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.