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.