausculta- tion, but to show how it should be learned, by pointing out the order in which the sounds of the chest should be sought for, by so describing the sounds, that, having been heard, they should be recognized in description, and by classifying them in such manner that their study may be methodical, and inclusive of the diseases in which auscultation is useful. The work was written at the unconscious suggestion of several pupils of Guy's, who intimated the kind of introduction they wanted by their inquiries, and by their objections to the books mentioned. The author does not make pretension to much originality of matter ; and he yields at once to any claim that may be brought against him by another; whilst to two articles by Dr. Forbes in the Cyclopeedia of Practical Medicine he acknowledges particular obligations. But Dr. Hughes claims for him- self this quality—that his views have been tested by experience, whether they have originally been formed by himself or derived from others ; and that they are here brought together for the first time in a form and ar- rangement adapted to the purposes of the pupil. A Clinical Introduction to the Practice of Auscultation contains a good deal more, however, than auscultation proper ; which is limited to sounds heard by the application of the ear to the chest or through the medium of the stethoscope. Dr. Hughes treats of the art of drawing conclu- sions from inspection—from palpitation or manual examination—from per- cussion, which is a species of auscultation—from mensuration, of which he however thinks lightly, as the eye will detect appearances that instruments cannot measure—and the old-fashioned mode of examination by listening to the sounds elicited by shaking the patient ; all methods probably of less certainty than auscultation itself, and mischievous if they divert the pupil's attention from severer studies, by flattering him with the notion that he is acquiring his profession, when he is really amusing himself by legerdermain.

The elementary and strictly professional character of this book limits it to professional readers ; but there are curious passages in it. Here is a description of the voice heard through the stethoscope ; a plan which pupils might begin with, as it would give them confidence in the power of the instrument, and some practice in its use.

'4 If the end of the stethoscope be placed upon the larynx of a healthy person, and, while one ear of the examiner is applied to the free end of the instrument, and the other ear is closed by a finger of the disengaged hand, the individual !unlined be directed to talk, his voice will pass through the stethoscope directly ndo the ear, and will appear as distinct as and perhaps even more loud than if his lips were close to the ear. This is perfect pectorikry, (chest-talking,) and the best possible illustration of that important sign as it exists in some forms of disease.

"if now the end of the cylinder be removed from the larynx and placed upon the lower part of the trachea, and the person be directed to talk as before, it will

be noticed that, though the voice appear in some measure to permeate the tube, and though the individual still seem to speak into the ear, yet the voice is not so clear and distinct as in the former case. Such is imperfect pectoriloguy.

"Let the examiner now move the stethoscope to the upper bone of the sternum, to the cartilages of the second and third ribs, or to the inter-scapular regions, and again direct the person to talk. A fresh modification of the voice is now observed. It does not appear to permeate the instrument at all, and though loud, is compa- ratively distant and indistinct. The sound appears to be obstructed by the inter- vention of a bad conductor between the mouth of the speaker andethe ear of the listener. This is bronchophony (bronchial sound.) " If, finally, the end of the stethoscope be placed upon other parts of the chest than those specified, the sound of the voice is still heard, and differences of into- nation can be recognized,_ but, under ordinary circumstances, articulation can be scarcely said to exist. The distinctness, as well as the loudness of the sound, diminishes the farther the stethoscope, or the ear (if that be now employed) is removed from the larynx and the larger bronchial tubes: the former is the source of the sound, and the latter are its best conductors. Thus it will be found, that at the most distant parts, as over the thin edge of the lungs, the voice, if heard at all, is reduced to an indistinct buzzing. "Such, then, are perfect pectoriloquy, imperfect pectoriloquy, bronchophony, and the distant voice in the natural condition.'

TILE RHYTHM OF THE HEART.

If the ear, or the stethoscope, be placed upon the pnecordial region, and the heart be acting naturally, a regular succession of sounds, and cessation of the sounds or of intervals, will be noticed by the most casual observer. In the first place will be noticed a sound comparatively long, then a sound comparatively short, and then an interval without any sound; after which, again, will occur the long, then the short sound, and then the interval. The long and short sound, together with the interval, make up the time occupied by one complete circuit of the heart's function; and as these sounds and this interval have been observed constantly to bear a definite relation to each other, the period occupied by them, or the complete circuit of the heart's action, has been divided into corresponding portions of time. Supposing, then that the whole period of this time be divided into fifths—the first sound has been calculated to occupy two-fifths, the second sound to occupy one-fifth, and the interval between the sounds to occupy the remaining two-fifths. The period occupied by the whole corresponds to the time between one stroke of the pulse and another. So that if a person's pulse beat eighty times in a minute, there would be eighty long sounds, eighty short sounds, and eighty intervals. Si- milar relations would exist, supposing that they could be correctly estimated, and that the pulsations were at the same timeregular, if there were a hundred, or a hundred and sixty strokes of the pulse in a minute. This regular division of the time occupied by one complete circuit of the heart's function constitutes the rhythm of the organ. When the sounds of the heart, and the interval between them, bear the relation to each other which has been mentioned above, the rhythm is said to be natural': when they do not hear that relation to each other, the rhythm is said to be conte- nted, and the action of the heart is said to be irregular. Irregularity of action, then, is the same thing as an unnatural rhythm.

But mark the uselessness of this, unless sagacity and knowledge are brought to the case.

"Is, then, a natural rhythm indicative of a sound heart, and an unnatural rhythm necessarily characteristic of an unsound one ? Both these questions must be answered in the negative.

"A heart greatly diseased, so long as the circulation is undisturbed and Use patient remains quiet mentally as well as bodily, may pulsate with perfect

krity. The rhythm of a merely irritable heart, as that of an hysterical girl, dyspeptic, a valetudinarian, a hypochrondriac, or of a person greatly alarmed or excited, may exhibit all sorts of Irregularities. The rhythm, thereforeconai- dered alone, is of little diagnostic importance' as the mere fact of snaking an examination for the purpose of ascertaining its character may, in a nervous sub- ject, alter it altogether.