Symptomatology may be dismissed, as I have already shown how cases were described and the various symptoms are included in the discussion of the other topics. Their value, too, is lessened by the great change in nomenclature and pathology. Diagnosis. I have already alluded to the many minor points upon which Vieussens based the diagnosis of cardiac disorders. The pulse. of which Galen described no less than twenty-six varieties, was a very important factor, so much so that in cold weather physicians were accustomed to carry muffs lest the cold should lessen the delicacy of touch. The small pulse of mitral stenosis, the water-hammer pulse of aortic insufficiency and the hard pulse of hypertrophy were all recognized. Even the pathognomic importance of various pulsations in the neck in aneurism of the right ventricle was clearly set forth and explained by Lancisi, Hypertrophy and dilatation were distinguished by laying the hand on the pericardium and estimating the force of the heart action; they also noted the site of the apex-beat and the extent of the area over which the heart action was visible. It is difficult to say to what extent these investigators used auscultation and percussion; we know, however, that Lancisi employed percussion on the sternum. Haeser, in discussing the work of Albertini, states that no mention is made of applying the ear to the chest; yet it is scarcely conceivable that this should not have been attempted. Undoubtedly it was soon abandoned, since only well-advanced cases, with their confusing chaos of sounds, came under observation. It is a popular error to suppose that auscultation originated with Laennec. Not so; his discovery consisted in the use of the stethoscope, or mediate auscultation, as stated on the title page of his celebrated treatise. The mucous râle and succussion were both discussed by Hippocrates (460370 B. C.). The school of Cnidos knew the pleuritic friction sound; this sect flourished 400 B. C. Auscultation is also alluded to in the works of Cælius Aurelianus, who lived in Rome at the end of the IV century, A. D. The diagnosis of cardiac disorders was strengthened by the presence of shooting pains in the thorax, shoulders, radiating thence to the middle. of one or both arms; it might also be present in the scapular region. In addition, the previous occurrence of prolonged mental depression or sudden, violent injuries, carrying of heavy burdens, prolonged marches, syphilis, alcoholism and the playing of wind instruments-these were the guides of Albertini. It was admitted that it was difficult to recognize varicose aneurisms (dilatation) because of the increased area of impulse and the feebleness of the heart action. The same is true of pericardial adhesions. cardial effusions were discovered has already been stated. How peri The relations of pulmonary oedema, congestion of lungs and hæmoptysis to cardiac lesions were known to Albertini. Treatment. This need not detain us long, as the drugs of this era are so opposed to those of our own time; furthermore each physician endeavored to make his treatment correspond to the theories of the school to which he owed allegiance. Thus Albertini, a believer in the mechanical school, taught that the pressure of the fluid elements upon the solids ought to be lessened, and the resistance of the latter ought to be increased; in other words, that the blood pressure ought to be lowered. Accordingly he recommended venesection, low diet, rest in bed, iron preparations, etc. Naturally venesection played a very prominent part in all treatment at this time, although it was employed even more extensively in the early part of this century. The prevailing idea was to lessen the volume of blood, and in this way to diminish the work of the heart. Its timely use would prevent all organic diseases of heart; yet it was to be avoided when the patient is very weak or when the heart was failing. A small, irregular or rapid pulse did not necessarily contraindicate it, unless the patient was dropsical. Senac's general indications for treatment were: (1) Venesection; (2) avoidance of overexertion; (3) careful diet and mode of life; (4) regulation of the bowels; (5) regulation of the functions of the stomach. and liver-here certain mineral waters were valuable; (6) quieting of the nervous system, especially with Hoffmann's anodyne; (7) no mental excitement; (8) the cure of other diseases, if present, especially hæmorrhoids and worms; (9) treatment of attacks and dropsy (in the latter squills was very valuable). In attacks of stenocardia it was advised to use hot hand- and footbaths and cold syringing of chest. Kermes mineral and squills were also employed. In the intervals, iron waters were employed; prolonged use of milk, whey, etc., were also advised. In aneurism of the vessels and of heart Morgagni advised very low diet and rest in bed for forty days, so that, at the end of the cure, the patient was scarcely able to lift his hand. These methods are employed even now, and with success. These, then, are a few of the facts which a study of this period have revealed. I greatly regret that lack of time to-night prevents my going into further details on this interesting subject. One is amazed at the penetration and ingenuity of these pioneers in cardiac pathology in in terpreting the complex problems set before them. A careful study of their writings will repay any one; indeed in our anxiety to explore unknown fields, we have neglected what has already been accomplished. It is greatly to be regretted that the study of the history of medicine is entirely ignored in all of our colleges. The above also shows how much well-directed observation can accomplish. How much more ought we do when all our modern means of research are employed as well! The practical conclusion is that, once having established the diagnosis, the heart murmur is of relative unimportance. Our guide, thereafter, is the patient's general condition, and the heart is to be treated only in so far as is necessary for this purpose. And in this lies the secret of why the physicians of the XVIII century, ignorant of all our modern pathology and diagnostics, could do as much as they did. SUPRAPUBIC CYSTOTOMY FOR STONE. SOME COMPLICATIONS.* The usual preparatory treatment was administered: the bladder being washed out just before the operation, and filled with sterilized water, and the rectal bag was used. The patient did well until 6 A. M., when he became restless and suffered pain in the abdomen; pulse 98, temperature 101.4°. At 12 M., pulse 110, temperature 103.2°, with all the symptoms of septic infection of the peritoneal cavity, viz.: distended and rigid abdominal muscles, face flushed and anxious, nausea, etc. It was determined to open the abdomen immediately. The bladder was first washed out and the incision which had been made in the bladder at the first operation was closed with *Read before the Richmond Academy of Medicine and Surgery, July 15, 1897. interrupted silk sutures; a catheter was placed in the urethra to insure drainage and to prevent the urine from soiling the peritoneum and wound, after it had been washed and dressed. On opening the abdominal cavity, the visceral and parietal pelvic peritoneum was found inflamed and bathed in a dirty sero-purulent fluid, an evidence of fibrino-purulent peritonitis. Near the bladder the peritoneum looked dark and very ugly, and in a few hours, without irrigation and drainage, would have been attended by diffuse suppuration or septic peritonitis. The cavity was irrigated for some time with hot sterilized water. The lower end of the peritoneal wound was closed with a continuous silk suture; the cavity well drained with iodoform gauze, and silk-worm sutures placed in such a position as to close the abdominal wound after removal of the gauze. The patient was put to bed in a fairly good condition; pulse 120, temperature 101.2°. He rallied well, with a steady decrease of temperature, until May 26, at 2.30 P. M. The drainge had ceased, the gauze was removed, and the abdominal wound closed; temperature 100.6°, pulse 88, respiration 26. By 7.30 P. M., temperature 102°, pulse 89, respiration 26. A dose of salts was given, and at 9 P. M. an enema was administered with good effect, reducing the temperature to 100.8° by 10 P. M. As he had been much nauseated, the patient was fed and stimulated by enemas. The bladder commenced to drain through the suprapubic wound on the sixth day after operation, showing that the sutures in the bladder had given way. The catheter was removed from the urethra. The abdominal wound soon became infected and sloughed somewhat. The abdominal stitches were removed on June 2d, and the wound dressed with chloral solution. From this time the temperature varied. from 98.8° to 99.6° until June 17, when at 6 A. M. the condition was: temperature 101°, pulse 102, respiration 24; at 5 P. M., temperature 103.6°, pulse 116, respiration 26; delirious and in a condition of profound sepsis. The origin was difficult of location. When not delirious. he would complain of great pain in the head, back and abdomen, and of nausea. Refusing all nourishment, he was fed by nutritive enemas, and also was given one grain of calomel every hour until six grains had been taken; then a full, high enema was given which proved very effective. June 18, 9.15 A. M., temperature 100°, pulse 105, respiration 24; complained of feeling chilly, still nauseated and suffering pain in his head and abdomen; 5 P. M., temperature 103°, pulse 100, respiration 26. This condition continued, with morning temperature about 100° and afternoon temperature 103°, until June 21 at 3.30 P. M., when he became very restless and weak, suffered intense pain in his back in the region of the right kidney, aching in the limbs, head and abdomen; pulse 120, temperature 104°, respiration 34. Sponge baths of iced water and alcohol were ordered to be given every two hours, and the nurse was told to push stimulants and nourishment. The next morning at 8.30 a great deal of pus escaped from the suprapubic wound and continued for several days. Whenever an enema was given to wash out the bowel, he would pass urine through the urethra, which would be filled with pus. Temperature remained up until June 23, 4 A. M., when his condition improved. He looked and felt better; temperature 100°, pulse 84, respiration 22. June 25, he again suffered from absorption of pus. temperature going up to 103.4°. The wound was washed out, as had been done before, with peroxide of hydrogen, every six hours. By the 28th the temperature was normal, but would vary during each day, going as high as 100°. The poor little fellow's troubles had not yet ceased, for on July 7 he had another rise of temperature, it being at 6 P. M. 103.8°, with all symptoms of sepsis. The wound was drained well and freely, so another focus of infection had to be sought. Later in the evening he passed a large quantity of decomposed mucus from the rectum, and continued to do so three or four times daily for several days, the temperature varying during this time from 101.5° to 103.8°. The trouble in the rectum was due, no doubt, to the effect of the nutrient enemata he had been having so continuously during his illness. After washing out the bowel for several days the temperature was again brought down to normal by the 10th, remaining so until July 14, when it again rose to 102.6°, from the same cause in the bowel. After washing out the latter for a few days it fell to normal and remained so. To-day he was removed to his home in this city with the abdominal wound nearly healed, water being passed per via naturalis, and in an apparently good condition after nine weeks' illness. Several interesting points might be brought out in reviewing this, but, in concluding, I will only refer to two: 1. Suppurative septic peritonitis may follow suprapubic cystotomy without mechanical injury to the peritoneum. 2. The early, prompt and thorough flushing of the abdominal cavity, followed by drainage for suppurative, septic, peritonitis, will save life, where a few hours' delay would only bring surgery into disrepute, and the patient's life would be doomed. |