TRANSCRIBER’S NOTE
Italic text is denoted by _underscores_.
Some minor changes to the text are noted at the end of the book.
The superscript re is denoted by 1^{re}.
OBSERVATIONS,
_&c. &c._
OBSERVATIONS
ON
M. LAENNEC’S
METHOD OF FORMING A DIAGNOSIS
OF THE
DISEASES OF THE CHEST
BY MEANS OF
THE STETHOSCOPE,
AND OF
PERCUSSION;
AND UPON SOME POINTS OF
THE FRENCH PRACTICE OF MEDICINE.
BY
CHARLES SCUDAMORE, M.D. F.R.S.
Member of the College of Physicians in London; Honorary Member of
Trinity College, Dublin; of the Medico-Chirurgical Society of
Edinburgh; and of the Medical Society of Paris; Member of the
Medico-Chirurgical Society of London; Physician in Ordinary to
His Royal Highness the Prince Leopold of Saxe Coburg, &c. &c.
London:
PRINTED FOR THE AUTHOR,
By Joseph Mallett, 59, Wardour Street, Soho;
AND PUBLISHED BY
LONGMAN, REES, ORME, BROWN, AND GREEN,
PATERNOSTER ROW.
1826.
TO
Sir HENRY HALFORD, Bart.
K.H. F.R.S.
PRESIDENT OF THE COLLEGE OF PHYSICIANS, PHYSICIAN TO
THE KING, &c. &c. &c.
MY DEAR SIR,
In requesting the honour of dedicating to you the following pages, I
am actuated by the feelings of respect and personal regard, which I
entertain equally for your public and for your private character.
It is also with more than ordinary interest that I address my
observations to you, as the President of the College; an office
which, it may with truth be said, you fill with no less dignity to
yourself, than with benefit to the whole profession.
In becoming an advocate for the employment of the stethoscope, I
disclaim adopting principles in the practice of physic, which might
with any justice be called mechanical.
It cannot however be denied, that with all the improvements which
the art of medicine has received, it still must, on many occasions,
depend greatly on conjecture.
Some of the diseases of the chest are attended with such obscurity,
that the detection of their precise nature bids defiance to the
most acute penetration. What prudent physician, then, will disdain
to avail himself of the means which this simple but philosophical
instrument affords, of obtaining a more faithful diagnosis?
It is not intended that its use should supersede those established
principles of our art, which early and regular education, as well as
experience, have pointed out to us; but that it should serve as an
auxiliary in the investigation of obscure disease.
For my own part, I have no apprehension that the judicious employment
of the stethoscope can, in any degree, tend to make us negligent in
observing the symptoms of diseases, or indifferent to the study of
the usual means of diagnosis.
In the hope, that the general opinions which I have offered in this
volume, may receive the high sanction of your approval,
I have the honour to remain,
DEAR SIR,
Your most obliged, faithful,
And obedient Servant,
CHARLES SCUDAMORE.
Wimpole Street,
April 14th, 1826.
PREFACE.
Having expressed my opinion generally on the merits of the
stethoscope, in the course of the following Essay, I have little to
say in the form of a preface.
Although the credit of the invention is due to the ingenuity of M.
Laennec alone, and the volume which he has presented to us abounds
with valuable pathology, it is of no small importance that the
sentiments and the experience of others should also be collected and
recorded.
Before any new method in the practice of medicine can be firmly
established, or even deserve to be regarded in the light of fixed
authority, it is incumbent upon us to examine all the collateral
evidence which can be produced in its favour; and he who, with this
view, contributes to the general stock of information, may claim
the merit of usefulness, although he be not entitled to the more
brilliant distinction awarded to genius.
It appears to me, that whoever adopts the use of the stethoscope,
must study it for himself, and consider, that all which is offered
to his attention by the industry and observations of others, is
calculated to serve his purpose only as an introductory lesson.
The skilful employment of this instrument must be the result of
practice. Every case which occurs, presents new and distinct matter
for investigation. It is peculiarly necessary to be accurate in
marking with nicety the nature of the impressions which are made upon
the ear, and to reflect upon the phenomena with all the skill and
care of the physiologist, the anatomist, and the physician. Nothing
must be left to the imagination; for, if this creative faculty be
exercised, the judgment may be misled, rather than informed and
assisted.
I have purposely confined myself to a limited sketch of the general
subjects which I have embraced; so that if the following pages should
not appear to possess the merit of great novelty, they will, I
hope, at least escape the imputation of being tedious and devoid of
interest.
OBSERVATIONS,
_&c. &c._
In a late visit to Paris, I availed myself of the opportunity of
attending the principal hospitals; of inquiring into the general
practice of French medicine; and of studying, at the hospital of La
Charité, the method brought to so much perfection by M. Laennec, of
investigating the diseases of the chest; in regard to which, I had
also the advantage of receiving every kind attention and personal
instruction from this distinguished physician.
The method of which I now purpose to offer a brief account, embraces
the use of percussion and of the stethoscope.
It appears that percussion was first practised by Avenbrugger in
Germany, who published a treatise on the subject in the year 1761,
which was translated into French by the celebrated Corvisart, with
commentaries, in 1808. This author, in his Treatise on the Diseases
of the Heart, constantly founds much of his diagnosis on the
indications afforded by percussion.
The method consists in striking the respective parts of the chest,
which return a hollow kind of sound, when the contents of this cavity
are in a healthy state; but give a duller sound, when, from any
cause, there is impediment to the free entrance of air into the cells
of the lungs. When the obstruction is considerable, the perception is
very much the same as when you strike upon the thigh. The sound is
flat instead of hollow.
Simple as it may appear, there is a considerable tact in the mode
of percussing; and it is of importance to practise it in aid of the
information derived from the stethoscope.
The linen covering over the chest may remain, but thick dress should
be removed, and the surface also ought to be smooth. The integuments
should be rendered rather tense by the favourable position of the
arms. The four fingers being held close, bent, and a little curved,
the chest is to be struck rather sharply and in quick succession;
and when the indication of obstruction is manifest by the dulness of
sound, the corresponding part on the opposite side, is to be struck
with equal force; nice care being observed that all circumstances
are equal; as for example, the kind and strength of percussion, the
quantity of covering on the part, and the position of the patient. At
small points of examination, it will sometimes be convenient to use,
in the same manner, only two fingers; or, now and then, on a broad
surface, the flat hand, percussing rather slowly and gently.
M. Laennec displays no less skill and accuracy in his mode of
percussion than in the use of his stethoscope; and he attaches great
importance to it as an auxiliary source of information.
Through the industry and ability of Dr. Forbes of Chichester, who
translated the work of Laennec in 1821, and who has also lately
published an original volume of great merit on the subject; and
through the medium of our medical journals, more especially the
excellent quarterly works published at Edinburgh by Dr. Duncan, jun.,
and in London by Dr. James Johnson, the professional public has been
made acquainted with the nature and uses of the stethoscope; but up
to the present time, it is so much a novelty in medical practice,
as well as with the public at large, that I trust no apology is
necessary for presenting an abridgment of the opinions of M. Laennec,
with a few reflections on the subject derived from my own observation
and practice.
As with percussion, the use of the stethoscope is founded upon a
simple philosophical principle; that of ascertaining whether the
cells of the lungs are healthy, and fitted for the free reception
of air in the function of respiration; or whether the membranes of
the chest, or the vessels, valves, and cavities of the heart, are
obstructed by any disordered action, or by any permanent disease.
The instrument which has received the name of _stethoscope_ (derived
from στῆθος, pectus, and σκοπέω, speculor or exploro), was invented
by M. Laennec; and the idea of it occurred to him from reflecting on
the well-known fact in acoustics, that the impression of sound is
augmented, when conveyed through certain solid bodies, as, when we
hear the scratch of a pin at one end of a piece of wood, on applying
our ear to the other. In examining a disease of the heart, he first
made use of a quire of paper rolled into a cylindrical form, and,
satisfied with the result, he soon proceeded to investigate the
various phenomena afforded by the vibrations of air within the chest,
through the medium of the stethoscope; which he constructed from the
suggestion already mentioned.
After making various experiments as to the form of the instrument,
and the kind of material, he found most success in using a wood of
medium density, as cedar. This proves very favourable for conveying
the delicate vibrations caused by respiration, from the walls of
the chest to the ear. For the information of those who have never
seen the instrument, I may observe, that it is of cylindrical form,
shorter in length, but larger in diameter, than the common flute.
It has a cylindrical perforation throughout its whole length, and
is divided into two parts for the convenience of using the whole or
half length, according to the situation of the patient in bed. The
end of each part terminates in a funnel-shaped cavity, the one to
receive the separate half of the instrument, and the other to receive
the part acting as a stopper, which latter has a short pipe, made of
brass or silver to enter the bore of the cylinder.
The instrument is used without the stopper, when employed to
ascertain the state of respiration; and with it, either to examine
the action of the heart, or the signs afforded by the voice, in
certain states of disease affecting the lungs, or the pleural
membrane.
In using the stethoscope, care is to be taken that it is kept
perfectly flat upon the part to which it is applied, in order that
sound may not escape, nor air be admitted; for which purpose it is
convenient to hold it at its lower part, while the other end (with
the even surface) should be in close contact with the ear, so that
the aperture of the instrument be in direct communication with the
internal ear. Silk covering, as causing a creaking sort of noise,
and thick dress, as obscuring the sound of respiration, should be
removed; but the linen or flannel dress may remain on the person
without disadvantage. A beginner will be very apt to fail in his
early trials, from inattention to some of these points, and from the
difficulty which at first attends the tuition of the ear.
A skilful use of the instrument requires much practice. It is not,
as some may imagine, a simple matter of hearing a delicate sound.
_Tact_ is necessary, but this will be acquired by perseverance. For
two days of my own study, I was frequently at a loss to distinguish
the peculiar sound or murmur of respiration, and almost despaired of
success. I mention this circumstance, that others beginning with the
practice of this instrument, may not be deterred from proceeding, by
the awkwardness and disappointment which they at first encounter.
At _La Charité_, the best informed students are great enthusiasts in
the practice of this discovery, and regard it as an indispensable
source of information in the diagnosis of the diseases of the
chest. Such reliance on the stethoscope is very natural, when
constant proofs are afforded of the accuracy of opinion formed by
M. Laennec, and others, who are competent in using it. The proofs
of sure diagnosis are derived from dissection; as, necessarily, the
diseases of the lungs and of the heart, allow frequent opportunity of
obtaining this test of the physicians’ judgment.
I will relate one instance which came within my immediate knowledge;
although equally strong proofs are so numerous, that the regular
observer can no more doubt the merits of the stethoscope, than the
mathematician can distrust a resolved problem.
In the clinical record of a case of consumption, M. Laennec had
stated his opinion, that the upper portion of one lung was the
exclusive seat of ulceration. The patient died, and examination
was made. The lungs were removed from the chest, and the expected
evidence of disease did not appear. M. Laennec, making a closer
inspection, discovered that a small part of the upper lobe had been
left in the chest, and upon its removal, the ulceration was found
exactly as he had predicted.
Some persons assert, that the discovery of the precise situation
of an ulceration of the lung is merely a matter of curiosity, as
when arising from tubercles, they consider it incurable; but surely
this is not a good medical objection. Our art may improve so as to
enable us to remedy these evils; and assuredly our chance of success
will be increased by a knowledge of the seat of tubercles, their
commencement, and their progress. While those persons therefore who
have made use of the stethoscope with success, praise it in terms
which may seem romantic and beyond the truth; others, and perhaps
those chiefly who have never even seen the instrument, speak of it
with ridicule, or censure it as a piece of quackery.
It is not just that any one wholly unacquainted with the stethoscope,
should assume the right of pronouncing an opinion on its properties.
It certainly does not deserve the imputation of quackery; for this
opprobrium belongs to the concealment of a remedy; or to some
mysterious plan of practice, studiously kept secret for the mere
purpose of gain. Candour is most honourable to the educated mind; and
to be sensible of our ignorance on any particular subject, is the
first step to the acquirement of knowledge.
It has been said that the use of the stethoscope may be injurious, by
leading the physician to know too much of the danger in a bad case;
to make him despond and resign the patient to his fate too soon.
Such an observation scarcely requires refutation. In no instance of
dangerous disease can the physician see his way too clearly; and at
all times to know the disease, is at least making a considerable
approach towards the cure. The judgment, the discretion, and the
humanity of the good physician, will be a sure protection to the
patient against any abrupt decision, any gloomy opinion, and much
more against unkind desertion, in the most hopeless circumstances of
disease.
The following case serves to shew the converse proposition, and
the happy purpose to which superior knowledge and discernment were
applied.
M. Laennec was consulted in the case of a gentleman who was supposed
to be dying from phthisis pulmonalis, and in a state so desperate,
that he was not expected by his medical attendant to survive more
than two or three days.
M. Laennec made his usual investigation, and persuaded himself that
the case had been mistaken, and that the alarming symptoms did not
arise from ulceration of the lungs, but from empyema, or purulent
collection within the pleuræ. He strongly recommended that the
operation for this disease should be performed; and, after a little
hesitation and delay, his advice was adopted. A large quantity of pus
was evacuated, and immediate relief was afforded. The amendment was
rapid, and the progress of cure so favourable, that the gentleman
recovered his health in less than three months.
In thus rendering my homage to the merits and science of M. Laennec,
I do not wish it to be thought, that I consider even his authority
as infallible; but it is nothing more than is justly due to the new
practice, to admit, that it may become of very great importance; and,
that by no other mode can we examine the interior state of the chest,
with equal accuracy.
Let it be further remarked, that we are not required to lay aside any
of our ordinary methods of investigation: This additional mode comes
to our aid in cases of obscurity and difficulty. If the physician
of long experience be so confident in his powers of diagnosis, that
he rejects this invention as unnecessary for his purpose, it need
not follow that he should disapprove of it for others who are less
experienced, and are more diffident of their skill and penetration.
Most assuredly it is a great help to the judgment; and I am fully
persuaded, that, in proportion as it is understood, it will be more
generally received, and more highly esteemed.
If the naked ear be applied to any part of the chest, it is made
sensible of the entrance of the air into the cells of the lungs; and
the beginner in this study will receive the impression more fully
and sensibly, than by the medium of the stethoscope, because the
vibrations are collected from a larger surface; but it is a less
accurate method, and much less analytical. He may with advantage
practise with the naked ear occasionally, in order to become familiar
with the sounds of respiration; but under many circumstances, such
a mode is inconvenient and inapplicable. The listening by the ear
only is technically called, immediate auscultation; and by the
stethoscope, mediate auscultation.
In examining the chest of a person whose respiration is calm, we
should desire that it be made purposely quicker, and stronger;
but not so audibly as to cause confusion by that external sound.
The perception afforded to the auscultator by healthy lungs, is
that of air entering a cavity, as it were with a gentle stream
of sound. If the pupil first apply his naked ear to the chest,
he will have a clear idea of what he has to expect. As a general
rule, in making our investigation of the state of the lungs, the
stethoscope should be applied immediately under the clavicle, near
the axilla; and the learner will do well to choose the right side,
lest he become confused by the action of the heart. In seeking for
ordinary respiration, it should not be applied near the trachea, as
the stronger action of the air in the bronchial tubes would mislead
the ear. To ascertain the state of the posterior part of the lungs,
the instrument is to be applied on the scapula, above or below the
spinous process.
In my own practice, I have derived the utmost advantage from the
use of the stethoscope in cases of pneumonia, with regard to local
treatment. When we find a patient ill with severe symptoms arising
from inflammation of the lungs, we do not require the aid of
auscultation to determine us in employing the lancet as our first and
most important remedy; but we may desire immediately to join with the
general bleeding, local depletion; and, most commonly, the period
arrives when we wish to use local treatment exclusively, by cupping
or leeches, and blisters. Under such circumstances, it is of the
utmost importance that we should be able to ascertain the exact seat
of the inflammation; and when, as commonly happens in pneumonia, the
patient cannot direct us by any sensation of pain, but is labouring
under a general sense of oppression and suffocation; we resort to the
stethoscope as a positive and most valuable source of instruction.
Even when it is manifested to us by ordinary indications, that the
inflammatory action is prevailing on one side of the chest, it is of
great advantage that we can detect, by means of the instrument, the
particular part of the lungs most affected. I shall illustrate the
truth of these remarks by the recital of a few cases.
A gentleman dangerously ill with inflammation of the lungs, which
had supervened on an attack of asthma, experienced, in the evening,
a renewal of the feelings of suffocation, which, in the morning had
been relieved by copious bleeding from the arm. In the middle of the
upper part of the chest, he had a severe sensation of tightness,
but was not conscious that the lungs were affected more on one side
than the other. His cough was most urgent. The stethoscope, applied
to the lower part of the right side, conveyed to the ear a strong
sonorous rattle, both on inspiration and expiration, much resembling
the sounds of loud snoring. These sounds could not be detected in any
other part of the chest. In addition, therefore, to a fresh bleeding
from the arm, cupping was used very freely at this part, and with
evident good effect. Almost immediately the sounds abated. Two days
after, leeches and a large blister were used with further benefit;
and the actual relief of the patient perfectly corresponded with
the improving indications afforded by the stethoscope. Occasional
bleedings from the arm were afterwards required; but the inflammation
was finally subdued, and the constitution was restored to its
previous state; this gentleman being habitually subject to spasmodic
asthma.
A female patient was in a state of most alarming difficulty of
breathing from neglected inflammation of the bronchiæ, which had
extended to the lungs. The pulse was sharp and frequent, the skin
hot, and every urgent symptom of high fever and irritation was
present. Her cough was extremely violent, and the expectoration
difficult. The expectorated matter was dense and almost puriform in
appearance. On applying the stethoscope over the upper part of the
right side of the chest, at every point, and also over the whole
of the right shoulder blade, I heard acute sounds similar to those
produced by air strongly passing through a key-hole. I considered
that these sounds indicated active inflammation in the whole
ramifications of the bronchiæ of the right lung. A large quantity
of blood was drawn from the right arm; and cupping was also freely
employed, both on the chest and shoulder blade. A saline draught with
tartar emetic and nitre was administered every two hours. I need not
detail the exact progress of the case. These principles of treatment
being diligently followed up, the patient finally recovered.
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.
The general objection amongst the French to the use of calomel
prevails almost as strongly as at former periods; and certainly
amounts to a prejudice. I learnt, on good authority, at Paris,
that this medicine is usually found to act in a peculiar manner on
the constitution of the French patient; as it commonly produces
irritation in the intestinal canal to a degree that causes extreme
discomfort. I need not relate with what freedom and satisfaction the
English make use of this active medicine.
I apprehend that the difference of operation is to be ascribed
chiefly to the respective nature of the diet in the two countries.
The remark applies most particularly to the free use of light wines,
amongst the French. The vin ordinaire must produce very different
effects from the English malt liquor; or the use of plain or soda
water, in conjunction with wines of more sound quality. Indeed the
difference of regimen appears to me a sufficient explanation. I may
here remark how very materially the action of mercurial medicine
on the bowels is controuled by suitable preparation of the patient
with mild mucilaginous drinks. If, on the contrary, the stomach and
intestinal canal be charged with acescent liquor, vinous, or of any
other kind, acescent food, and fresh fruits, irritation and disorder,
more or less painful, may be expected as almost a certain consequence.