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 firstpractised 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 considerabletact 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 convenientto 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 ofstethoscope(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. Thisproves 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 toexamine 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 fromthe 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.Tactis 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.
AtLa 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 onthe 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 evenseen 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 hismedical 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 evenhis 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 causeconfusion 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 theutmost 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 manifestedto 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 strongsonorous 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, whichhad 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 principlesof 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, probablyfrom 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 tartarizedantimony 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 clotand 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 blisterwas 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 itdoeshave 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 toreason 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 dissectionin 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 tochoose 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 superiorlobes 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 termœgophonism, orcaprine 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 thepleuralmembrane, occasioned by inflammation and its consequences; or, sometimes by spasmonly 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 palpitationis 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, andalso 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 wristdoes 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 theheart 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 bevariously 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.