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’