Oldalképek
PDF
ePub

tributed not a little to their more complete elucidation. That he has great and manifold faults as a medical writer cannot be unknown to our readers. In some respects, he is one of the most dangerous guides that could be selected by any young practitioner. Bold, confident, and presumptuous, he labours with most assiduous energy to give currency to his opinions, which all savour of a spirit of extravagance and exaggeration alike in matters of doctrine and in those of practice. He is ever seeking to bring within the domain of arithmetic exactitude the phenomena and course of diseases on the one hand, and to establish with an almost unvarying precision the indications for their therapeutic treatment on the other ; as if the former could be weighed in a balance, and the latter could be measured with a plumb-line! Hence it is that he is continually laying down, in the most dogmatic and peremptory tone, certain rules for the detection and cure of most maladies, as if he were describing a mere problem in mathematics to be worked out.

In our former notice of his present work,* we exposed the numerous errors and inconsistencies into which he had fallen in discussing the difficult question of Fevers, and we pointed out the pernicious consequences of medical practitioners allowing themselves to be guided by him in the treatment of this truly multiform class of diseases. It is unnecessary to revert to this subject further than to remind our readers that he actually treats of Synocha or sthenic fever under the terms of Angioitis or inflammation of the vascular system; as we shall have occasion to allude, although very briefly, to the history of genuine Arteritis towards the close of the present article. What often adds much to the difficulty of clearly ascertaining his views, is the strange and most perplexing arrangement of diseases which he has chalked out; so that the reader is obliged to be continually turning from one to another of his five bulky volumes to discover the complete history of any one set of diseases. On no subject is this vexatious confusion more annoying than in his account of Diseases of the Heart. The reader must therefore make some allowance, if the extracts, &c., to be given prove less interesting than we could have desired.

The point, at which we had left off in our analysis of Dr. Latham's valuable work, was where he was treating of what he calls "mock Hypertrophy of the Heart;" in other words, of those cases where the actions of this vital organ are so forcible and impetuous as very naturally to suggest the idea of the actual enlargement of its volume, although in truth no such serious change has taken place.

"Impulse of the heart," says he, "taken alone, however great and however extensive it may be, is not a sure physical sign of hypertrophy. Hypertrophy indeed cannot exist without excess of impulse, but excess of impulse can exist without hypertrophy. When the impulse of the heart is excessive, and at the same time its sounds are obtuse, muffled and indistinct, and the præcordial region presents a larger space than natural which is dull to percussion, then the signs of hypertrophy are complete. And hypertrophy so sure and unquestionable was never cured within my experience. But when the impulse of the heart is in excess, and at the same time its sounds are as loud and clear as ever, or louder and clearer still, and the

* Vide Medico-Chirurgical Review for July, 1846.

1847.] Auscultatory and other Phenomena of Chlorosis, &c. 343

whole præcordial region is quite resonant to percussion save the small space which is naturally dull, then the signs of hypertrophy are incomplete.-P. 249.

It is well known that those of mock or simulated Hypertrophy are especially common in young females affected with Chlorosis. We shall therefore first allude to the cardiac, &c., complications of this very frequent disorder, taking the "Nosographie" as our text-book on the occasion. After alluding to the aspect and general appearance of chlorotic patients which M. Bouillaud, with his accustomed exaggeration, declares to be invariably so marked and decisive that there never ought to be any room for doubt on the part of the physician, he treats of those diagnostic signs which are furnished by the Auscultation of the Heart and Arteries, and by the exploration of the pulse.

"In every well-marked case," says he, "of Chlorosis or Chloro-anæmia, the carotid and subclavian, sometimes also the crural, arteries give out the continuous blowing, humming, or whistling sound, which I have described at length in my treatise on Diseases of the Heart. Not a day passes without my seeing cases of this sort. It is of the highest importance in a diagnostic and therapeutic point of view to ascertain whether this symptom be present or not; and yet it is strangely neglected by a vast number of medical practitioners. For if this one symptom be present, we may confidently assert, from this circumstance alone, that a chlorotic or anæmic condition of the system is present; and vice versa, whenever a patient exhibits the external features of this condition, we may predict that the arterial sound in question will be found."

It is thus described:

"In well-marked Chlorosis may be heard, during the first or systolic action of the heart's movements (au premier temps des mouvements du cœur), a gentle, soft and silky blowing sound; it is most distinct over the orifice of the aorta, and extends along the course of this vessel to where it gives off the carotids and subclavians, with whose continuous murmur it becomes confounded.

[ocr errors]

"The pulse of chlorotic patients is soft, unresisting, and conveys to the finger, when the artery is gently pressed, a sort of fremitus, with large vibrations, of the column of blood; it may be called the chlorotic fremitus,' to distinguish it from other vibratory movements present in certain organic diseases of the heart and blood-vessels. It is exactly similar to the sensation felt by the finger, when this is applied to the canal of the urethra during the act of micturition. The touch alone serves to satisfy us that the artery is not sufficiently full, and that the blood, contained within it, has not its due consistence and density. In cases of simple anæmia, the touch will also enable us to ascertain that the volume or calibre of the vessel is less than in the healthy condition."

According to M. Bouillaud, the Diagnosis of the Cardiac affections, dependent upon an attenuated state of the blood, is yet most imperfectly understood among his fellow-countrymen.

"During the last fifteen years that my attention has been directed in an especial manner to the history of the chlorotic and anæmic maladies, scarcely a day has passed over that I have not seen cases where they have been mistaken, and confounded, either with inflammatory or with organic diseases by the most distinguished physicians of the different schools, which have hitherto disputed the empire of medicine;—some, diagnosticating inflammatory or organic diseases where all was dependent upon a chlorotic condition; while others, on the contrary, have mistaken cases of the most serious and decided organic alteration for those arising from mere impoverishment and attenuation of the circulating fluid.

I do not exaggerate when I affirm that errors of this sort are, in the present day, committed by thousands in different countries of medical Europe. What is the cause of this? Because, in the schools to which we allude, observation has not been directed to the study of the morbid changes of the fluids, of the blood more particularly, and because the exact methods of exploration-those which furnish the physical and characteristic signs of most diseases have not been duly practised. So true is this that, among the several hundred of pupils who, for some years past have followed my clinical practice, there is not one who, after a few months' assiduous study, has not learned to discriminate with accuracy every case of Chlorosis and Anæmia. All have been astonished to see almost daily patients come into our wards, labouring under affections which had been generally treated by antiphlogistic remedies in consequence of having been mistaken for an inflammatory or congestive malady, or for some organic lesion, such as Aneurism, Hypertrophy of the Heart, Scirrhus or Cancer of the Liver, Spleen, Stomach, &c."

M. Bouillaud then adds:

"The physical signs of chlorosis and of chloro-anæmia are so manifest and so sure that for a physician to be unable to distinguish them, must imply on his part an utter ignorance of this branch of semeiology."

He is forced however to admit that, in certain instances, the diagnosis is by no means without some difficulty.

'

"In those cases, more numerous than is generally believed, where Chlorosis, Anæmia, and their nervous accompaniments, coincide with an organic affection either of the Heart or some other viscus, the physician will be able to recognise the different elements of these complex cases by means of the signs or symptoms proper to each of them. But it must be confessed that these are problems, the solution of which can be made only by those who have been long familiar with all the difficulties of exact clinical medicine, and the number of whom is unfortunately not so large as it ought to be. Those who have followed our practice know full well that examples of the most varied morbid complications are not of unfrequent occurrence, and that, nevertheless, by means of a minute and searching examination, it rarely happens that the diagnosis is not determined with the greatest exactitude. But, if physicians shall still persist in taking Chlorosis for a chronic metritis, or for an asthenia of the generative organs, or for a chronic arteritis,* or for an asthenic condition of the sanguineous system, consisting principally in a diminution of the stimulant properties of the blood, or for a chronic gastritis, or for an aneurism of the Heart, &c.; if, I say, these and such like errors continue to be committed by medical practitioners, then assur edly the fault lies not so much in the art of diagnosis, as in the culpable ignorance of him who practises it; non crimen artis, quod professoris est.

It will be perceived that, in the above extracts from M. Bouillaud's description of the auscultatory phenomena of Chlorosis and other kindred maladies, he makes the arteries the seat of the continuous humming sound, the "bruit de diable," (as he has called it,) now recognised as one of the surest signs of an anæmic condition of the system, or, perhaps we

*This strange ætiological doctrine has been much insisted on by the celebrated Italian professor, Tommassini. We exposed the absurdity of the hypothesis in the number of this Journal for January, 1845. M. Bouillaud may well express his astonishment that any sensible man should entertain such an idea; for there is surely not a shadow of probability that can be adduced in its favour.

1847.]

Murmurs in the Veins.

345

should rather say, of a poor and watery state of the blood. The omission of even so much as a passing allusion to any other interpretation of the phenomenon in question is not very creditable either to his professional knowledge or to his professional candour. Let us see what Dr. Latham has said upon the subject. After alluding to the blowing or bellowssound heard over the heart and the trajet of the large arteries in chlorosis, he goes on to remark :

66

Generally accompanying the endocardial and arterial murmur, when it is owing to anæmia or an impoverished blood, there is another sound quite different in kind, and formed neither in the heart nor in the arteries, but traceable to the same pathological condition.

"In following the murmur from the heart along the aorta and the subclavian artery, and then above the clavicle, when you reach the carotid you find a new sound superadded to it. You perceive the bellows-murmur coming and going with distinct whiffs, and keeping time with the systole of the heart in the neck as in the chest; but in the neck you perceive, moreover, a continuous hum, like that which reaches the ear from the hollow of a marine shell. This is a thing so evident, that it was noticed and described, and variously speculated upon by those who first practised auscultation. But their speculations were wide of the mark. Whence or how it arose no one could tell, until the sagacity of Dr. Ogier Ward traced it to the veins, and showed it to proceed from the movement of the blood within them.

"The vein, which offers itself most readily to the application of the stethoscope, and admits all the easy experiments which serve to certify the fact, is the internal jugular. Place the instrument upon the neck by the side of the trachea, and pretty close to it, and at the same time rest your finger upon the space between the angle of the jaw and the mastoid process; and when your ear has caught a continuous humming sound, and listened for a while and made sure of it, then press your finger firmly down upon the vein, and the sound, if it be the true venous murmur, will immediately cease, then raise your finger, and if it be the true venous murmur it will immediately return.

"A little management and address are needed to find this venous murmur, and then keep it within hearing when you have found it. I have seen it found by accident, heard for a minute, and then lost and never heard again. The instrument has been laid carelessly upon the neck, and the murmur has been audible immediately; and then, in expectation of making it heard to more advantage, the neck has been put upon the stretch, the chin raised, and the head thrown back, or turned far round to the opposite side, whereupon the murmur has ceased. Then the neck has been relaxed, the head brought forward, and the chin inclined towards the sternum, but the murmur has not returned. The truth is, a very free current of blood is essential to the production of the venous murmur. A slight degree of pressure upon the vein will alter its character, and pressure very far short of that which would arrest the current of blood will abolish it altogether. And thus, the neck being put upon the stretch, the muscles, which lie parallel with the vein and across it, are made to exercise pressure enough upon it to interfere with the free current of blood, and to stop the sound; or the neck being relaxed, the vein and the integuments get folded together, and so pressure is produced in another way, and this equally stops the sound. Try different degrees of pressure upon the internal jugular vein with the stethoscope when the venous murmur is distinctly audible, and you will find how lightly you must hold the instrument to keep it constantly within hearing, how inconsiderable an amount of pressure will obliterate it, and how each degree short of that which obliterates it will give it sundry varieties, and make it musical."-Vol. I., p. 72.

The circumstances connected with the history of this Venous Murmur

have not yet, it must be confessed, been accurately made out. We have just seen that Dr. Latham states that the slightest tension of the muscles of that side of the neck, where the sound is heard, will generally cause it to cease; whereas, other auscultators assert, as the result of their experience, that "it is augmented when the vein and sterno-mastoid muscle are made tense, by turning the head strongly to the side opposite to that which you are examining." Our observation leads us rather to side with Dr. Latham. The pressure of the stethoscope must be steady, but not very strong, to catch the murmur. We have detected it much oftener on the right than on the left side of the neck. Occasionally it may be heard on both sides, but generally upon the right one most distinctly. It is sometimes not easy to recognise the venous murmur at once, in consequence of the marked blowing or whiffing to be heard in the subclavian and carotid arteries at the same time, especially, too, as the impulse or throb of these vessels is also stronger than usual. As we remarked upon a former occasion, the venous sound has more resembled, to our hearing, that produced by water rushing along a leaden pipe than any other sound that we know. It is, no doubt, a most valuable diagnostic phenomenon; as its presence, when once clearly made out, will go very far to determine the real nature of many cases-in male, as well as in female, patients-where the symptoms so closely resemble those of decided organic disease of the heart, that even the most experienced may hesitate at once to decide. We need scarcely say that, on the accuracy of Diagnosis, will entirely depend the appropriateness and success of the Treatment that will be recommended. The mistakes, that are so often committed in the discrimination of the real nature of many cases of cardiac disease, are alike discreditable to our profession and most pernicious to our patients. If the case be one of chlorotic or anæmic disturbance of the heart's actions, every one is acquainted with the remedies that will almost infallibly bring about a cure; and should it be one of organic lesion of that vital organ, we shall still have the satisfaction of knowing that, by judicious treatment, a most essential mitigation of suffering may be insured to the poor sufferer. Before alluding to the general principles of treatment, as laid down by Dr. Latham, in actual hypertrophic enlargement of the Heart, let us briefly notice what M. Bouillaud has said on the important subject of its ætiology. The following passage in his fourth volume will best exhibit his views on this point:

"If the general law, which we have propounded in our remarks upon the rationale of Hypertrophy,* be not an empty hypothesis, it may be fairly presumed that hypertrophy of the muscular substance of the Heart ought to be frequently met with after long-continued inflammation of its lining membranes, more especially of its inner one, or, in other words, of the Endocardium. The results of

"All accurate observers know how frequent an occurrence it is to meet with hypertrophic thickening in organs which have been the seat of a long-continued inflammatory congestion. And the remarkable circumstance is, that in the cases alluded to, the pure and simple Hypertrophy implicates the tissues which are adjacent to where the inflammation was seated, more than the tissue itself that was immediately affected. (This becomes enlarged, it is true; but then it almost invariably experiences at the same time some serious alteration, such as softening, induration, disorganization, &c.) Thus it is that the cellular

« ElőzőTovább »