SURGERY OF THE HEART Removal of Foreign Bodies Retained in the Heart Wall. —The safety of the methods of surgical approach to the heart has been demonstrated. Surgeons in many countries have removed war missiles from the wall of the heart and from the pericardium with a surprisingly small mortality. R. le Fort (Bull. et Mem. Acad. de Med., vol. 8o, p. 147, 191 8) removed r r foreign bodies from nine patients, with one death. Roberts successfully removed a bullet from the posterior wall of the left ventricle, which had been present for seven years and was causing cardiac disturbance. The approach by resection of one rib and traversing the pleura was excellent. He had also removed four fragments of shell from the pericardium in four patients by the same route, with no mortality.
Operations for Stenosis of the Valvular Orifices of the Heart.—A new field for surgery in the treatment of what has for long been a purely medical subject is being opened up by work which has hitherto been largely experimental. The subject is still in its infancy, but enough has been done to show that with further experience certain selected cases of mitral stenosis, in which the musculature of the heart has not been too much dam aged, may be submitted to operation with a fair prospect of improvement. Duff S. Allen and E. A. Graham (Jour. Amer. Med. Assoc., Sept. 23, 1922, and Arch. of Surg., Jan. 1924) have in vented an instrument which they call a cardioscope. This is a tube, closed at one end by a lens, which is introduced into the heart through a small incision. When the lens is pressed against the heart wall so that no blood intervenes, the endocardium, illuminated by a small electric bulb, is clearly visible. In the wall of the tube is fitted a rod ending in a small knife, with which a stenosed valve may be incised under direct vision. In dogs, when the incision to introduce the cardioscope was made in the auricu lar appendix, all the dogs recovered. E. C. Cutler and S. A. L. Levine (The Boston Med. and Surg. Jour., June 28, 1923), be lieving that a mere incision in the stenosed ring will heal without relief of the stenosis, invented an instrument which punches out a piece of tissue.
They have used this successfully in the case of a girl, aged 12, suffering from mitral stenosis. She was alive 10 months later and was still improving. H. S. Souttar (Brit. Med. Jour., Oct. 3, 1925) reports a brilliant operation on a girl of 15 with mitral stenosis and regurgitation. He exposed the heart by a flap opera tion, and placed a light clamp on the base of the auricular ap pendix. After two guide sutures had been inserted, the appendix was incised and drawn over the finger like a glove, haemorrhage being thus obviated. The interior of the auricle was easily explored by the finger, no effect on the pulse being noted. The blood pres sure instantly fell to zero as the passage of blood through the orifice was abolished. Souttar intended to divide the stenosed orifice with a knife passed along the finger, but as the stenosis was found to be of moderate degree with little thickening of the valve, he contented himself with stretching the orifice with the finger. The appendage was ligated at its base and the wound of the chest wall closed. The patient's condition was improved and she was well three months later, though still somewhat breathless on exertion.
Jonnesco, of Bucharest, in 1916 first performed the removal of the left cervical sympathetic chain, including the upper and middle cervical ganglia and the first thoracic ganglion. The result, fol lowed for four years, was complete relief from symptons. T. Jonnesco operates under spinal anaesthesia (La Presse Med., April 26, 1922). W. B. Coffey and P. K. Brown (Arch. Int. Med., vol. 31, p. 200, 1923) report six cases with one death and great improvement in the other five, H. Lilienthal (Arch. of Surg., vol. 10, p. 531, 1925) three cases. In one, the cervical sympathetic was removed on both sides. All were cured. H. H. Kerr (Ann. of Surg., vol. 82, P. 3J4, 192 5) reports five cases. He removes the superior cervical ganglion only, under local infiltration anaesthesia by novocain, and obtains the same results as the others by the more formidable operation performed by Jonnesco.