J Milner Fothergill
1881 The Lancet  
622 cautery, made a third epoch, to be completed as time went on, in our.own land, in the last and greatest, that of John Hunter. I bring before you these four names, called by a distinguished professor, the "four apostles of surgery," because they more or less aptly serve to indicate the direction of your inquiries in tracing out the writings of those who filled in the spaces left between these periods. Your thoughts will turn to Alexandria, undoubtedly the cradle of anatomy, and where Galen
more » ... mself learnt. After Galen to the Arabians, thence to the names surrounding the teaching at Bologna, the earliest university. It will repay you to learn something about Vesalius, the father of anatomy, of Fabricius, who did so much for operative surgery, and so onward through the multitude of glorious names fixed indelibly in our literature, and in the nomenclature of anatomical study. A very few cited convince us as to how they worked and what they left us. Fa,llopius, Eustachius, Glisson, Steno, De Graaf, Nuck, and Winslow. And so to the days of Hunter, and to search amongst the writings of the men who immediately preceded and followed him, Cheselden and Pott, Abernethy and Cooper. These, then, faintly sketched, are some of the means for cultivating the art of medicine in Birmingham. The road to them is wide and straight. You must, however, tread it yourselves. None of us here can more than direct your footsteps. The burden of responsibility you carry may be light or heavy ; light it certainly will be with hope and truth graven on your hearts ; and should any fall out by the way, as having lost hope, when help was probably most near, do you, the survivors, bestow on their memory the blessing belonging to a faithful comrade, to one who has shared with you both labour and danger, and do you with hope renewed and truth abiding" fill in the ranks and march on." known repeated instances of wretchedness for years caused by the belief that apoplexy might be expected at any time, and that death might occur at any moment in cases of purely functional disorder of the heart. Even in cases where a liability can be recognised, as in cases of angina pectoris, fatty heart, and certain aortic lesions, the event may not occur for a long period, if the patient do not die of some intercurrent affection." Now, you see even in some of the gravest forms of diseases of the heart, death does not occur so quickly as is anticipated; in less grave cases the termination is often far distant. A number of cases are present in my mind's eye, which cause me to quote another seiatence from Flint. "It does not confer credit on the profession for healthy persons to be able to say that in years past they were pronounced incurable, and the time of death specified." Nor does it make one feel altogether comfortable when a patient tells one that into the teens of years ago he was pronounced to have a "fatty heart," and that he might die suddenly at any moment, and to have to tell him that he possesses a feeble heart truly, but that there are no evidences of organic disease present in it. Nor will I say more about the patient's feelings than that the sensation of relief at hearing this is poisoned by the memory of the long years of anxiety, misapprehension, and misery he has lived through from the rashly expressed opinion, based on a false apprehension, a misinterpretation of the case, given by his whilom medical adviser. Every error of this kind carries with it a far-radiating influence of scepticism as to the accuracy of medical information as regards disease of the heart. For the sake of the profession, for the sake of the public who put their trust in us, it is desirable that such mistakes occur as rarely as may be. 3 Macleod. Nor do I wish to have it understood that such errors are confined to that section of the profession known as "the general practitioner." The most serious errors have been made, and to a less extent are still being made, by those who are regarded as more specially informed-namely, the consultants. It is not many years since I was consulted by a north-country gentleman of twenty-four, a man of magnilicent physique, in the bloom of early manhood, who had been condemned by two of the most eminent of the untitled members of the profession to a life of inactivity, and all his future clouded by their misinterpretation of a cardiac murmur, discovered by his family physician by an accident. The murmur was a pulmonary murmur, disappearing when a full inspiration drove a piece of lung down betwixt the chest wall and the pulmonary artery. Feeling that my opinion, as opposed to two such eminent authorities, ought not to stand alone, I took the patient to Dr. Broadbent, merely saying there was a dispute about the case; but not even telling him that the case was cardiac. It was a pleasure to see the light that broke over the patient's face as the examination progressed. My opinion was corroborated in almost the exact words I had used, and the subsequent history of the case has fully borne out the view we took. Again, some years ago a lady well known in literary circles consulted me for a mitral affection of some nine years' standing. There was a regurgitant murmur with dyspnoea on exertion, and unquestionable deformity of the mitral valve:!. She had some time before consulted a wellknown physician, lately deceased, whose knowledge no one would for a moment think of calling in question. Himself the subject of the gravest valvular disease, yet one of the hardest-working members of the profession, he forbad her to work at her desk. Deprived of her favourite occupation, her general health suffered very seriously. The case, as I interpreted it, was one of long-past non-progressive valvu. litis, leaving behind a certain amount of deformity, which only became really operative on physical exertion. At her desk the defect was not felt. My counsel was to avoid exertion in all forms; but there seemed to me no reason why her literary work should be suspended. She returned to her desk, with the result that there is no falling off in her work, except such as may be fairly expected when the cares and the demands upon her time as a wife and mother are allowed for. Now, to the more practical part of my paper-namely, how are such errors to be avoided ? The first thing to insist upon is this : a murmur is not always produced by deformity in the cardiac valves. Anæmic aortic, and, still more, pulmonary murmurs, are now generally recognised. Dr. George Balfour, in his work on " Diseases of the Heart," has followed Naunyn in describing what he designates as " curable mitral regurgitation ;" and certainly all mitral murmurs are not organic in origin. A form of mitral regurgitation was described by the late Dr. Pearson Irvine (whose premature death we all so deeply regret) as the result of the weakening of the walls of the heart due to ansemia. Nor is it a mitral regurgitant murmur alone which is not due to preceding valvulitis ; an obstructive murmur is often heard, unaccompanied by any evidence of structural change. One of the loudest mitral obstructive murmurs I ever listened to was heard some half-dozen years ago in the person of a clergyman from Quebec, who for years had several times a day mounted the heights of Abraham without discomfort. He did not consult me about his heart, but the conversation ran on to that topic. The murmur was heard first when he was a boy of fourteen at Eton. Its discovery caused the greatest consternation, and his alarmed parents took him to the late Dr. Latham, who calmed them by saying that his later and more extensive experience had taught him that such murmurs were not always pathognomonic of structural change, and said that he did not regard it as of any significance. That wise physician has left on record his views as to disease of the heart in a work all too small. He first carefully discriminated between grave and comparatively trivial injuries to mitral valve curtains by endocarditis. In "consequences to life and health from the permanent unsoundness of the heait remaining after endocarditis," he held that , there were three divisions—(1) Cases in which, besides the permanent endocardial murmur, there is no other symptom refer-4able to the heart; (2) cases in which, besides the murmur, there is occasional palpitation ; and (3) cases in which, besides the murmur, there is constant palpitation." Now, it is this last division only which comprises the typical cases of our text-
doi:10.1016/s0140-6736(02)36377-3 fatcat:2bplootlwneh5bovt7rnyhoeiq