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ON THE OPERATION OF CARDIOLYSIS: ILLUSTRATED BY A CASE.
1742 i known of the regulation of respiration in health, and with alveolar air. We have suggested that the extreme diminution is 1 of the carbon dioxide in the blood in coma is in part due to the changes which take place in the body in severe diabetes. the rapid removal of carbon dioxide by the hyperpnoea, !Similar changes will be taking place in all the other cells of 1 an explanation which Dr. Pavy accepts. Before coma the body, and we imagine that as the acidosis increases the a begins and after it has passed off there is still presentmetabolic activity of the tissues is thereby slowly and promarked fall of carbon dioxide in the blood andgressively diminished until consciousness, and finally life, is a alveolar air, but it is less in degree than in coma.no longer possible. Dr. Pavy in his lectures reaches several conclusions in Further, it may be present when the total pulmonary ventilation is low and cannot therefore be due to an ex- regard to diabetes in general from which we strongly dissent. cessive pumping of carbon dioxide out of the body. When But we defer a consideration of the subject until the publicasuch a patient is made to hold his breath, he is not able to tion of our observations on diabetic patients, when we propose stop breathing sufficiently long to raise the percentage of to raise the points in question. carbon dioxide in his alveolar air to the normal-that is, his References.-Beddard and Pembrey: Brit. Med. Jour., vol. ii., 1908, respiratory centre owing to the acidosis reacts more readily p. 580. Beddard, Pembrey, and Spriggs: THE LANCET, May 16th, 1903, to carbon dioxide. If he is given oxygen to breathe con- p. 1366. Idem: Proceedings of the Physiological Society, Journal of vols. xxxi.-xliv., 1904. Idem: Ibid., vols. xxxvii.-xxxix., taining a percentage of carbon dioxide 2’ 5 per cent. greater Physiology, 1908. Geppert and Zuntz : Archiv fur die gesammte Physiologie, than that in his alveolar air, he absorbs the carbon dioxide vol. xlii., 1888, p. 189. Haldane: Brit. Med. Jour., vol. ii., 1908, p. 578. from the mixture into his blood. We conclude, therefore, Haldane and Priestley : Journal of Physiology, vol. xxxii., 1905, p. 225. W. Pavy: THE LANCET, Nov. 21st (p. 1499) and 28th (p. 1577) and that the low percentage of carbon dioxide in the patient’s F. Dec. 12th (p. 1727), 1908. Pembrey and Cook: Journal of Physiology, blood and alveolar air is due not to his blood being unable vols. xxxvii.-xli., 1908. Walter :Archiv fur Experimentelle Pathologie to take up more than it was found to contain, but to a und Pharmakologie, vol. vii., p. 148,1877. diminished production of carbon dioxide by his tissues and to an increased sensitiveness of his respiratory centre to carbon dioxide.
and ON
shown that in the precomatose comatose states of diabetes the blood can take up more carbon dioxide than it contains and that there is not an accumulation of carbon dioxide in the tissues. Failing any other explanation, we conclude that the diminution of carbon dioxide in the blood is caused by a decreased production and by the hyperpncea when present, and that both are alike caused by the acidosis. It is necessary to explain the onset of the byperpncea. Haldane and Priestley and others have shown that in health carbon dioxide is the chief stimulus to the respiratory centre. In diabetic coma, hyperpnoea begins and continues although the quantity and tension of carbon dioxide in the blood are low and there is no accumulation of carbon dioxide in the tissues. At first sight it is not obvious how in this case carbon dioxide could be an effective stimulus to the centre. If carbon dioxide could affect the centre only in virtue of a specific chemical action it could not be the stimulus in coma. Wehave shown that in diabetic coma the respiratory centre is not stimulated to greater activity, as it is in health, by a slight increase of carbon dioxide in the blood. A patient in coma was given air to breathe containing 2.6 per cent. more carbon dioxide than was in his alveolar air and the hyperpnosa was not increased. The same patient, three days’
We
have, therefore,
THE OPERATION OF CARDIOLYSIS: ILLUSTRATED BY A CASE.1 BY F. J.
ASSISTANT
POYNTON, M.D. LOND., F.R.C.P. LOND.,
PHYSICIAN
TO
UNIVERSITY
COLLEGE
HOSPITAL,
ETC.;
AND
W. TROTTER, M.S. LOND., F.R.C.S. ENG., ASSISTANT SURGEON TO UNIVERSITY COLLEGE HOSPITAL, ETC.
THE operation of cardiolysis was first suggested in 1902 by Brauer and put in practice by Petersen-two names which to-day are associated with another and much more important advance in the surgery of the chest. The name cardiolysis is perhaps a little misleading, as it is at any rate more impressive than the surgically simple procedure to which it is given. It was pointed out by Brauer that in certain cases of adherent pericardium where the heart is embarrassed by fixation to the surrounding parts, a considerable amount of this overloading of the heart’s action could be got rid of by rendering the prsecordial part of the chest wall more flexible than normal by removing its bony and cartilaginous framework. No extensive separation of adhesions was suggested, and it is obvious that under the circumstances in which the operation has to be done such procedure would be very was when he conscious and his had dislater, hyperpnoea dangerous. In the first place the circulatory conditions 2’ was air 6 to breathe containing again given appeared, very unfavourable for prolonged general anaesthesia, per cent. more carbon dioxide than was in his alveolar are while the risk of tearing the left pleura or even the heart his and returned at once. Carbon air, hyperpnœa The suggestion of wall would seem to be very great. dioxide is also an acid substance, and although it therefore an excellent one, and it Brauer was facie prima be the it is no means the only, may principal, by acid substance produced even in normal metabolism, obtained immediate practical justification in the operations much less in severe diabetes. We therefore put forward the done on his cases. The operation was extremely simple and view that the effective stimulus to the respiratory centre in short and the results were encouraging. Nevertheless, it A review of the subject seems to have been very little done. coma was the increasing concentration of unneutralised acid substances. Our view was expressed in these sentences: published in August, 1908, by Ernst Venus2 gives a total of " It is suggested that the following process is taking place in 17 cases, three of them being Brauer’s. The article contains the nerve cells of the medulla. The decreasedreactivity’ a summary of all the cases and seems to be founded on a very of the protoplasm of the cells due to the prolonged acidosis complete study of the literature. There is no death recorded renders their reaction more easily disturbed by, and there- as the consequence of the operation, and the results appear on fore makes them more sensitive to, the stimulating influence the whole to be very good. In regard to the indications for operation there is a fairly of any acid body, including carbon dioxide and other acids general metabolism." this view agreement amongst the various authors that those When criticising produced during Dr. Pavy quotes against us the work of Haldane and cases only are suitable in which the heart has shown some recovery under treatment by rest in bed. Priestley, which indicates that in health the activity of the capacity ifforrelief of the overloading of the heart is to be Clearly, vaues with the of carbon centre tension respiratory directly dioxide in the blood. Dr. Pavy therefore calls our explana- obtained by mobilisation of the prascordium, the capacity of tion of the hyperpneea in diabetic coma "vague, un- the heart to recover must be demonstrable when the oversubstantiated, and extraneous." When Dr. Pavy wrote loading is relieved by rest. It would seem then that the most this criticism he was apparently unaware that Haldane, like suitable cases are those in which the heart is just inadequate other observers, had already maintained that carbon dioxide for active life. In all the published cases general anaesthesia seems to is not the only substance which stimulates the respiratory centre, and that in order to explain the regulation of respira- have been used, on the whole without much trouble. The tion it is necessary to believe that even in health acid bodies operation need not last more than a few minutes and no very other than carbon dioxide do stimulate the centre. This profound degree of anæsthesia is necessary, so that if the view was put forward originally by Pfliiger, Geppert, and patient has been kept at rest for some time previously there Zuntz, and has been amply confirmed by the recent work of 1 A paper read before the Clinical Section of the Royal Society of Haldane, Pembrey, and others. In fact, our view of the Medicine on May 14th, 1909. 2 Centralblatt fur die cause of the hyperpnœa in coma is in strict accord with what Grenzgebiete, Band xi., No. 14.
1743 great objection to the use of chloroform. If it necessary, however, to do the operation at a time when the heart was in an unsatisfactory condition there can be ’little doubt that a local anaesthetic should be preferred. As is well known, the chest wall can be very satisfactorily infiltrated with eucaine and adrenalin, and one has been able, for example, to open the pericardium very freely under it in a child with purulent pericarditis without seems no were
causing pain.
’
under the care of Sir Thomas Barlow. He came to the hospital complaining of cedema of the legs:and swelling of the face in the which had on come morning, gradually during the preceding three months and had steadily grown worse, until he was compelled to abandon his occupation. The only point in his previous history that appeared to throw any light on the causation was a somewhat vague account of pulmonary tuberculosis two years previously. On admission he was well developed and healthy-looking, except for some cyanosis. The evening temperature usually rose to 99° F. The whole interest of his case centred on the circulatory system. The pulse, 88, was of very low tension and small calibre, though regular. The pulsus paradoxus was present. The veins in the neck were very full and pulsated visibly. The heart showed a wide impulse, extending
The technical details of the operation are very simple. A on the left side from the third to the sixth intercostal spaces. Change horseshoe-shaped flap should be marked out having its base of posture made no alteration in the position of the impulse. There above at the third rib and its apex at the seventh. The was great systolic retraction all over this area with a powerful left inner edge should be over the sternum and the outer in the ventricle beat. On palpation systolic and diastolic shocks were felt. On auscultation there was a triple rhythm; the first sound was short, region of the nipple line. The flap is turned up with the but no murmur of any kind was audible. Sir Thomas Barlow pointed to the The ribs. out that the cardiac sounds were muffled below the level of the fourth .pectoralis and all the structures external fourth and fifth ribs are those most commonly excised, but costal cartilage on the left side. Both lungs showed some congestion the bases posteriorly. The liver extended almost two fingers’ breadth the extent of the rib resection will, of course, depend on what at below the right ocstal margin, was tender, and unduly hard. The spleen is found. A length of at least 3 or 4 inches of combined rib extended two fingers’ breadth below the left costal margin. There was and cartilage must be removed. The third, the sixth, and marked cedema of both lower extremities, extending up to the thighs. The urine, of specific gravity 1015, was free from albumin and blood. .even the seventh rib must also be dealt with if it appears Sir Thomas Barlow, in a special note, expressed his opinion that these of the sternum and even the left has been necessary, edge symptoms pointed to an adherent pericardium with mediastinitis, left pleurisy, and perihepatitis. There was great improvement after rest, excised when the heart was obviously fixed to it. the cedema entirely disappeared in three weeks. The patient was There has been but one subject of disagreement in the and readmitted under Dr. Poynton, acting for Dr. S. Martin, on Sept. 21st, matter of technique, and that is the question of the removal with the history that on his leaving the hospital all the symptoms at of the costal periosteum. Kuttner, Danielsen, Leukenbach, once returned. This time his condition was obviously worse, although had not done any active work. His pulse was more rapid (90-100), and von Beck all insist on the importance of removing the he the oedema had reappeared, and there was some fluid in the abdomen. whole periosteum of the resected ribs lest the mobilised part The face was cyanosed and engorged and the jugulars very full. of the chest wall become rigid again. König, however, Breathlessness and palpitation were now complained of. The caidiao condition showed all the phenomena noted above, and the triple points out that this is extremely difficult to do, and has, in rhythm and small, low-tension pulse were extremely well marked. addition to the general disadvantage of prolonging the The liver was larger, reaching almost to the umbilicus, and the spleen the same size. There was no albuminuria. operation under circumstances where saving of time is very about It was evident on investigation that the rest in bed rapidly got rid of important, the special disadvantage that there is consider- the cedema, but on the least exertion it reappeared and breathlessness able risk of a wound being made in the left pleura. The was at once complained of. A walk up and down the ward was sufficient symptoms in these circumstances, and in face of the physical latter, as is now well known, comes inwards normally as far to cause signs it seemed possible that the operation of cardiolysis would be as the left edge of the sternum and is by no means necesbeneficial. The great difficulty in the decision was that of excluding a sarily obliterated in these cases. He recommends, therefore, considerable myocarditis, and with regard to this the most encouraging that the anterior periosteum only should be removed. That point was the rapid improvement that occurred when strict rest was He was accordingly transferred to Mr. Trotter’s care. this is the proper course to follow and is not likely to lead to enjoined. The operation was done by Mr. Trotter on Oct. 5th. A semicircular re-ossification is shown by a number of cases in which the flap was marked out in the præcordial region and was reflected upwards. It included all the structures anterior to the ribs. The fourth and fifth præcordium has remained flexible for a long period, and ribs those which seemed to move most with the movements of the especially by a case of Konig’s, in which, two and a half heart,were and a length (between 3 inches and 4 inches) of both was after the the died from years operation, patient having removed, the periosteum being left behind. The pericardium was found thickened and adherent to the chest wall over the region exposed. general tuberculosis, a necropsy was made. It was shown much After removal of the ribs the structures over the heart accommodated that practically no ossification had occurred. The possibility themselves far more easily to the cardiac movements. The flap was of leaving the periosteum without damaging the usefulness replaced and the wound completely closed. The after-treatment of the case has required close attention. It of the treatment makes the operation still more simple and seemed at first, in spite of the favourable result of the operation, as if removes the only serious risk it could be supposed to have. the cardiac muscle was more at fault than was thought, and that after In the case reported at the end of this paper the fourth all we were possibly dealing with a cardiac fibrosis. The patient’s ribs of and fifth were removed for a length about 4 inches mother brought alarmist accounts of him after his departure from hospital, which led us to believe he was in extrenzis and in front of the heart, the periosteum being left behind. The the enabled us to readmit him for a period into the hospital. latter was obviously adherent to the front of the pericardium On his return it was apparent that, farlong from being worse, his condition and pleura, and the extent to which it was drawn in and out showed distinct improvement. He remained on his third admission months in the hospital, of which about five weeks were spent in by the tumultuously beating heart gave one a very clear idea two bed. He was then allowed to get up and lastly to walk a little. In as to how much the cardiac movements must have been January he could sit up for six to eight hours, with his legs hanging down, without getting any, or very slight, oedema of the ankles. The hampered by the rigid chest wall. then only one finger’s breadth below the costal margin and the So far as the general condition of our patient was con- liver was spleen one and a half fingers’ breadth. a He he to be favourable case. cerned, At the present time we believe that the operation has been justified improved appeared the result even if the improvement goes no further; for the patient greatly with complete rest, but was quite unable to cope by can now go for a walk extending over half an hour, and in the evening with exertion of the most ordinary kind. His general health there is slight pitting over the ankles. He looks more healthy and and development were good, and his disposition was cheerful. is much only less breathless. His pulse has more power and is not so small There was no valvular lesion, and there were striking indi- in size. The size of the heart is somewhat diminished; the liver, though easily felt and harder than normal, is decidedly smaller, and cations of mechanical embarrassment. Nevertheless, we felt the spleen scarcely palpable. The veins in the neck are greatly then, as we feel now, that it is in reality a very difficult reduced in size. There is still a cantering rhythm. This improvement matter to gauge the condition of the myocardium. His has been very gradual and slow and we believe has been materially by the continuous use of small, repeated doses of digitalis improvement has been slow and we do not bring him assisted (m v. of the tincture) since November. No exercise of any sort except forward as an example of a complete cure, far from it, massage was permitted for three months after the operation, and since but he is undoubtedly in a much better condition than then it has been graduated. A month ago he was not quite so well. been a slight increase in the cedema and a sensation of he was, and we hope that with continued care he has There had fatigue on slight exertion, and as a consequence of this more rest was not yet reached the limit of his progress. We would ordered, and improvement has followed this precaution. emphasise in particular the great improvement in the force and volume of his pulse and the diminution ROYAL INSTITUTE OF PUBLIC HEALTH.-The in the size of the spleen and liver and the degree of dropsy. On the other hand, it must be pointed out Council has awarded the Harben gold medal for eminent that the cantering cardiac rhythm is still present and services to the public health, which it is empowered to the action irritable, as it is in some cases of soldier’s do triennially, to his Excellency Professor E. von Behring, heart." We believe that the choice of suitable cases is not M.D., Marburg, Germany, and has appointed Brevet- easy, and would in particular look with suspicion upon cases Lieutenant-Colonel W. B. Leishman, M.B., R.A.M.C., Proof multiple serositis in which there may be, so far as the fessor of Pathology, Royal Army Medical College, the Harben heart is concerned, indication for this operation, but which lecturer for the year 1910, and Professor Angelo Celli, M.D., from their tendency to show exacerbations and to spread Rome, the Harben lecturer for the year 1911. As already from serous membrane to serous membrane, would probably announced, the Harben lectures for 1909 will be delivered not be favourably influenced by surgical interference. by Professor R. Pfeiffer, M.D., Breslau, in the lecture room The patient, a male, aged 16 years, was first admitted to University of the institute on Monday, June 21st, IVednesday, June 23rd, College Hospital on August 16th, 1908, and remained until Sept. 8th, and Friday, June 25th, at 6 P.M.
and ON
shown that in the precomatose comatose states of diabetes the blood can take up more carbon dioxide than it contains and that there is not an accumulation of carbon dioxide in the tissues. Failing any other explanation, we conclude that the diminution of carbon dioxide in the blood is caused by a decreased production and by the hyperpncea when present, and that both are alike caused by the acidosis. It is necessary to explain the onset of the byperpncea. Haldane and Priestley and others have shown that in health carbon dioxide is the chief stimulus to the respiratory centre. In diabetic coma, hyperpnoea begins and continues although the quantity and tension of carbon dioxide in the blood are low and there is no accumulation of carbon dioxide in the tissues. At first sight it is not obvious how in this case carbon dioxide could be an effective stimulus to the centre. If carbon dioxide could affect the centre only in virtue of a specific chemical action it could not be the stimulus in coma. Wehave shown that in diabetic coma the respiratory centre is not stimulated to greater activity, as it is in health, by a slight increase of carbon dioxide in the blood. A patient in coma was given air to breathe containing 2.6 per cent. more carbon dioxide than was in his alveolar air and the hyperpnosa was not increased. The same patient, three days’
We
have, therefore,
THE OPERATION OF CARDIOLYSIS: ILLUSTRATED BY A CASE.1 BY F. J.
ASSISTANT
POYNTON, M.D. LOND., F.R.C.P. LOND.,
PHYSICIAN
TO
UNIVERSITY
COLLEGE
HOSPITAL,
ETC.;
AND
W. TROTTER, M.S. LOND., F.R.C.S. ENG., ASSISTANT SURGEON TO UNIVERSITY COLLEGE HOSPITAL, ETC.
THE operation of cardiolysis was first suggested in 1902 by Brauer and put in practice by Petersen-two names which to-day are associated with another and much more important advance in the surgery of the chest. The name cardiolysis is perhaps a little misleading, as it is at any rate more impressive than the surgically simple procedure to which it is given. It was pointed out by Brauer that in certain cases of adherent pericardium where the heart is embarrassed by fixation to the surrounding parts, a considerable amount of this overloading of the heart’s action could be got rid of by rendering the prsecordial part of the chest wall more flexible than normal by removing its bony and cartilaginous framework. No extensive separation of adhesions was suggested, and it is obvious that under the circumstances in which the operation has to be done such procedure would be very was when he conscious and his had dislater, hyperpnoea dangerous. In the first place the circulatory conditions 2’ was air 6 to breathe containing again given appeared, very unfavourable for prolonged general anaesthesia, per cent. more carbon dioxide than was in his alveolar are while the risk of tearing the left pleura or even the heart his and returned at once. Carbon air, hyperpnœa The suggestion of wall would seem to be very great. dioxide is also an acid substance, and although it therefore an excellent one, and it Brauer was facie prima be the it is no means the only, may principal, by acid substance produced even in normal metabolism, obtained immediate practical justification in the operations much less in severe diabetes. We therefore put forward the done on his cases. The operation was extremely simple and view that the effective stimulus to the respiratory centre in short and the results were encouraging. Nevertheless, it A review of the subject seems to have been very little done. coma was the increasing concentration of unneutralised acid substances. Our view was expressed in these sentences: published in August, 1908, by Ernst Venus2 gives a total of " It is suggested that the following process is taking place in 17 cases, three of them being Brauer’s. The article contains the nerve cells of the medulla. The decreasedreactivity’ a summary of all the cases and seems to be founded on a very of the protoplasm of the cells due to the prolonged acidosis complete study of the literature. There is no death recorded renders their reaction more easily disturbed by, and there- as the consequence of the operation, and the results appear on fore makes them more sensitive to, the stimulating influence the whole to be very good. In regard to the indications for operation there is a fairly of any acid body, including carbon dioxide and other acids general metabolism." this view agreement amongst the various authors that those When criticising produced during Dr. Pavy quotes against us the work of Haldane and cases only are suitable in which the heart has shown some recovery under treatment by rest in bed. Priestley, which indicates that in health the activity of the capacity ifforrelief of the overloading of the heart is to be Clearly, vaues with the of carbon centre tension respiratory directly dioxide in the blood. Dr. Pavy therefore calls our explana- obtained by mobilisation of the prascordium, the capacity of tion of the hyperpneea in diabetic coma "vague, un- the heart to recover must be demonstrable when the oversubstantiated, and extraneous." When Dr. Pavy wrote loading is relieved by rest. It would seem then that the most this criticism he was apparently unaware that Haldane, like suitable cases are those in which the heart is just inadequate other observers, had already maintained that carbon dioxide for active life. In all the published cases general anaesthesia seems to is not the only substance which stimulates the respiratory centre, and that in order to explain the regulation of respira- have been used, on the whole without much trouble. The tion it is necessary to believe that even in health acid bodies operation need not last more than a few minutes and no very other than carbon dioxide do stimulate the centre. This profound degree of anæsthesia is necessary, so that if the view was put forward originally by Pfliiger, Geppert, and patient has been kept at rest for some time previously there Zuntz, and has been amply confirmed by the recent work of 1 A paper read before the Clinical Section of the Royal Society of Haldane, Pembrey, and others. In fact, our view of the Medicine on May 14th, 1909. 2 Centralblatt fur die cause of the hyperpnœa in coma is in strict accord with what Grenzgebiete, Band xi., No. 14.
1743 great objection to the use of chloroform. If it necessary, however, to do the operation at a time when the heart was in an unsatisfactory condition there can be ’little doubt that a local anaesthetic should be preferred. As is well known, the chest wall can be very satisfactorily infiltrated with eucaine and adrenalin, and one has been able, for example, to open the pericardium very freely under it in a child with purulent pericarditis without seems no were
causing pain.
’
under the care of Sir Thomas Barlow. He came to the hospital complaining of cedema of the legs:and swelling of the face in the which had on come morning, gradually during the preceding three months and had steadily grown worse, until he was compelled to abandon his occupation. The only point in his previous history that appeared to throw any light on the causation was a somewhat vague account of pulmonary tuberculosis two years previously. On admission he was well developed and healthy-looking, except for some cyanosis. The evening temperature usually rose to 99° F. The whole interest of his case centred on the circulatory system. The pulse, 88, was of very low tension and small calibre, though regular. The pulsus paradoxus was present. The veins in the neck were very full and pulsated visibly. The heart showed a wide impulse, extending
The technical details of the operation are very simple. A on the left side from the third to the sixth intercostal spaces. Change horseshoe-shaped flap should be marked out having its base of posture made no alteration in the position of the impulse. There above at the third rib and its apex at the seventh. The was great systolic retraction all over this area with a powerful left inner edge should be over the sternum and the outer in the ventricle beat. On palpation systolic and diastolic shocks were felt. On auscultation there was a triple rhythm; the first sound was short, region of the nipple line. The flap is turned up with the but no murmur of any kind was audible. Sir Thomas Barlow pointed to the The ribs. out that the cardiac sounds were muffled below the level of the fourth .pectoralis and all the structures external fourth and fifth ribs are those most commonly excised, but costal cartilage on the left side. Both lungs showed some congestion the bases posteriorly. The liver extended almost two fingers’ breadth the extent of the rib resection will, of course, depend on what at below the right ocstal margin, was tender, and unduly hard. The spleen is found. A length of at least 3 or 4 inches of combined rib extended two fingers’ breadth below the left costal margin. There was and cartilage must be removed. The third, the sixth, and marked cedema of both lower extremities, extending up to the thighs. The urine, of specific gravity 1015, was free from albumin and blood. .even the seventh rib must also be dealt with if it appears Sir Thomas Barlow, in a special note, expressed his opinion that these of the sternum and even the left has been necessary, edge symptoms pointed to an adherent pericardium with mediastinitis, left pleurisy, and perihepatitis. There was great improvement after rest, excised when the heart was obviously fixed to it. the cedema entirely disappeared in three weeks. The patient was There has been but one subject of disagreement in the and readmitted under Dr. Poynton, acting for Dr. S. Martin, on Sept. 21st, matter of technique, and that is the question of the removal with the history that on his leaving the hospital all the symptoms at of the costal periosteum. Kuttner, Danielsen, Leukenbach, once returned. This time his condition was obviously worse, although had not done any active work. His pulse was more rapid (90-100), and von Beck all insist on the importance of removing the he the oedema had reappeared, and there was some fluid in the abdomen. whole periosteum of the resected ribs lest the mobilised part The face was cyanosed and engorged and the jugulars very full. of the chest wall become rigid again. König, however, Breathlessness and palpitation were now complained of. The caidiao condition showed all the phenomena noted above, and the triple points out that this is extremely difficult to do, and has, in rhythm and small, low-tension pulse were extremely well marked. addition to the general disadvantage of prolonging the The liver was larger, reaching almost to the umbilicus, and the spleen the same size. There was no albuminuria. operation under circumstances where saving of time is very about It was evident on investigation that the rest in bed rapidly got rid of important, the special disadvantage that there is consider- the cedema, but on the least exertion it reappeared and breathlessness able risk of a wound being made in the left pleura. The was at once complained of. A walk up and down the ward was sufficient symptoms in these circumstances, and in face of the physical latter, as is now well known, comes inwards normally as far to cause signs it seemed possible that the operation of cardiolysis would be as the left edge of the sternum and is by no means necesbeneficial. The great difficulty in the decision was that of excluding a sarily obliterated in these cases. He recommends, therefore, considerable myocarditis, and with regard to this the most encouraging that the anterior periosteum only should be removed. That point was the rapid improvement that occurred when strict rest was He was accordingly transferred to Mr. Trotter’s care. this is the proper course to follow and is not likely to lead to enjoined. The operation was done by Mr. Trotter on Oct. 5th. A semicircular re-ossification is shown by a number of cases in which the flap was marked out in the præcordial region and was reflected upwards. It included all the structures anterior to the ribs. The fourth and fifth præcordium has remained flexible for a long period, and ribs those which seemed to move most with the movements of the especially by a case of Konig’s, in which, two and a half heart,were and a length (between 3 inches and 4 inches) of both was after the the died from years operation, patient having removed, the periosteum being left behind. The pericardium was found thickened and adherent to the chest wall over the region exposed. general tuberculosis, a necropsy was made. It was shown much After removal of the ribs the structures over the heart accommodated that practically no ossification had occurred. The possibility themselves far more easily to the cardiac movements. The flap was of leaving the periosteum without damaging the usefulness replaced and the wound completely closed. The after-treatment of the case has required close attention. It of the treatment makes the operation still more simple and seemed at first, in spite of the favourable result of the operation, as if removes the only serious risk it could be supposed to have. the cardiac muscle was more at fault than was thought, and that after In the case reported at the end of this paper the fourth all we were possibly dealing with a cardiac fibrosis. The patient’s ribs of and fifth were removed for a length about 4 inches mother brought alarmist accounts of him after his departure from hospital, which led us to believe he was in extrenzis and in front of the heart, the periosteum being left behind. The the enabled us to readmit him for a period into the hospital. latter was obviously adherent to the front of the pericardium On his return it was apparent that, farlong from being worse, his condition and pleura, and the extent to which it was drawn in and out showed distinct improvement. He remained on his third admission months in the hospital, of which about five weeks were spent in by the tumultuously beating heart gave one a very clear idea two bed. He was then allowed to get up and lastly to walk a little. In as to how much the cardiac movements must have been January he could sit up for six to eight hours, with his legs hanging down, without getting any, or very slight, oedema of the ankles. The hampered by the rigid chest wall. then only one finger’s breadth below the costal margin and the So far as the general condition of our patient was con- liver was spleen one and a half fingers’ breadth. a He he to be favourable case. cerned, At the present time we believe that the operation has been justified improved appeared the result even if the improvement goes no further; for the patient greatly with complete rest, but was quite unable to cope by can now go for a walk extending over half an hour, and in the evening with exertion of the most ordinary kind. His general health there is slight pitting over the ankles. He looks more healthy and and development were good, and his disposition was cheerful. is much only less breathless. His pulse has more power and is not so small There was no valvular lesion, and there were striking indi- in size. The size of the heart is somewhat diminished; the liver, though easily felt and harder than normal, is decidedly smaller, and cations of mechanical embarrassment. Nevertheless, we felt the spleen scarcely palpable. The veins in the neck are greatly then, as we feel now, that it is in reality a very difficult reduced in size. There is still a cantering rhythm. This improvement matter to gauge the condition of the myocardium. His has been very gradual and slow and we believe has been materially by the continuous use of small, repeated doses of digitalis improvement has been slow and we do not bring him assisted (m v. of the tincture) since November. No exercise of any sort except forward as an example of a complete cure, far from it, massage was permitted for three months after the operation, and since but he is undoubtedly in a much better condition than then it has been graduated. A month ago he was not quite so well. been a slight increase in the cedema and a sensation of he was, and we hope that with continued care he has There had fatigue on slight exertion, and as a consequence of this more rest was not yet reached the limit of his progress. We would ordered, and improvement has followed this precaution. emphasise in particular the great improvement in the force and volume of his pulse and the diminution ROYAL INSTITUTE OF PUBLIC HEALTH.-The in the size of the spleen and liver and the degree of dropsy. On the other hand, it must be pointed out Council has awarded the Harben gold medal for eminent that the cantering cardiac rhythm is still present and services to the public health, which it is empowered to the action irritable, as it is in some cases of soldier’s do triennially, to his Excellency Professor E. von Behring, heart." We believe that the choice of suitable cases is not M.D., Marburg, Germany, and has appointed Brevet- easy, and would in particular look with suspicion upon cases Lieutenant-Colonel W. B. Leishman, M.B., R.A.M.C., Proof multiple serositis in which there may be, so far as the fessor of Pathology, Royal Army Medical College, the Harben heart is concerned, indication for this operation, but which lecturer for the year 1910, and Professor Angelo Celli, M.D., from their tendency to show exacerbations and to spread Rome, the Harben lecturer for the year 1911. As already from serous membrane to serous membrane, would probably announced, the Harben lectures for 1909 will be delivered not be favourably influenced by surgical interference. by Professor R. Pfeiffer, M.D., Breslau, in the lecture room The patient, a male, aged 16 years, was first admitted to University of the institute on Monday, June 21st, IVednesday, June 23rd, College Hospital on August 16th, 1908, and remained until Sept. 8th, and Friday, June 25th, at 6 P.M.