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A CASE OF COMPLETE HEART-BLOCK, WITH POST-MORTEM EXAMINATION.
271
ptosis. The view has lately been put forward that lesser curve ulcers are more common in women than in men. This has not been my experience. The hour-glass stomach, it is true, is almost wholly limited to women, all of my cases due to a simple ulcer occurring in women, and ptosis was very often present. On the other hand, of the 146 lesser curve ulcers 104 were found in men and only 42 in women. If, then, a gastro-enterostomy is unsatisfactory, the operation will have to consist either of local treatment of the ulcer, such as excision or cautery excision, which must be combined with gastro-enterostomy to prevent recurrence, or of partial gastrectomy. The choice of these two operations will vary with different surgeons. Excision is more likely to be followed by recurrence or the onset of carcinoma, but a, gastrojejunal ulcer, in my experience, does not occur after A partial gastrectomy, on the an ulcer of this type. other hand, is more likely to have a higher mortality. It is by the careful consideration of these two possibilities that a choice will have to be made, and hence it is probable that there will not be perfect among different surgeons, for their figures in this respect are liable to vary. One has a relatively low mortality for partial gastrectomy, .another for excision. The danger of recurrence after excision alone is universally agreed to be considerable and therefore this operation should never be performed. If, however, it be combined with posterior gastroenterostomy and occlusion of the pylorus the danger is very slight, especially if only catgut sutures be used. In mv own series of 167 cases there was a local recurrence in two, and I believe that it, in both cases, was due to the fact that sulficient care had not been taken to obtain complete apposition of the posterior layer of the mucosa. The danger of after-carcinoma is here, as with the pyloric ulcers, slight if a careful history be taken, for not only are the symptoms of this variety of ulcer very definite, but the onset of carcinomatous changes may give a very clear change in the symptoms. If there be a suggestive change in any one of the symptoms a partial gastrectomy will, of course, be the operation of choice. In my own series carcinoma occurred after operation in two cases, in one at the site of the ulcer and in the other at the pylorus. Apart from these dangers the results have been exceptionally good and no other complications have followed. Of the 167 cases, 149 have been treated with excision combined with posterior gastroenterostomy and pyloric occlusion. Occlusion of the pylorus in all cases was performed by means of a silk mattress suture, which obstructs the passage for about two months only; after which X ray investigation shows that the canal is again opened up and the food passes through. I have for a long time been convinced that a permanent occlusion is unnecessary. It is only required until such time as the ulcer is healed. In these 149 cases there were three deaths, giving an operative mortality of 2 per cent. Partial gastrectomy, on the other hand, is followed by practically no danger of recurrence or carcinoma, but, as with the case of pyloric ulcer, I believe that the mortality will always be higher. It is my custom only to perform it when there is a doubt as to the presence of carcinoma, or with large adherent ulcers which are difficult to free, so as to allow of a satisfactory excision. It was performed in my series in 20 cases, five of whom died as a result of operation, which gives a high mortality of 22 per cent. The total mortality for both cases grouped together was therefore 167 cases with eight deaths—that is a percentage of 4’8, but it must be remembered that there .are included in this list all cases whatever complications may have been present. My personal view is therefore that the operation of choice is one of free excision, which, in my opinion, gives a wider removal than .cautery excision, followed by occlusion of the pylorus and posterior gastro-enterostomy. If there be the slightest question as to the presence of carcinoma, or in some difficult adherent cases, a partial gastrectomy of
unanimity
should be the operation of choice. I believe that by these means the total mortality will be less than will occur with a routine partial gastrectomy, and will give a higher percentage of satisfactory results even if there be added the small possibility of recurrent ulceration or of the onset of carcinoma. A CASE OF
COMPLETE HEART-BLOCK, WITH POSTMORTEM EXAMINATION. BY HENRY WALDO, M.D. ABERD.,
M.R.C.P.LOND.,
CONSULTING PHYSICIAN, BRISTOL ROYAL INFIRMARY ;
AND
C.
E.
K.
HERAPATH, M.C., M.D. LOND.,
ASSISTANT PHYSICIAN, BRISTOL ROYAL INFIRMARY; CARDIAC SPECIALIST TO MINISTRY OF PENSIONS, BRISTOL AREA.
Tun following case is sufficiently remarkable to merit record. The notes are by Dr. Waldo and the pathological report by Dr. Herapath. A bachelor of 62 years of age, always of temperate habits, contracted a primary sore 25 to 30 years ago and was treated for some years with mercury by one of the surgeons at the Lock Hospital. Hecame under my care 10 years ago with what he called a bilious attack with vomiting. There was a well-marked systolic murmur all over the front of the chest with increased cardiac dullness and a rather feeble impulse displaced downwards and outwards ; the pulse was 44 to the minute, regular, and not of the Corrigan type. From then onwards he took mercury either by the mouth or by inunction, but has never had intravenous or muscular injections of any kind. Seven years ago he developed a gumma on the back of his wrist, which recurred within six months. The pulse gradually became slower and varied between 33 and 23 to the minute, though the venous pulse in the neck could be counted at 60 to the minute. He had several attacks resembling petit mal, the first two without and later ones with loss of consciousness ; he passed urine involuntarily, though he never bit his tongue. During these attacks he was more flushed than pale ; thought they were brought on by mental strain and by hunger. He complained of some shortness of breath, especially when ascending stairs, but had no cardiac pain of any kind. The systolic blood pressure in August, 1918, was 110 mm. Hg. In February, 1920, two of my colleagues, Dr. J. E. Shaw and Dr. F. H. Edgeworth, saw the patient with me, and we agreed on the diagnosis of heart-block with destruction, probably complete, of the auriculo-ventricular bundle. The patient died in October, 1920, in an unconscious attack.
he
Pathological Report on the Heart by Dr. HERAPATH.1 The heart is very large, all chambers being markedly
dilated and both ventricles very much hypertropbied. The auriculo-ventricular rings are wide, and the heart increased in length from base to apex. The muscle is fatty and friable. There is atheroma of the ascending portion of the aorta. The coronary arteries are somewhat occluded and much thickened wherever cut across. The right surface of the auricular septum is hard and glistens as though it were more fibrous than usual. The following blocks were cut out for microscopic examination: (1) A portion of the right auricle to include the sinu-auricular node ; (2) a portion of the septum including the mouth of the coronary sinus and the whole length of the bundle of His ; (3) a small portion of the apex and base of each ventricle ; (4) portions of the right and left auricular appendices. Right Auricular Block.-The node area small and surrounded by more fat than is usual ; node itself and elongated as though pulled out. Marked narrow increase of fibrous tissue in the node, extending into 1 This examination was made in the course of under a grant from the Colston Research Fund.
a
research
272
Intraventricular septum (low-power objectivel. , Auricular muscle ; 2, fibrous tissue ; 3. remains of the bundle; 4, ventricular muscle ; 5, artery to the bundle ; 6, left branch of bundle ; 7, tricuspid valve.
all its main branches ; the
artery
to the node much
Intra ventricular septum (high-power objective). 1, Remnants of cardiac muscle ; B’, fibrosed left branch of the bundle ; 3, ventricular muscle ; 4, remains of bundle ; 5, fibrous tissue ; 6, artery to the bundle, much thickened.
by the
main branches of the
a.-v.
bundle.
A few
thickened : muscle of right auricle fibrotic, the small fibres still recognisable as cardiac muscle can be vessels thickened ; thereare small areas of peri- found in the bundle, but no muscular connexion vascular cardium.
lymphocytosis.
Some
thickening of
endo-
Septal Block.-Lower part of auricular septum taken vertically from coronary sinus side backwards ; each section 15µ thick, and every tenth section out and cut
mounted. Sub-endocardial fibrosis on both sides of inter-auricular septum reaching on the right from level of mouth of coronary sinus to base of tricuspid valve ; on left fibrosis includes lower fibres of left auricular muscle where they are inserted into the central fibrous body. Muscle passing down into base of tricuspid valve also replaced by fibrous tissue. Central fibrous body much elongated and appears to have been pulled out. It extends much higher than usual and, to a large extent, has been replaced by newly-formed fibrous tissue; at several points active lymphocytosis is going on. Lower part of interauricular septum contains a large amount of fat which appears to have replaced the bundles of muscle usually rtiet with in this area ; a thin layer of muscle passing down on each side of the septum just below the thickened and fibrosed endocardium. In this pad of fat are a few fibrosed strands of muscle fibres-all that remains of the tangle of muscle fibres, constituting the a.-v. node, and normally found just below the mouth of the coronary sinus. Traced backwards through the series of sections, this pad of fat pierces the central fibrous body in the same way and in the same place as the " bundle." and certainly represents all that is left of the bundle of His. Vessels accompany it; one, a well-marked artery, is the artery to the bundle and is much thickened, chiefly from proliferation of the intima. Tracing on through the series it breaks off from the auricular side and comes to lie wholly inside the central fibrous body, and later dividing into two branches ; one passing down the left surface of the inter-ventricular septum just beneath the endocardium, the other passing down between the bundles of ventricular muscle on the right side of septum in the positions, that is to say, usually occupied was
traceable from the bundle into either of its branches, the upper part of the branches being composed of fibrous tissue ; lower down in these branches healthy fibres begin to appear, and still lower they are quite normal. (Figs. 1 and 2.) Apical and Basal Blocks from each TTeyatricle.-All healthy, except block from base of left ventricle, which showed marked thickening of coronary artery which was almost occluded. Right and Left Auricular Appendices.—Nothing abnormal found. Remarks. In the absence of tracings the case was diagnosed as one of syphilitic heart-block. Post mortem, complete destruction of the bundle of His was found ; the junctional tissues had been picked out for attack and the damage was almost confined to this area, the whole bundle being destroyed, even to the upper part of its two main branches. The heart had evidently been contracting for some years with no connecting link between the auricles and ventricles ; in other words, the stimulus for the ventricular contractions had been arising from some part of the bundle, and the rhythm was what is termed the idioventricular rhythm. Cessation of ventricular action occurred because the fibrosis finally cut the ventricles off from this last stimulus-producing area, and no further stimulus for contraction could reach the ventricular muscle.
AN ITALIAN CONGRESS
OF
MEDICAL RADIOLOGY.-
The fourth Italian Congress of Medical Radiology (general secretary, Prof. Mario Ponzio, Ospedale Mauriziano, Turin) will take place in Bologna on May 9th, lOth, and llth next, in the Orthopaedic Institute, Rizzoli, under the presidency of Prof. Aristide Busi. Annexed to the Congress an exhibition of radiological apparatus will be held, in which foreign Information can as well as Italian firms can participate. be obtained from Dr. Alberto Possati, Villa Verde, Bologna., secretary of the Congress.
ptosis. The view has lately been put forward that lesser curve ulcers are more common in women than in men. This has not been my experience. The hour-glass stomach, it is true, is almost wholly limited to women, all of my cases due to a simple ulcer occurring in women, and ptosis was very often present. On the other hand, of the 146 lesser curve ulcers 104 were found in men and only 42 in women. If, then, a gastro-enterostomy is unsatisfactory, the operation will have to consist either of local treatment of the ulcer, such as excision or cautery excision, which must be combined with gastro-enterostomy to prevent recurrence, or of partial gastrectomy. The choice of these two operations will vary with different surgeons. Excision is more likely to be followed by recurrence or the onset of carcinoma, but a, gastrojejunal ulcer, in my experience, does not occur after A partial gastrectomy, on the an ulcer of this type. other hand, is more likely to have a higher mortality. It is by the careful consideration of these two possibilities that a choice will have to be made, and hence it is probable that there will not be perfect among different surgeons, for their figures in this respect are liable to vary. One has a relatively low mortality for partial gastrectomy, .another for excision. The danger of recurrence after excision alone is universally agreed to be considerable and therefore this operation should never be performed. If, however, it be combined with posterior gastroenterostomy and occlusion of the pylorus the danger is very slight, especially if only catgut sutures be used. In mv own series of 167 cases there was a local recurrence in two, and I believe that it, in both cases, was due to the fact that sulficient care had not been taken to obtain complete apposition of the posterior layer of the mucosa. The danger of after-carcinoma is here, as with the pyloric ulcers, slight if a careful history be taken, for not only are the symptoms of this variety of ulcer very definite, but the onset of carcinomatous changes may give a very clear change in the symptoms. If there be a suggestive change in any one of the symptoms a partial gastrectomy will, of course, be the operation of choice. In my own series carcinoma occurred after operation in two cases, in one at the site of the ulcer and in the other at the pylorus. Apart from these dangers the results have been exceptionally good and no other complications have followed. Of the 167 cases, 149 have been treated with excision combined with posterior gastroenterostomy and pyloric occlusion. Occlusion of the pylorus in all cases was performed by means of a silk mattress suture, which obstructs the passage for about two months only; after which X ray investigation shows that the canal is again opened up and the food passes through. I have for a long time been convinced that a permanent occlusion is unnecessary. It is only required until such time as the ulcer is healed. In these 149 cases there were three deaths, giving an operative mortality of 2 per cent. Partial gastrectomy, on the other hand, is followed by practically no danger of recurrence or carcinoma, but, as with the case of pyloric ulcer, I believe that the mortality will always be higher. It is my custom only to perform it when there is a doubt as to the presence of carcinoma, or with large adherent ulcers which are difficult to free, so as to allow of a satisfactory excision. It was performed in my series in 20 cases, five of whom died as a result of operation, which gives a high mortality of 22 per cent. The total mortality for both cases grouped together was therefore 167 cases with eight deaths—that is a percentage of 4’8, but it must be remembered that there .are included in this list all cases whatever complications may have been present. My personal view is therefore that the operation of choice is one of free excision, which, in my opinion, gives a wider removal than .cautery excision, followed by occlusion of the pylorus and posterior gastro-enterostomy. If there be the slightest question as to the presence of carcinoma, or in some difficult adherent cases, a partial gastrectomy of
unanimity
should be the operation of choice. I believe that by these means the total mortality will be less than will occur with a routine partial gastrectomy, and will give a higher percentage of satisfactory results even if there be added the small possibility of recurrent ulceration or of the onset of carcinoma. A CASE OF
COMPLETE HEART-BLOCK, WITH POSTMORTEM EXAMINATION. BY HENRY WALDO, M.D. ABERD.,
M.R.C.P.LOND.,
CONSULTING PHYSICIAN, BRISTOL ROYAL INFIRMARY ;
AND
C.
E.
K.
HERAPATH, M.C., M.D. LOND.,
ASSISTANT PHYSICIAN, BRISTOL ROYAL INFIRMARY; CARDIAC SPECIALIST TO MINISTRY OF PENSIONS, BRISTOL AREA.
Tun following case is sufficiently remarkable to merit record. The notes are by Dr. Waldo and the pathological report by Dr. Herapath. A bachelor of 62 years of age, always of temperate habits, contracted a primary sore 25 to 30 years ago and was treated for some years with mercury by one of the surgeons at the Lock Hospital. Hecame under my care 10 years ago with what he called a bilious attack with vomiting. There was a well-marked systolic murmur all over the front of the chest with increased cardiac dullness and a rather feeble impulse displaced downwards and outwards ; the pulse was 44 to the minute, regular, and not of the Corrigan type. From then onwards he took mercury either by the mouth or by inunction, but has never had intravenous or muscular injections of any kind. Seven years ago he developed a gumma on the back of his wrist, which recurred within six months. The pulse gradually became slower and varied between 33 and 23 to the minute, though the venous pulse in the neck could be counted at 60 to the minute. He had several attacks resembling petit mal, the first two without and later ones with loss of consciousness ; he passed urine involuntarily, though he never bit his tongue. During these attacks he was more flushed than pale ; thought they were brought on by mental strain and by hunger. He complained of some shortness of breath, especially when ascending stairs, but had no cardiac pain of any kind. The systolic blood pressure in August, 1918, was 110 mm. Hg. In February, 1920, two of my colleagues, Dr. J. E. Shaw and Dr. F. H. Edgeworth, saw the patient with me, and we agreed on the diagnosis of heart-block with destruction, probably complete, of the auriculo-ventricular bundle. The patient died in October, 1920, in an unconscious attack.
he
Pathological Report on the Heart by Dr. HERAPATH.1 The heart is very large, all chambers being markedly
dilated and both ventricles very much hypertropbied. The auriculo-ventricular rings are wide, and the heart increased in length from base to apex. The muscle is fatty and friable. There is atheroma of the ascending portion of the aorta. The coronary arteries are somewhat occluded and much thickened wherever cut across. The right surface of the auricular septum is hard and glistens as though it were more fibrous than usual. The following blocks were cut out for microscopic examination: (1) A portion of the right auricle to include the sinu-auricular node ; (2) a portion of the septum including the mouth of the coronary sinus and the whole length of the bundle of His ; (3) a small portion of the apex and base of each ventricle ; (4) portions of the right and left auricular appendices. Right Auricular Block.-The node area small and surrounded by more fat than is usual ; node itself and elongated as though pulled out. Marked narrow increase of fibrous tissue in the node, extending into 1 This examination was made in the course of under a grant from the Colston Research Fund.
a
research
272
Intraventricular septum (low-power objectivel. , Auricular muscle ; 2, fibrous tissue ; 3. remains of the bundle; 4, ventricular muscle ; 5, artery to the bundle ; 6, left branch of bundle ; 7, tricuspid valve.
all its main branches ; the
artery
to the node much
Intra ventricular septum (high-power objective). 1, Remnants of cardiac muscle ; B’, fibrosed left branch of the bundle ; 3, ventricular muscle ; 4, remains of bundle ; 5, fibrous tissue ; 6, artery to the bundle, much thickened.
by the
main branches of the
a.-v.
bundle.
A few
thickened : muscle of right auricle fibrotic, the small fibres still recognisable as cardiac muscle can be vessels thickened ; thereare small areas of peri- found in the bundle, but no muscular connexion vascular cardium.
lymphocytosis.
Some
thickening of
endo-
Septal Block.-Lower part of auricular septum taken vertically from coronary sinus side backwards ; each section 15µ thick, and every tenth section out and cut
mounted. Sub-endocardial fibrosis on both sides of inter-auricular septum reaching on the right from level of mouth of coronary sinus to base of tricuspid valve ; on left fibrosis includes lower fibres of left auricular muscle where they are inserted into the central fibrous body. Muscle passing down into base of tricuspid valve also replaced by fibrous tissue. Central fibrous body much elongated and appears to have been pulled out. It extends much higher than usual and, to a large extent, has been replaced by newly-formed fibrous tissue; at several points active lymphocytosis is going on. Lower part of interauricular septum contains a large amount of fat which appears to have replaced the bundles of muscle usually rtiet with in this area ; a thin layer of muscle passing down on each side of the septum just below the thickened and fibrosed endocardium. In this pad of fat are a few fibrosed strands of muscle fibres-all that remains of the tangle of muscle fibres, constituting the a.-v. node, and normally found just below the mouth of the coronary sinus. Traced backwards through the series of sections, this pad of fat pierces the central fibrous body in the same way and in the same place as the " bundle." and certainly represents all that is left of the bundle of His. Vessels accompany it; one, a well-marked artery, is the artery to the bundle and is much thickened, chiefly from proliferation of the intima. Tracing on through the series it breaks off from the auricular side and comes to lie wholly inside the central fibrous body, and later dividing into two branches ; one passing down the left surface of the inter-ventricular septum just beneath the endocardium, the other passing down between the bundles of ventricular muscle on the right side of septum in the positions, that is to say, usually occupied was
traceable from the bundle into either of its branches, the upper part of the branches being composed of fibrous tissue ; lower down in these branches healthy fibres begin to appear, and still lower they are quite normal. (Figs. 1 and 2.) Apical and Basal Blocks from each TTeyatricle.-All healthy, except block from base of left ventricle, which showed marked thickening of coronary artery which was almost occluded. Right and Left Auricular Appendices.—Nothing abnormal found. Remarks. In the absence of tracings the case was diagnosed as one of syphilitic heart-block. Post mortem, complete destruction of the bundle of His was found ; the junctional tissues had been picked out for attack and the damage was almost confined to this area, the whole bundle being destroyed, even to the upper part of its two main branches. The heart had evidently been contracting for some years with no connecting link between the auricles and ventricles ; in other words, the stimulus for the ventricular contractions had been arising from some part of the bundle, and the rhythm was what is termed the idioventricular rhythm. Cessation of ventricular action occurred because the fibrosis finally cut the ventricles off from this last stimulus-producing area, and no further stimulus for contraction could reach the ventricular muscle.
AN ITALIAN CONGRESS
OF
MEDICAL RADIOLOGY.-
The fourth Italian Congress of Medical Radiology (general secretary, Prof. Mario Ponzio, Ospedale Mauriziano, Turin) will take place in Bologna on May 9th, lOth, and llth next, in the Orthopaedic Institute, Rizzoli, under the presidency of Prof. Aristide Busi. Annexed to the Congress an exhibition of radiological apparatus will be held, in which foreign Information can as well as Italian firms can participate. be obtained from Dr. Alberto Possati, Villa Verde, Bologna., secretary of the Congress.