CONVALESCENT HOMES ASSOCIATION.

625 the membranous space and run through the musculature of operation wounds and to the inadequacy of the present conthe septum to the Eustachian (g) and Thebesian (A) valves valescent system to supply the increasing needs of hospitals. and are of importance because they undoubtedly represent Lord Lytton’s remedy was to collect a large sum of money the lower or auricular fornix of the right and left venous to build and endow a small convalescent hospital of 21 beds. valves which guard the orifice of the sinus venosus of the It has been considered that the same objects could be better embryonic heart and which therefore inform us that the and more economically attained if the existing convalescent orifice of the sinus venosus in the human heart reached homes could be persuaded to devote some beds to this special forwards as far as the membranous space. Out of 12 purpose. This will no doubt entail additional expenditure hearts I was able to dissect out the bundle of His on the part of the convalescent homes but we are assured in three of them by the naked eye; fresh hearts that many hospitals would be willing to secure these inare useless; specimens must be hardened in a 5 per creased benefits by paying a higher rate for their convalescent cent. solution of formalin; those which have been treated surgical patients. In the’case of homes that are willing to by the Kaiserling method serve very well for the pur- provide such special beds but unable to do so for want of pose. The position of the bundle is shown in the figure funds, an appeal may well be made to the charitable public (e, f). I found it best to begin by cutting the base of the for further support. A constitution and rules have been formulated and an septal cusp in line with the inferior margin of the ventricular part of the membranous space and then raising the fibrous executive committee is engaged in carrying out the objects The council has found that there is tissue covering that margin ; it is beneath the fibrous of the association. tissue that the bundle of His terminates (f). At the some hesitation on the part of both convalescent homes and base of the septal cusp the bundle perforates the central hospitals to become members. It is thought that this may fibrous body of the heart and joins the musculature of the be due in a measure to misapprehension as to the ultimate Tawara traced it to the musculature of objects in view, groundless suspicion on the part of some auricular canal. the sinous venosus, but in the three cases in which I success- homes that their independence of management will be interfully followed it the bundle joined the supel ficial fibres of fered with, and doubts on the part of hospitals as to the the auricular canal, as is hown in the accompanying figure. benefits they will obtain. The initial efforts of the associaHaving learned the exact position of the bundle I cut out, tion have already been attended with success, the offer of for microscopical examination, the auriculo-ventricular part beds for surgical cases having been obtained from some of the of the cardiac septum which contains the membranous space more important homes’, ard it is believed that, with time, a and the adjoining muscular tissue in which the bundle of very much larger number of special beds will become We contend that, in this direction alone, His lies, and placed the block so cut out on the microtome, available. so that the inferior margin of the membranous space lay in the Convalescent Homes Association will confer a benefit the plane of section. When cut in this plane I found a upon every London hospital and relieve the congestion that bundle of auricular fibres perforating the central fibrous prevails, and, moreover, the influence of the association body in each one of the five hearts examined. The auricular will be exerted in many ways to discourage the use of confibres of this bundle are, as Tawara described, fine, multi- valescent institutions as holiday homes and to promote nucleated with indistinct striation ; I observed also, as he economy and concerted action. The work of the association did, that the fibres were accompanied by numerous nerve cannot be carried on without a small expenditure and if a fibres, and there are cells, too, which have the appearance larger number of homes and hospitals would join and pay of ganglionic nerve cells. A large artery (with a calibre of the small subscription proposed we feel sure that the benefits 1 to 1. 5 millimetres) invariably perforates the central fibrous their patients would derive would amply repay them. Up to the present a considerable number of convalescent body just behind the bundle ; the artery is always bigger homes have joined and amongst the hospitals are St. Barthan the muscular bundle at the point of perforation. In my previous search I had looked for a complete con- tholomew’s, St. Thomas’s, and King’s College. We shall be tinuity of the auricular and ventricular fibres. As Tawara glad to receive applications from any convalescent home or asserts, there is no direct continuity of ordinary auricular any hospital which is willing to join us in securing the and ventricular muscular fibres. The auricular bundle, above-mentioned advantages for patients in need of them. after perforating the central fibrous body, ends in a layer or Communications should be addressed to the secretary of the collection of cells which are of peculiar type and resemble Convalescent Homes Association at 32, Sackville-street, W. We are, Sirs, your obedient servants, Purkinje’s cells, but I cannot trace the wide subendocardial W. S. CHURCH, distribution of these cells which has been described by Chairman. Tawara. Thus it will be seen that at the point where M. O. 0. FITZGERALD, the to sections of are made experimental septum produce S. H. HABERSHON, arhythmia of the cardiac chambers there is not only a Feb. 27th, 1906. Honorary Secretaries. muscular bundle but nerves and a large artery; how much of the result of section is due to cutting of the adjacent structures is certainly a point which should be AN AFTER-CARE DESIDERATUM. investigated. If the bundle of His commenced in the coroTo the Editors of THE LANCET. nary sinus, a direct remnant of the sinus venosus, then one would expect the wave of contraction, which spreads from SIRS,-One of the speakers at the recent meeting of the the sinus to the rest of the auricle, to reach the ventricle After-care Association offered a suggestion which appears almost as soon as the auricle. On the other hand, if it arises well worth the consideration of the authorities of county from fibres of the auricular canal, the last part of the asylums and of those generally concerned with the adminisauricle to contract, then the spread of the contraction wave tration of the lunacy laws. The After-care Association is a small body with very limited means but it has proved itself through this bundle becomes more easily understood. An investigation into the development of the bundle of the pioneer of a system of the greatest advantage in securing His and into its comparative anatomy will probably help us the completion of the cure in persons who have been disbetter to understand its nature. The fibrous tissue between charged from county asylums. There may be a great differthe mitral and tricuspid valves, which is perforated by the ence between the person who leaves an asylum actually bundle, is believed to be formed from the endocardial recovered and the one who is only recovered in a legal cushions ; if this belief is rightly founded then the bundle sense. The latter having lost all the symptoms of the insanity of His would appear to be developed by the formation of a for which he was placed under certificates cannot be further new muscular connexion between auricle and ventricle. immured. However advisable it is that he should have the I am, Sirs, yours faithfully, benefit for a shorter or longer time of fresh air and good food A. KEITH. he cannot be detained, partly because he is legally well and London Hospital Medical College, E., Feb. 3rd, 1906. partly because of the pressure on the accommodation ; moreover, it is not always clinically advisable that a patient who has for the time recovered the use of his mental faculties should CONVALESCENT HOMES ASSOCIATION. remain associated with those who are still impaired ; nor is it To the Editors of THE LANCET. right that he should remain longer than is necessary under SIRS,—We should be glad to be allowed to recall the the fetters of certificates. Some of these discharged patients circumstances under which the Convalescent Homes Asso- are taken up by the After care Association to go through a ciation was founded. We owe much to Lord Lytton and his process of annealing which shall fit them for their life duties, committee of the Home of Recovery for calling attention to shall improve their bodily condition, and prevent the the great need for more beds for surgical convalescents after tendency to a relapse. But good as the objects of the society