Gunnar Biörck

Unusual cyanosis in a boy with congenital pulmonary stenosis and tricuspid insufficiency. Fatal outcome after angiocardiography

Abstract A case of congenital pulmonary stenosis with tricuspid insufficiency and a peculiar type of cyanosis in an 19-year-old boy is described. The patient died in connection with angiocardiography. At autopsy, the clinical diagnosis was verified; in addition to the cardiac lesion there was a malignant carcinoid of the jejunum with metastases to the liver. The findings are briefly discussed and an explanation of the type of cyanosis is suggested.

Pulmonary circulatory dynamics in mitral stenosis before and after commissurotomy

Abstract 1.1. Forty-six cases of mitral stenosis were operated upon by digital commissurotomy. No case was in right heart failure. No other valvular lesions of important degree were demonstrated. Seven cases died in direct connection with the operation. 2.2. All cases were studied with the heart catheterization technique before and about six weeks after operation. The response to slight, graded work was also studied before and after valvulotomy in eleven cases. 3.3. The best objective results from operation were obtained in cases below the age of 45 years, with sinus rhythm and heart size less than 600 ml/m 2 B.S.A. and symptoms corresponding to Group III or IV. 4.4. Commissurotomy has afforded beneficial results to many cases of mitral stenosis, suggesting further operative treatment of this disease: Thorough hemodynamic studies are still needed to form proper indications and contraindications.

Studies in mitral stenosis: VI. Pulmonary vessels in mitral stenosis

Abstract 1. 1. The first fifty consecutive patients operated upon for mitral stenosis by the same surgeon were analyzed as to the state of the lungs preoperatively, pulmonary complications at the time of operation, and present results of the surgical intervention. 2. 2. Pulmonary complications were regarded as the predominant cause of postoperative disturbances and deaths. The reasons for this are discussed. 3. 3. In the majority of patients a biopsy of the lingula was obtained for histologic study at the time of operation. The findings at preoperative examinations of the lungs were correlated with the histologic findings. The value of the various examinations was analyzed and evaluated on the basis of structural changes of the lung. 4. 4. All fatal cases and the majority of patients with severe pulmonary complications showed pulmonary changes histologically. In our material, morphologically abnormal lungs have proved to be particularly vulnerable in connection with operation. If the pulmonary complications are overcome, however, the prospect of a satisfactory response is as good in this group as in the other. 5. 5. Angiopulmography was carried out in most patients and yields more pathologic findings than do the lingula biopsies. There is a good agreement between the findings of these two examinations in spite of the fact that they cover different parts of the pulmonary structure. The reason for this correlation is discussed and the value of angiopulmography for the evaluation of changes in the pulmonary vessels is emphasized. Pathologic angiopulmograms seem to occur more often and earlier than the structural changes in the lungs. Chest radiograms yield less information and are difficult to evaluate. As pulmonary complications were more frequent in the biopsied group and the lingula biopsies in general gave little additional information, this procedure is now abandoned. 6. 6. Among other clinical examinations carried out in order to evaluate the state of the lungs, the arterial oxygen saturation level was found most informative. A decreased oxygen saturation occurred only with concomitant morphologic changes. Data as P.V.R. and cardiac index, as well as duration of symptoms, age, and functional group of the patients were of moderate value, whereas mean pulmonary arterial pressure and the remaining data referred to in this paper were noninformative. 7. 7. The further development of preoperative functional pulmonary tests is emphasized.

Studies in mitral stenosis. II. Observations on incidence of active rheumatic carditis in left auricular appendages resected at operation for mitral stenosis

Abstract The possibilities of clinical and laboratory diagnosis of active rheumatic processes in the heart of each patient to be operated upon for mitral stenosis are discussed on the basis of biopsies from left auricular appendages, resected at operations for mitral stenosis. Rheumatic activity was found to be present in spite of negative clinical and laboratory findings. Pathologic sedimentation rate or antistreptolysin titers alone should not be regarded as positive evidence of such activity. Long-term follow-ups are necessary to evaluate the importance of active rheumatic endocarditis for the prognosis in operated cases of mitral stenosis.

Studies in mitral stenosis. IV: The relative merits of various diagnostic methods in mitral valvular disease☆

Abstract In order to investigate which diagnostic signs were most useful for the evaluation of the degree of mitral regurgitation in cases of mitral valvular disease, several methods were employed in a number of candidates for mitral valvulotomy. These methods were: palpation of the apex beat, auscultation, standard and unipolar electrocardiography, electrokymography, roentgenography of the heart, angiocardiography, and cardiac catheterization. In addition, ballistocardiograms were recorded in some patients and determinations of circulation time with Decholin were made. The individual methods were put to a scoring test, the results of which are tabulated and discussed. Since auscultation of cardiac murmurs was found to be most informative, a more detailed stating of the often rather vague diagnostic criteria given in the literature has been advanced for the purpose of further discussion. The possibility that the size of the mitral orifice and the degree of regurgitation may not always parallel each other has been discussed and the need for a differentiation here has been stressed.

Studies in mitral stenosis. III. Observations on the incidence and distribution of cerebral emboli with regard to the possibilities of their prevention during operative procedures

Investigations have been carried out on autopsy material, and experimentally on rabbits, in order to ascertain whether cerebral emboli are equally distributed in the right and left hemispheres. Both the autopsy material and the experiments showed that the distribution is even and that no significant predominance of one vessel to the other exists.

Contribution of the coronary arteriogram to diagnosis of coronary heart disease

Abstract Sixty-five patients were studied by coronary arteriography over a period of three years in order to analyze the relation between the roentgenologic findings and the presence or absence of “typical” anginal pain and ischemie electrocardiographie change. Complications caused by the examination were rare and nonfatal. In 34 of 35 patients with typical anginal pain together with an ischemie electrocardiographic pattern, the coronary arteriogram showed structural change. In 13 of 14 patients without the aforementioned clinical and electrocardiographic features, no arterial change was visible. In 16 patients whose clinical history and electrocardiographic patterns were dissociated, arterial change was present in 9. The results suggest that coronary arteriography can provide an important clue to the diagnosis of coronary heart disease. Appraisal of the prognostic value of coronary arteriography is important and must await follow-up examinations.

The Doctor's Job. Looking Ahead to the Computer

of the problems that are now facing Swedish medical education, I recently observed: ‘The physician almost regardless of where he is working is a person whose main activity is one of making decisions. Every patient is a problem of decision, every ward round is a long series of decisions, often on the basis of very fragmentary data, or very cursory presentation of facts. This is the core of our job, yet we are rarely told about it during our training, and there ought to be in the medical curriculum a subject which might be called “professional technique’’ in which we should study the process of our own work.’