325

in the tissue spaces was eliminated as far as possibleby giving Mercupurin intravenously. The operationswere done under oxygen and ether by the intra-tracheal method, so that positive pressure was

available in the event of laceration of the left pleuralreflexion. The pericardium was exposed by resectionof the second to the fifth costal cartilages togetherwith short segments of the corresponding ribs on theleft side, and it is Heuer’s practice to preserve theperichondrium and periosteum. He finds it possibleafter freeing the pleura from the left surface of thepericardium to obtain access to the right surface ofthe heart by depressing the heart so that there is aspace between it and the sternum. The pericardiumis incised over the left ventricle. This chamber isfreed and then the dissection is carried out over theright ventricle. No attempt is made to free thepericardium above the level of the auriculo-ventricularsulcus. The wound is closed without drainage.Several interesting facts emerge from the detailedcase-histories. In one instance microscopical examina-tion showed that operation had been done for atuberculous pericarditis, yet contrary to generalexperience the patient was cured. In another patientimprovement was gradual and the cardiovascularderangement did not completely disappear for a yearbut more usually the effects of the operation wereimmediate. This is one of the few procedures, eithermedical or surgical, capable of transforming a bed-ridden patient into a man fit to engage in vigorousathletics.

NERVOUS COMPLICATIONS OF SULPHONAMIDE

THERAPY

ADVANCES in chemotherapy seem inevitably to befollowed by a tale of sporadic mishaps, and thesulphonamides have not enjoyed exemption in thisrespect. A variety of complications have been

reported ranging from blood changes, such as sulp-hsemoglobinaemia, acidosis, ansemia and leucopenia,to skin rashes of different kinds with or withoutfeatures suggestive of serum-sickness, and these havelately been reviewed by Holman and Duff. Theircomment that the nervous system in man is in generallittle affected by these drugs is undoubtedly correct,but Dr. J. H. Fisher and Dr. J. R. Gilmour show intheir paper on p. 301 of this issue that the centralnervous system is not immune. Their fatal case isof considerable pathological interest in that the spinalcord, which alone was affected, showed changes thathave previously been described after antirabic treat-ment and spinal anaesthesia and in encephalomyelitisfollowing smallpox. Perivascular areas of demye-lination were a conspicuous feature. That thesewere secondary to vascular damage is stronglysuggested by the necrosis and inflammatory infiltra-tion of certain of the thrombosed vessels. Themassive softening of the lumbar enlargement is thusexplicable as an infarct and the term myelomalaciais a suitable term for this condition rather thanmyelitis, which implies a primary inflammation.Why such a pathological sequence should crop up

as a rare complication of some disease or form oftherapy it is difficult to understand ; in attributingit to idiosyncrasy we advance no further. It hasbeen argued that such reactions are allergic. Whilethis explanation does not cover all the observedfacts in the reported cases it may reasonably beadvanced in connexion with Fisher’s two patients.In these symptoms of nervous complications arose

1. Holman, W. L., and Duff, G. L., Amer. J. med. Sci. 1938,195, 379.

14 and 6 days respectively after the administrationof sulphonamide was begun, a period at which anantigen-antibody reaction might be anticipated. Thepossibility that the sulphonamides may have someantigenic effect can hardly be doubted in view of thedemonstrations by Landsteiner and his co-workersof such properties in organic compounds of relativelysimple composition, notably the arsphenamines. Thepathogenesis of the encephalomyelitis that maycomplicate vaccination, smallpox and measles hasnever been satisfactorily elucidated. Efforts todemonstrate virus activity by transmission experi-ments have failed and have failed once more inFisher’s first case. The possibility that all theseconditions are dependent on sensitisation has beensuggested on clinical grounds and deserves furtherconsideration.

JOHNS HOPKINS JUBILEE

IN May, 1889, the Johns Hopkins Hospital wasopened and fifty years later its famous Bulletin 1

has reprinted the addresses given at the opening bythe three men who translated Hopkins’s ideas intofact. Johns Hopkins, as Francis King, John Billingsand Daniel Gilman told their audience, wished thathis hospital should compare favourably with anyin his own country or Europe. He was careful toleave his trustees almost entire freedom in theirmethods and designs. In two things only he antici-pated their decisions ; he provided a splendid siteand willed that his hospital and medical school shouldconstitute the medical department of his university.The board of trustees were worthy of his confidence.As we look back on this half-century and read intheir own words the hopes and aims which inspiredthem there rise again to our minds the old familiarphrases-" Wisdom hath builded her house ; shehath hewn out the seven pillars.... through wisdomis an house builded, and by understanding it isestablished ; and by knowledge shall the chambersbe filled with all precious and pleasant riches." Thefame of Johns Hopkins has gone out into all lands,and the aims and inspiration of the founder and histrustees have proved a beneficent stimulus to medicinethroughout the civilised world. Johns Hopkinsdreamed a dream, as did Rahere in an earlier century,and his dream has been translated to the great hos-pital which, like Milton’s eagle, now " mews his

mighty youth."BILATERAL PLEURAL EFFUSIONDIL..J.B I I:.nJ.BL. rL.I:.U nJ.BL. 1:.1’" I’" Ui:)IVI’I

AT any stage of tuberculosis bilateral pleuraleffusion may occur, but setting aside tuberculous

polyserositis and winter influenzal outbreaks intuberculous persons the condition has not often beendescribed. As a complication of chronic pulmonarytuberculosis it is rare, because the pleural cavitybecomes partially or wholly obliterated by adhesionsfrom repeated attacks of dry pleurisy. Many yearsago Wilson Fox noted that 4 per cent. of his cases ofphthisis had bilateral pleurisy. Wilson has recentlyreported ten instances of bilateral pleural effusionaccompanying pulmonary tuberculosis in a series of1552 persons admitted to the Gayford Farm Sana-torium, Connecticut, during a ten-year period 1928-38.In seven there was definite involvement of both lungsbeneath, three having pericardial involvement, onea peritoneal effusion also, and another concomitantbone and joint tuberculosis. A coincident effusioninto the pericardial sac is not surprising and merely

1. Bull. Johns Hopk. Hosp. 1939, 65, 3.2. Wilson, G. C., Amer. Rev. Tuberc. 1939, 39, 745.