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346 support as presidential candidate at the National Democratic Convention. In 1905 he was Democratic candidate for mayor of New York on the Municipal Ownership ticket, and four years later on the Independence League ticket; in 1906 he was candidate for governor of New York on the Democratic and Independence League tickets, in every instance being defeated. He strongly opposed the League of Nations.

HEART AND LUNG SURGERY. In recent years notable ad- vances have been made in the surgery of the heart and lung.

1. HEART. It has been proved experimentally and verified by actual experience of operations in man that the heart may be safely handled, incised, and sutured; and cardiac surgery, thought to be impossible 30 years ago, had by 1921 achieved many striking successes. Operation on the pericardium and heart is undertaken (i) for the relief of pericardia! effusion, serous, purulent or haemorrhagic ; (2) for releasing pericardial adhesions; (3) for injuries and the removal of foreign bodies; (4) for the reanimation of a heart which has ceased to beat. (5) It has been proposed and attempted for the relief of certain valvular lesions, and for (6) tumours of the heart.

Pericardial effusion. When it is decided to evacuate the contents of the pericardium it should be exposed and a sufficient incision made in it; paracentesis of the pericardium is uncertain and dan- gerous; as an operation it should be abandoned, though the cautious use of an exploring needle for diagnostic purposes may occasionally be desirable. Especially when the effusion is purulent every en- deavour should be made to avoid opening a healthy pleura. The extent to which the pericardium is overlapped by the pleura varies considerably, but, according to Voinitch, there is invariably a triangular area of safety at the inner end of the 6th and 7th left costal cartilages. Pericardial effusion by no means always displaces the reflection of the pleura, but the surgeon can generally recognize the pleura and push it aside.

The lower the opening in the pericardium the better the drainage. Mintz (Zentralblatt fur Chir., 1904, p. 59) opened the pericardium in a case of suppurative pericarditis after resecting the 5th costal car- tilage, and at once decided to drain it from below. He made an incision along the lower border of the 7th cartilage, separated the attachments of the abdominal muscles and of the diaphragm and continued blunt dissection until he reached the pericardium, which he then incised on a probe introduced through the upper wound. In the operation he subsequently advised the patient is placed with the chest somewhat raised ; the surgeon, standing on the right, makes an incision along the lower border of the left 7th costal cartilage ex- tending 7 or 8 cm. outwards from the costo-ziphoid angle. The abdominal muscles are disinserted and the cartilage divided at each end of the wound, the diaphragm is next disinserted and the cartilage and skin retracted upwards. The prolongation of the internal mam- mary artery is seen and tied or displaced. The anterior inferior angle of the pleura is identified and avoided, and, nearer the median line, the pericardium is defined and incised.

In the operation recommended by Voinitch the left 6th and 7th cartilages and the adjoining edge of the sternum are resected.

Delorme and Mignon (Rev. de Chi., 1895) give the following direc- tions for opening the pericardium: (i) Make a vertical incision I cm. external to the left border of the sternum from the lower border of the 7th to the upper border of the 4th costal cartilage. (2) Dissect off soft parts from ribs and cartilages for I cm. towards middle line and for two fingers breadth outwards. (3) Disarticulate and resect a piece of 5th and of 6th cartilage. (4) Carry the incision through intercostal muscles and perichondrium down to triangularis sterni. (5) With a director worked parallel to posterior surface of sternum detach insertions of triangularis sterni, introduce finger and com- pletely detach soft parts from posterior surface of sternum, seek the pericardium just above the insertion of the cartilages into the ster- num and separate it with the finger from the cellular tissue which covers it, then, when its opaque surface is clearly exposed and its transverse fibres recognized, continue the separation through the whole extent of the wound. Thus the pleura and the internal mam- mary artery are displaced outwards and are not seen. (6) Pick up the pericardium with forceps and incise it. These methods or some modification of them are those recommended for the surgical treat- ment of pericardial effusion, but they are not suitable as the first stage of operation on the heart itself.

Cardiolysis. Intra-pericardial separation of adhesions (endo- pericardial cardiolysis) has been suggested, but its possible utility is not apparent. Extra-pericardial cardiolysis in which adhesions between the pericardium and the mediastinal tissues are separated is more likely to be useful. It has been proposed to introduce a graft of fat or of fascia lata to prevent fresh adhesions.

Pericardial thoracolysis, in which adhesions between the peri- cardium and the chest wall are separated and portions of ribs or costal cartilages excised, is an operation designed to free the heart from the rigid chest wall in front and to relieve an enlarging heart

from compression in a too confined space. Good results have been obtained. The first operations of this kind were done in 1902 by Peterson and Simon at the suggestion of Brauer. Thorburn of Manchester (Brit. Med. Journ., 1910, vol. i., p. 10) discusses the question and gives a table of 15 cases collected from literature. He relates one case done by himself and refers to two other operations by Stabb at the suggestion of Alexr. Morrison.

Heart Wounds. The course and symptoms of heart wounds vary considerably. Instantaneous death may result from a quite small wound, and extensive injuries may be brought for treatment. Under war conditions most cases die on the field of battle with the symp- toms so long ago described by Celsus (V. 26. 8.) : " When the heart is wounded much blood is poured out, the pulse fails, pallor becomes extreme, the body is bedewed with cold and ill-smelling sweat, the extremities become chilled and speedy death ensues."

When seen the diagnosis may be obvious, or difficult and uncer- tain. The symptoms may be severe and the injury to the heart nil; thus Tuffier remarks, " the case in which the diagnosis of wound of the heart seemed to us the most obvious and the most clearly demonstrated by the situation of the wound and the grave condition of the patient was that of a woman in whom the revolver bullet had not even penetrated the thorax." This was probably an in- stance of contusion of the heart and analogous to the phenomenon of arterial paralysis. When the initial symptoms have subsided and the external haemorrhage has ceased the diagnosis is based upon the history of the case, the situation of the external wound and the signs of haemo-pericardium or haemothorax, or of .a foreign body.

The classical signs of pericardial effusion are: the cardiac impulse and sounds are feeble or imperceptible and the area of cardiac dull- ness is enlarged ; sometimes abnormal (pericardial) sounds can be heard, of these that known as the mill-wheel sound (bruit de moulin) has been much discussed ; it is chiefly associated with air and fluid in the pericardium and was for a time thought to be pathognomic. It is thus described in a work by Stokes published in 1854: " They were not the rasping sounds of indurated lymph, or the leather creak of Collin, nor those proceeding from pericarditis with valvular murmur, but a mixture of the various attrition murmurs with a large crepitating and gurgling sound, while to all these phenomena was added a distinct metallic character."

Sudden distension of the pericardium with blood is a great surgical emergency. The auricles are compressed and signs of venous ob- struction appear; there is great dyspnoea with cyanosis. The res- piration is laboured and shallow and the pulse small, rapid and of low tension. It is urgent freely to open the pericardium and to decompress the heart.

In purulent pericarditis the upper segments of both recti may be rigid, and there may be a narrow band of oedema round the front and left side of the trunk about the level of the 5th interspace. The present writer has seen this band of oedema and has known sup- purative pericarditis to be mistaken for inflammation below the dia- phragm. Absence of diaphragmatic movement suggests pus in con- tact with the diaphragm. In pericarditis with effusion the right lobe of the liver is low; in dilatation of the heart the right lobe of the liver is not depressed. Many observers have found a small area of dullness in the left back just internal to the angle of the scapula, a purulent pericardial effusion has been tappecT from the back in mistake for an empyema. The early diagnosis of purulent peri- carditis is greatly assisted by X-ray examination and by the blood- count. These should never be omitted.

Bullets and other foreign bodies may lodge in the pericardium or in the heart muscle or in one of the cavities, in which it may become fixed or remain freely movable. Sometimes few or no symptoms are observed, and their presence is only demonstrated by radiography ; sometimes they cause more or less frequent and severe attacks of pain and syncope, and give rise to abnormal sounds. Only by radi- ography can an accurate diagnosis be made.

The story of the wanderings of bullets and other foreign bodies in the vascular system of man is very remarkable. A bullet may per- forate the heart or aorta without causing fatal haemorrhage.

A bullet may enter the hepatic vein or vena cava and pios on into the right ventricle, or enter a pulmonary vein and lodge in the left ventricle. Or it may enter the inferior vena cava and be carried by gravity against the blood current and be arrested in an iliac vein, or again a bullet may be expelled from the left ventricle into the aorta and travel with the blood current and be arrested in an artery, or from the right ventricle may be ejected into the pulmonary artery. In several cases during the World War the course of the projectile has been followed by radiography, and removed by opera- tion from the vessel in which it became arrested.

Operations for injury and the removal of foreign bodies The operation must be so planned that free access to the heart is ob- tained and that any required operation on it can be carried out. We have to consider (a) the exposure of the heart ; (b) the surgical manip- ulation of the heart ; (c) the control of haemorrhage ; (d) drainage of the pericardium.

The chief methods of opening the chest for exposure of the heart which have been successfully utilized are as follows :

I. The various forms of flap operation of which the Delorme- Mignon-Kocher operation may be taken as a type: a vertical in- cision is made down the middle of the sternum from the level of the