Part 5

The other case was that of a young woman, affected with many of the same symptoms which I have related in the foregoing case, but in a more acute degree. From accidental circumstances timely treatment had been omitted; and I found the highest degree of general fever, with a pulse frequent, hard, and obstructed. The breathing was laborious, but not attended with any fixed pain in the chest. Her voice was rather hoarse, and had lost its natural tones. The cough was urgent, and the expectoration took place with difficulty. The expectorated matter was, for the most part, frothy, and had a remarkably acid odour. The cheeks were flushed with a deep hue of purplish red, and the lips assumed a very dark appearance. Such was the laboured state of the circulation, that the patient was affected with an almost constant disposition to faint. She complained of a sense of extreme burning, and also of soreness, over the whole of the chest. She had not enjoyed any sleep for three nights, nor any in the day; her mind was occasionally delirious; and her countenance wore the greatest anxiety.

In the upper part of the right side of the chest, I discovered by the stethoscope remarkably acute sounds, both in inspiration and expiration, and in the left side similar sounds, but in a weaker degree. I also distinguished the mucous rattle in some points. Blood was taken freely from the arm, and it was cupped and buffy in the extreme. Sixteen leeches of full size were applied to the right side, and eight to the left side of the chest. Tartar emetic was administered internally in the manner I have before mentioned. The altered and improved situation of the patient in a few hours, was equally remarkable and satisfactory. All the urgent symptoms were alleviated, but all continued sufficiently troublesome to require a repetition of general and local bleeding, in the course of the three following days. It is worthy of remark, that free depletion removed the disposition to faint. At the end of eight days, the symptoms of active inflammation were removed, and at the same period the sounds had ceased, and the stethoscope afforded only the indication of the mucous rattle. The tartar emetic solution, although joined with the syrup of poppy, caused more than usual sickness in this case; but it appeared highly beneficial, by useful instruction in regard to the seat, the removing more freely, than the simple act of expectoration could accomplish, the viscid matter, which, latterly, was muco-puriform, and was less acid in odour. After the reduction of the inflammation, pulv. ipecac. compos. was given in a saline draught at night, with great advantage in assisting sleep and allaying cough.

This patient is convalescent and takes the mild medicine of sarsaparilla with hot milk, just now described, in conjunction with the draught at night, and gentle aperients occasionally.

I think I have here shewn, that by means of the stethoscope,[13] I obtained much extent, and the progress of the inflammatory symptoms; and that I was thereby enabled to direct my local treatment with greater accuracy and advantage, than I could have done, if confined to the ordinary modes of investigation.

The cases which I have here related, correspond with Laennec’s description of acute pulmonary catarrh, or bronchitis, a term which I have been accustomed to consider, more applicable to the inflammation affecting the larger branches of the bronchia proceeding immediately from the trachea. When the ramifications extending through the lung are inflamed, it constitutes a case, either mixed with, or, so much resembling genuine pneumonia or inflammation of the substance of the lungs, that, in a practical point of view, the distinction does not perhaps appear important; but yet, accuracy of diagnosis should always be desired.

In the case of a young gentleman lately under my care, the symptoms of inflammation in the lungs were acute, of considerable continuance, and apparently distinct from any affection of the bronchia, as the stethoscope did not afford the sonorous rattle, but only the crepitating and mucous kinds. I do not speak of this as a solitary example which has occurred to me. At this moment I am attending an elderly gentleman severely ill with pneumonia; and, in examining his chest, I cannot discover the sonorous rattle except in one small point; but I meet with other phenomena, as the crepitating rattle in one part, and the indication of obstruction of the air cells in another.

I take this occasion to observe, that in my study of the volumes of Laennec and Forbes, I do not discover so much mention as my experience would have led me to expect, of the strong sonorous rattle, or sharp tones (which in their variety admit of almost endless comparisons), as being characteristic of the existence of more or less active inflammation of the bronchia. I have found this species of rattle serve, in a remarkable manner, to point out the exact seat of the inflammatory action; and in proof that I have not been drawn into false conclusions from these particular indications of the stethoscope, I have been successful in my treatment, and have ceased to perceive the tones, in the same proportion as the inflammation has passed away.

Laennec, when speaking of the sonorous rattle, observes, “I am led by my dissections to believe that it is produced by the partial obstruction or narrowing of part of the tract of a bronchial tube, whether this takes place from the pressure of a tumour, or of a portion of the lung condensed by inflammation, or by the obstruction produced by a portion of tenacious mucus, or by the partial thickening of the internal coat of a bronchial ramification.”

The absence of the respiratory sound may arise from an impermeable state of the cells, or the bronchial ramifications, and have for its cause the presence of tubercles, or other matter of obstruction; or it may proceed from some secretion or effusion, the produce of disease. But the student, when he does not discover any sound of respiration, must be careful to avoid drawing false conclusions from his yet imperfect tact in the art; it so commonly happens, that calm respiration does not afford any distinct perceptions to the unpractised ear.

It appears to me worthy of consideration, whether or not, in some states of hydrothorax, the evacuation of the fluid by puncture may be a desirable expedient? The increased accuracy of diagnosis attainable by means of the stethoscope, would here be very important towards deciding the fit period for the performance of the operation.

In the narration of my cases, I have not made mention of percussion. Suffice it to observe, that I have seldom used it except in chronic diseases of the chest, as the indications by the stethoscope, in addition to the general symptoms, have afforded me all the information which I have required.

I shall here bring my Observations to a conclusion, having endeavoured to present in a concise and intelligible form, a part of the results of my own experience in the use of the stethoscope; and to consider briefly the merit of some points of practice; inquiring at the same time into the nature of several medicines, which claim our particular attention, both from their novelty and their importance.

The value of any practical opinion must be decided by the suffrages of the many; but, whoever collects and records his facts with care and fidelity, renders some contribution to the advancement of the medical art.

FINIS.

MALLETT, PRINTER, WARDOUR STREET.

FOOTNOTES:

[1] I am inclined to think, that during the inflammatory diathesis, a larger proportion of fibrin than natural is actually formed in the assimilating process; and it is further probable that it is not distributed as usual to the several fibrous textures of the body. In my Essay on the Blood, I have suggested this last hypothesis.

[2] See Forbes’s Translation, p. 19.

[3] In 1822, M. J. A. Legumeau de Kergarader published a Memoir “Sur l’Auscultation,” &c. in reference to gestation; and in 1824, M. J. Lisfranc, a Memoir, to show the powers of the stethoscope in enabling the surgeon to detect with greater nicety the fractures of bones. I have read these essays, which must be allowed the praise of ingenuity; and I conceive that cases may occur of each description, in which the aid of the stethoscope would be found not unimportant.

[4] I am happy to state, that an institution similar in principle to the _Maison Royale de Santé_, is established in London. It is called the _Asylum for the Recovery of Health_. It is situated in Lisson Grove. Already it has been highly patronised, and well does it deserve to grow in the favour of the public. It is supported in part by voluntary contributions, and in part by moderate weekly payments from the patients, who require, however, the ticket of a subscriber for admission.

[5] The use of white mustard is at present very popular, and, like all popular remedies, is employed too indiscriminately. Its medicinal power is not a new discovery. Cullen, in his Materia Medica, vol. ii, p 171, observes, “As much of the unbruised seeds as an ordinary table-spoon will contain does not prove heating to the stomach, but stimulates the intestinal canal, and commonly proves laxative.” Entirely with a view to determine the nature of this article as a medicine, I made an examination of the seeds in their whole state. In a few days after being digested in cold water, they became much enlarged, and the water had powerfully the smell of sulphuretted hydrogen. Submitted to distillation in a common alembic with water, the portions of the liquid which first came over possessed the taste of a weak infusion of malt, quite free from pungency. Digested in alcohol, they did not communicate strongly either smell or taste. Some seeds which had passed the alimentary canal, were found to be much swollen, and had lost some of their pungency. It is evident from these results, that the seeds, by treatment with these agents, were acted upon with difficulty in their entire state.

In the Journal de Chemie Médicale, de Pharmacie, &c. No. X. Année 1^{re}. M. M. Henry fils et Gorot, have given an elaborate report of their chemical examination of the mustard seed, of which the following is the substance: the seeds yield by expression a fixed and a volatile oil, and the latter may be separated from the former by digestion in alcohol. The alcoholic solution when evaporated affords a solid and crystallisable substance, possessing acid properties, to which the discoverers have given the name of sulpho-sinapic acid. Sulphur, it is stated, forms a constituent element of this peculiar acid.

M. Julia Fontenelle, in the same Journal (No. 3), informs us, that from his researches he is led to conclude, that the mustard seed owes all its medicinal powers to the volatile oil, for the extraction of which he recommends that the seeds should be reduced to powder, and distilled with eight or ten parts of water.

It may be considered therefore that the properties of the seeds become sufficiently extracted in the stomach and intestinal canal, to excite the mucous membrane to increased secretion, and also to influence the action of the nerves. They are found principally useful to those invalids who suffer from general deficiency of secretion in the intestinal canal, and from nervous langour. I do not conceive that they are so proper for persons of the inflammatory diathesis, and who become easily heated; and I should rather approve of them as an occasional than a constant remedy, for they are not a certain aperient, and I do not think it desirable to subject the canal constantly to this kind of stimulus. If the seeds accumulate very much, some inconvenience may be occasioned by their augmentation of bulk, and if they be retained in the intestines, some further inconvenience may result from the disengagement of sulphuretted hydrogen.

[6] M. Goupil, who was attached to the Hospital of Val-de-Grâce for two years, has given a clear view of these doctrines, in a work entitled Exposition des Principes de la Nouvelle Doctrine Médicale, &c. Paris, 1824.

[7] With regard to many other medicines, the most useful maximum of dose is an interesting question. I am certain that the largest quantity which the stomach will receive, is not the most efficacious. The action between the medicine and the stomach must be mutual. If we take, for example, so innocent a medicine as the carbonate of iron, I expect more effect from the dose of a dram than half an ounce, which would incommode the powers of the stomach by its mass. The observation applies to all medicines which are of a very insoluble nature. I do not mean, in a general sense, that a small dose of a medicine has equal power with a large one, but that there is a point of increase, beyond which the efficacy becomes lessened.

[8] Sulphate of quinine may be procured by digesting bruised bark in repeated portions of diluted sulphuric acid, until the liquor no longer possess a bitter taste. The different liquors are then to be mixed together and strained. To the strained liquid, lime is to be added, until the mixture assume a chocolate brown appearance, and a precipitate subside to the bottom of the vessel. This precipitate must be washed with a little cold water, dried, and digested in alcohol. The alcoholic solution, when submitted to distillation, leaves, in the retort, a brown viscous liquid, which is to be treated with a suitable quantity of boiling dilute sulphuric acid and a portion of charcoal. This solution is lastly to be filtered, and set aside to cool, when crystals of the sulphate of quinine will form. Mr. Garden informs me, that the largest portion of the sulphate of quinine which he has been able to prepare from the best yellow bark, is as one to fifty.

[9] Opium is to be digested in cold water, and the solution filtered. Pure ammonia is to be added to this liquid so long as a precipitate is produced. Impure morphine is thus obtained, which may be purified by dissolving it in acetic acid, and digesting it with animal charcoal. The solution is again decomposed by ammonia. This precipitate is to be washed with distilled water, and dissolved in boiling alcohol, from which pure morphine will crystallise upon cooling. The acetate is formed by dissolving the morphine in dilute acetic acid, and evaporating the solution to dryness upon a sand bath.

[10] I have borrowed some of these details from the “Formulaire pour la Préparation et l’Emploi de plusieurs Nouveaux Médicaments,” par F. Magendie, Septembre 1825.—Fifth edition.

[11] In the praise which appears to be so justly due to the foreign chemists, the German philosophers should not be overlooked. We may refer the discovery of the prussic acid to the labours of Scheele, and that of morphine to Sertunner; from which last discovery, we may consider that the idea of insulating the most important principles of other vegetable medicines took its rise.

[12] The establishment for filtering the water of the Seine is upon a grand scale, and admirably conducted. The water is passed through a very thick bed of charcoal and gravel. Many of the inhabitants use large filtering stones in their cisterns, for accomplishing the same object.

[13] M. Laennec had the goodness to present me with a stethoscope constructed according to his last improvement. For the convenience of my professional brethren, I have directed an ingenious workman to imitate this stethoscope; and Mr. Garden, Chemist, No. 372, Oxford Street, has under taken to keep a constant supply of the instruments for sale.

TRANSCRIBER’S NOTE

Obvious typographical errors and punctuation errors have been corrected after careful comparison with other occurrences within the text and consultation of external sources.

Some hyphens in words have been silently removed, some added, when a predominant preference was found in the original book.

Except for those changes noted below, all misspellings in the text, and inconsistent or archaic usage, have been retained.

p27-> ‘if it do have’ amended to ‘if it does have’ p37-> ‘or the plural’ amended to ‘or the pleural’ p57-> ‘in the same Jounal’ amended to ‘in the same Journal’ p73-> ‘to the epigastricregion’ amended to ‘to the epigastric region’ p93-> ‘the acetate of morphium’ amended to ‘the acetate of morphine’ p108-> the printed fraction ‘2/10’ is unclear, and may be ‘8/10’ or ‘9/10’ p119-> ‘genuine pnuemonia’ amended to ‘genuine pneumonia’