I have examined the filtered[12]water of the Seine, and obtained the following results:Its specific gravity is 1.0002.Solution of muriate of barytes added to the water produces an immediate but slight milkiness.Oxalate of ammonia causes, in a few seconds, a considerable milkiness.Nitrate of silver does not occasion any immediate change; but, after standing several minutes, an effect is just perceptible.Lime water does not disturb the transparency of the water.
I have examined the filtered[12]water of the Seine, and obtained the following results:
Its specific gravity is 1.0002.
Solution of muriate of barytes added to the water produces an immediate but slight milkiness.
Oxalate of ammonia causes, in a few seconds, a considerable milkiness.
Nitrate of silver does not occasion any immediate change; but, after standing several minutes, an effect is just perceptible.
Lime water does not disturb the transparency of the water.
From this examination the conclusion follows, that it is a water containing a very minute quantity of solid ingredient. In one thousand parts the specific gravity is only2/10higher than that of distilled water. From the nitrate of silver causing so slight a change, we see that the water is almost free from the muriates. It is evident that the chief solid ingredients are the sulphate and the carbonate of lime. Although I should certainly consider that a water still less impregnated with these salts, and especially the sulphate of lime, would be more wholesome, yet, when the small proportion existing in this water is estimated, I am led to the conclusion, that the disorder of thedigestive organs, which commonly happens to the visitors of Paris, is not attributable to the water of the Seine, but to the new mode of living, and above all to the free, and sometimes intemperate, use of the light acid or acescent wines. In such cases, weak brandy and water should be substituted, and if wine be taken, care should always be observed to procure such as is of the best quality, and the most free from acid.
Since the printing of the sheets on the subject of the stethoscope, I have met with many interesting and important cases, proving to my further and complete satisfaction the value of the indications afforded by the instrument.
In reverting to the subject, I shall offer a concise account of two instances in which I derived an accuracy of instruction for mytreatment, which I could not otherwise have obtained.
A lady fifty years of age, who enjoyed good health generally, and was not subject to cough, had been ill with symptoms of pneumonia and bronchitis, a week before I was consulted. I found the following symptoms: the pulse frequent, hard, and rather full; the skin hot; cheeks flushed; the tongue much furred; the urine high-coloured, not depositing sediment; the bowels torpid; cough rather occasional than constant, but for the most part violent; the expectoration copious and muco-puriform. In the upper parts of the right and left sides of the chest, the indications afforded by the stethoscope were, very sharp and strong sounds, both in inspiration and expiration, conjoined with the mucous rattle. She did not experience any pain, nor any sensible difficulty of respiration, although it was evident that she did notbreathe naturally; and fits of coughing were easily excited. Her countenance had a very feverish and anxious look. Previously to my visit she had been bled only once.
I directed a free bleeding from the arm in the morning, and the application of twenty leeches over the chest in the evening. I prescribed small doses of tartar emetic, in a saline draught, every four hours; some calomel, James’s powder, colocynth, and extract of poppy at bed time, with a saline aperient in the morning, and other general means. The blood was extremely cupped, with a dense buffy coat. The bleeding from the arm was twice repeated in the course of the three following days; and as the sounds were still indicated by the stethoscope, although in a less degree, the leeches were again applied twice in the course of the week; the medicines being regularly administered.By these means the pulse became reduced from one hundred and twenty to ninety, and acquired a degree of softness. When the heat of skin abated, a blister was applied on the chest; but it appeared to have the effect of creating more febrile irritation; and without affording relief to the cough. I have observed this disadvantage to follow from blistering in other cases of an inflamed and irritable state of the lungs; and I apprehend that we should, under such circumstances, take into consideration whether or not this peculiar stimulus may produce more injury than benefit, from the irritation which it creates in the chest being more influential than the counter-action produced on the surface.
The tartar emetic proved very decidedly useful in its effects. I did not increase the dose beyond three grains in the twenty-four hours, and in the commencement of its use,the smaller doses occasioned much sickness; but with the advantage of removing morbid secretions. The cough becoming very irritable, syrup of poppy was added to the saline antimonial draught; and, when all necessity for bleeding was removed, the infusion of digitalis, in small doses, was also employed; for, in this case, inflammatory action prevailed to a most troublesome degree. Indeed, the complaint became chronic, the fever decidedly hectic, and the situation of the patient appeared to be precarious. The expectoration had strongly a puriform appearance, was streaked with blood, and was very copious: its odour was faint, but not particularly offensive. The sounds which I have mentioned became less acute, and the rattle was more mucous. At this period I directed the use of tartar emetic ointment over the chest, which produced an extensive pustular eruption; and the advantage of this counterirritationwas very marked. I have the pleasure of adding that this patient is now most favourably convalescent. She is taking with advantage, as a mild restorative medicine, an infusion of the cortical part of sarsaparilla in lime water, mixed with an equal portion of milk made hot.
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, forthe 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 theextreme. 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, byuseful 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 muchextent, 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 resemblinggenuinepneumoniaor 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 ofthe 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 ofthe 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.