Part 2
A gentleman, subject to gout, took cold in the month of January from exposure to wet. He nursed himself, but not aware of the seriousness of his attack, had neglected to procure medical advice. I found him affected with advanced symptoms of inflammation of the lungs; and, without delay, directed a copious bleeding from the arm. There was very great irritation in the stomach and bowels, attended with painful diarrhœa; on which account, twenty leeches were applied to the middle of the abdomen. His cough was sharp and violent. The appearance of the blood indicated high inflammatory action, being cupped so as to form almost a round ball. The surface of the blood was covered with a thick buffy (fibrinous) coat, and the serum was very abundant, being pressed, and, as it were, squeezed out from the coagulum in the firmness of its contraction. The indication by the stethoscope on the left side, was that of the “râle crépitante,” or the rattle, which is compared to the crackling sound of salt when thrown upon hot iron, and serving to shew that inflammation was existing in the texture composing the air cells. Similar indications were presented on the right side, but in a slighter degree. The patient did not complain of pain in any part of the chest, but suffered severely from oppression, having the feeling that “the room was too small to breathe in.”
By means of repeated bleedings, blistering, and the use of suitable medicines, the urgent symptoms were removed, and the patient in a short time enjoyed the first feelings of convalescence. The weather suddenly became intensely severe, and, probably from an injudicious change of apartment, a relapse of the symptoms of violent cough, difficulty of breathing, fever and general irritation, immediately took place.
Now, by means of the stethoscope, I distinguished to a considerable extent at the upper part of the left side of the chest, a mixed rattle, composed of sounds rather deep than acute, and a gurgling noise, as if a large quantity of mucus was floating in the cells. At the shoulder blade, the instrument furnished the same signs. In addition to the repetition of bleeding from the arm, twenty ounces of blood were removed by cupping, part from the breast and part from the shoulder blade. Great and immediate relief was afforded. The general fever, of which, both now and before, occasional delirium was one symptom, was checked.
The medicine consisted of tartarized antimony and nitre in a saline draught, with the addition of syrup of poppy, in order to quiet cough and irritation. On the following day, blood was again taken from the arm freely; but, notwithstanding the blood exhibited the same signs as before in a great degree, no further depletion was required.
We are much instructed as to the degree of inflammatory action of the vessels by the appearance of the blood, which, when possessing these characters, is commonly, but inaccurately called inflamed. And we must not consider that continued bleeding is the indispensable remedy for restoring the circulation to a healthy state, and the blood to its natural condition. My view of the nature of blood of this description is, that it simply contains a larger proportion than usual of one of its constituent parts, termed the fibrin; and hence, a firmer clot and the buffy coat. It is important as being an attendant on inflammatory action[1], and an indication, therefore, to our treatment. Although we rightly attach all possible importance to the use of the lancet, and of local bleeding, we must not forget that we have other means of reducing the circulation; as, for example, the use of medicines, repose, and general regimen.
To return to the case, I have to add, that when heat of the skin and general fever were abated, the peculiar sounds just now mentioned, had also nearly disappeared. In this state of improvement, a large blister was applied over the affected side of the chest. As it seemed probable that further general bleeding might be avoided, digitalis was added to the medicine. This becomes a valuable agent at the period when we may hope to have laid aside the use of the lancet. If employed during the height of inflammation, most probably it will not render the pulse slower; and even if it does have this effect, it rather masks than cures the disease, leaving us in doubt whether the abatement of the pulse be fairly due to the diminution of inflammatory action, or to the influence of the digitalis. This gentleman recovered gradually, but in the most favourable manner.
The latest morbid indication by the stethoscope, was simply the mucous rattle.
In exploring the state of the chest with the stethoscope, it is incumbent upon us to reason carefully upon every phenomenon which we discover, and not to consider this or that circumstance as merely curious. We should weigh well the importance of the pathological indications; and form our conclusions, in great measure, from our knowledge of the anatomical structure of the particular parts of the organ which we find to be affected; and, also, from the relative situation of one part to another. For example, we discover different kinds of rattle, accordingly as the bronchial tubes, or the air cells, may be respectively affected; and the effect produced on the action of the heart by a morbid condensation of the left lung, is very different from that occasioned by the same state of disease in the right.
In cases of pulmonary consumption, it is important for us to ascertain whether or not ulceration has yet taken place.
In this investigation, we use the stethoscope with its stopper, as serving better to bring the sound of the voice to a focus. If there be an open tubercle (in synonymous terms, ulceration, or excavation), the vibrations produced by the voice passing more readily to the ear of the auscultator, than when there is no breach of surface in the lung, it seems as if the patient were speaking up the tube, and hence the exact situation of the ulceration is indicated. This phenomenon is called by the expressive term, pectoriloquism.
If the instrument be applied over the windpipe, when there is not disease, the voice produces in some measure the same effect; because at this part, the integuments are thin, and do not interpose much medium between the voice of the person speaking, and the ear of the auscultator.
It is a consoling circumstance that M. Laennec does not view tubercular consumption as an incurable disease. He mentions having several patients under his care ill with chronic catarrh, affording distinctly the sign of pectoriloquism, although in all other respects then free from symptoms of consumption.
He refers to the case of a lady, a patient of M. Bayle, in whom pectoriloquism was quite distinct. She had been decidedly affected with the symptoms of consumption eight years before: she had recovered beyond all expectation, and was then stout, not having any other symptom of pulmonary irritation than a slight cough.
M. Laennec next relates[2] the morbid appearances in the lungs, found on dissection in five cases of patients who died from other diseases. In each instance, tubercular excavations were found cicatrized, and for the most part lined by a semi-cartilaginous membrane; adding testimony therefore to the opinion already stated, that nature does sometimes exert a curative process, in cases of consumption which were apparently hopeless.
It should consequently be the study of our art to favour the salutary efforts of nature; and invariably to cherish and encourage, in a judicious manner, those hopes of the patient, which in this destructive disease are always, to a remarkable degree, so fondly entertained. It is to be observed that if a solid cicatrix be formed, and the bronchial tubes terminating in the part be obliterated, the phenomenon of pectoriloquism cannot be found; but we meet with it in two states of the diseased lung, the one in which the ulcerative process is at present going on; the other, in which there is a healed excavation or ulcer, lined by a newly-formed membrane, of a semi-cartilaginous nature, and fistulous. These respective conditions will of course be denoted by the relative state of the patient. The perfect cicatrix is more completely a curative process, than the formation of fistula.
The recovery of health from the cure of ulceration just described, may prove more or less lasting accordingly as the remaining part of the lung be free, or not, from tubercles. But even when they do exist, they may fortunately remain dormant for some years.
In every case of seeming recovery from consumption, it is incumbent on the patient to lead a life of the utmost care, and to choose a favourable climate, endeavouring to avoid the cold of winter, the extreme heat of summer, and the vicissitudes of spring and of the latter part of autumn, by the best possible management. M. Laennec is particularly partial to a sea-side residence for consumptive patients.
In some circumstances of consumption, the existence of pectoriloquism, as denoting the ulcerative process, is considered by this physician to be rather favourable than otherwise; because it is an indication that nature is making efforts towards a cure, by maturing and evacuating the tuberculous matter. The prognosis is favourable in proportion as we have reason to hope that the other parts of the lungs are healthy.
In some severe examples, numerous tubercles acquire an active state of disease; and the consequent irritation is so excessive, that death takes place without the usual process of ulceration.
The nature of the expectoration will guide us considerably in our diagnosis; but it is necessary to keep in recollection, that it should never be judged of separately from the other symptoms. It frequently happens that we witness the sputa of ill appearance and puriform, without danger in the patient; in so great a degree does the bronchial membrane, in common with the other mucous membranes, fall into a state of irritation and diseased action, which alters the secreting function most remarkably; and, as a consequence, we find the product similar in appearance to that which the vessels form, when there is actual breach of surface.
M. Laennec observes, “that the superior lobes of the lungs are the most common seat of tuberculous ulceration; but that they also occur in the centre of the lungs; in their anterior, middle, or lateral parts, or even in their inferior edge, while the superior lobes are uninjured.”
In a case in which we suspect pectoriloquism, we must therefore make our investigation sufficiently extensive.
Also, in a suspicious case, we are not to form a decision upon a single examination; “because the sputa contained in the excavations may obstruct for a time the communication with the bronchiæ, and thus suspend pectoriloquism for several hours.” M. Laennec further observes, “If, after repeated trials, we cannot discover pectoriloquism, we must infer, either that the tubercles are still immature, or, if softened, that they do not communicate with the bronchiæ; or, lastly, that the disease is not phthisis.”
In cases of pleurisy, when there is serous effusion between the layers of the pleuræ, the voice affects the stethoscope so as to produce that peculiar phenomenon of bleating sound, to which the term _œgophonism_, or _caprine pectoriloquism_, is given; from the supposed resemblance to the voice of a goat. M. Laennec considers that “the natural resonance of the voice in the bronchial tubes is rendered more distinct by the compression of the pulmonary tissue, and by its transmission through the medium of a thin layer of fluid.”
I have traced, in a case of pleurisy, the daily diminution of this phenomenon, in proportion as the absorption has taken place, and the healthy condition of the pleural membrane has returned.
I should add to this concise account, that M. Laennec considers œgophonism to be a favourable sign in pleurisy; because it indicates a moderate degree of effusion. It is not found, “if there have been a rapid and copious effusion, by which the lung becomes suddenly compressed against the mediastinum; nor where a former attack of the disease has firmly attached the posterior parts of the lung to the pleuræ.”
Four principal kinds of rale or rattle are enumerated, as discovered by the stethoscope. They are termed, “the humid or crepitous; the mucous or guggling; the dry sonorous, and the dry sibilous or hissing rattle.” Other characteristic varieties might be mentioned. For the physical explanation of these phenomena we must refer to the altered condition of the air cells, the bronchial tubes, or the pleural membrane, occasioned by inflammation and its consequences; or, sometimes by spasm only as regards the bronchiæ. For many details on this part of the subject, the reader is referred to M. Laennec’s Treatise by Forbes.
In the case of an elderly lady, ill with pneumonia and bronchitis mixed, I distinguished, on the right side, immediately under the clavicle, the râle crépitante; but, rather lower down, sounds like the chirping of a bird, an effect probably owing to spasmodic contraction of the minute branches of the bronchia, arising from inflammation. The other side of the chest afforded indications of free but noisy respiration. In addition to general bleeding, twelve leeches of full size were applied to the right side with great advantage. On the following day, the chirping sounds were lessened, and afterwards yielded entirely to further general and local bleeding. Instead of the chirping sound, we sometimes find that which is aptly compared to the cooing of the turtle dove.
It is certain that the diseases of the heart form a much more delicate and difficult study with the stethoscope, than those of the lungs.
In our ordinary means of investigation, it often exceeds our best powers of discrimination, to distinguish satisfactorily between functional and structural disease; and this difficulty, I apprehend, will not be removed by the use of the stethoscope, although I am well persuaded it will be very materially lessened. Both humanity towards the patient, and a regard for our own reputation, demand that we should use very great caution in forming our opinion on these occasions, and still greater in pronouncing it.
Inordinate action of the heart arises from many influential causes, both of a moral and physical nature. Nervous palpitation is of common occurrence. Intermission of pulse is not unfrequent; but I have had occasion to see most experienced practitioners mistaken concerning the true nature of this affection. It occurs as a sympathy with a morbid state of the brain, the stomach, and also the liver; but most frequently, according to my observation, when the stomach of an individual of nervous constitution is disordered with permanent indigestion.
The most remarkable cases of intermittent pulse which have occurred in my practice, have been connected with faulty action of the digestive organs, and of the liver especially, in gouty persons. We know how remarkably the gout affects the nervous system; and I can scarcely offer a stronger proof of it, than this kind of influence upon the heart; for although we meet with examples of the same kind of irregular action, in a disordered state of the digestive organs, in persons free from all disposition to gout, yet in such instances it is neither so permanent nor so remarkable.
I was consulted by a gentleman ill with gout, who related to me that, a few years before, he had been troubled with intermittent pulse for the long space of four years; and, during this period, his mind was alarmed with many gloomy apprehensions. His digestive organs were much disordered: medicine had given only partial relief. Quite suddenly, a painful and regular fit of gout took place, for the first time. Immediately the action of the heart became regular, and has so continued from that period.
I have met with similar instances less strongly marked.
In various affections of the heart, and also of the aorta, I have derived very useful information, and practical instruction, from the employment of the stethoscope. In the case of a female, the instrument, applied to the epigastric region, conveyed to the ear the peculiar sound which is compared to the blast of a pair of bellows strongly used, and which was attended with occasional pain, especially after taking food. The repeated application of leeches, with the use of sedative medicine, afforded permanent relief.
When we consider that, from the examination of the pulse at the wrist, we obtain information only of the action of the left ventricle of the heart, and that by means of the stethoscope we are made acquainted with the action of both ventricles and both auricles, the value of the instrument must appear unquestionable.
This fact, that the pulse at the wrist does not indicate the state of the whole heart, is important in a practical as well as a physiological point of view. The pulse, in certain diseases, may be weak and small, when the action of the heart is energetic, and which is to be ascertained by the stethoscope. On the other hand, there may be more energy in the action of the pulse than in the heart generally. The practitioner will receive very material instruction with regard to the use of the lancet, in these indications; and will know with more accuracy when he should prefer local to general bleeding.
In the first trials with the stethoscope, it is extremely difficult to distinguish the action of the ventricle from that of the auricle; and this confusion is greater if the heart be acting with more than ordinary frequency.
The motions of the left cavities of the heart are chiefly perceptible in the space comprised between the cartilages of the fifth and seventh ribs; and of the right, at about the middle of the sternum, or sometimes rather lower.
With the stethoscope, we first distinguish the action of the ventricles, which occurs at the same moment with the beat of the pulse at the wrist. It is accompanied by a rather dull, but distinct sound. Immediately after, and without any interval, the contraction of the auricles takes place, attended with a noise which M. Laennec compares to that of the lapping of a dog. The duration of this sound, and consequently the period of the contraction of the auricles, is less than that of the ventricles. Next, there is a very short, yet well-marked, interval of repose.
The regularity of this order will be variously disturbed, by the sympathy which the heart observes towards other organs, as I have already explained; but much more materially by changes taking place in its own structure.
The sounds occasioned by the action of the heart, or of the large arteries, when disordered, are remarkably characteristic in their nature, and, if well understood, assist in a very satisfactory manner, our diagnosis, pathology, and treatment.
The Treatise of M. Laennec, and the late original publication by Dr. Forbes, furnish us with much valuable information for the diagnostic use of the stethoscope in diseases of the heart. A new volume which is about to issue from the press, to be presented to us by the Master of this art, M. Laennec, will contain the important results of his later experience.
As, in a diseased condition of the lungs, when the symptoms are more serious in appearance than reality, we can obtain the comfort to the patient and ourselves, of giving a favourable prognosis by means of the stethoscope; so, in the disordered action of the heart, it may often be in our power to gain that clear perception of the case, which may arm us with confidence as to its true nature, and its freedom from danger, and thus enable us to dismiss much of the apprehension, with which the nervous mind of the patient is sure to be distressed.
Having thus brought in view an outline of the general merits of the stethoscope[3], and of the improved method of exploring the diseases of the chest, I proceed to the remainder of my subject; it being my purpose to discuss, in a brief manner, some leading points of theory and practice suggested to my consideration by the cases and facts which came under my notice at the hospitals in Paris; and also to offer a few observations on the most important new medicines which may be considered of French origin.
GENERAL OBSERVATIONS.
Hospitals, and hospices, are numerous in Paris. The latter establishments are for the reception of the aged and infirm, or foundlings. Some of the hospitals are general in their principle of administration; while others are appropriated to particular age, or sex, or disease.
A board of general administration is held daily for the purpose of examining the patients who apply for admission. By means of this arrangement, the physician of any hospital whose attention is directed to a particular disease, or class of diseases, may send a patient to the hospital to which he is attached. The attention of the medical officers of the different hospitals is highly laudable, and worthy of imitation. They make their visits of regular attendance in the wards daily, and usually at the early hour of seven, and deliver clinical lectures on the most interesting cases at nine. I was present at these lectures, both at the Hotel Dieu and at La Charité, and was much gratified with the ability displayed by M. Dupuytren at the former, and by M. Laennec at the latter hospital.
In most of these abodes of suffering, the sisters of charity exercise the kind office of superintending nurses, in which capacity, however, their humanity leads them to perform various active duties. It is quite delightful to witness the benevolence of their disposition, and the tender manner in which they pay their attentions to those under their pious care. How happily is the influence of religion here displayed, which can thus temper the mind to forego the pleasures of society, and even the common enjoyments of life, for a retirement, in which every hour and almost every moment, each thought and action, become a homage to the Creator, in the alleviation of human suffering!
There is an establishment in Paris which contributes exceedingly to the comfort and convenience of that class of persons who wish to avoid a hospital, but whose means are too limited to afford all the private aids which sickness requires[4]. I quote the following account of it from Galignani’s Guide to Paris.
“MAISON ROYALE DE SANTÉ.
“This house was opened in 1802 by the _Administration des Hôpitaux et des Hospices_, for the reception of invalids in middling circumstances, who pay a daily sum according to the accommodation they receive, as follows, viz. In rooms containing twelve or fourteen beds, two francs fifty cents; in those with two or three beds, three francs fifty cents. A room for a woman, five francs. A room for a man, six francs. In this charge, every thing, even vapour baths, mineral waters, &c. is included.”
That a material difference exists between the French and English practice of medicine, is universally known; and the compliment of superiority is seldom allowed to the former. Improvement, however, in the art of medicine, which the successful cultivation of chemistry and of morbid anatomy has so largely introduced in the last twenty years, is not confined to ourselves. The professors of chemistry at Paris receive their appointments and their conveniences from the government. That valuable commodity, time, is much at their command, because they confine their pursuits more than most of those who are engaged in teaching chemistry in London. The facility of procuring, at Paris, the examination of dead bodies is such as to favour the study of morbid anatomy most completely.