Paul Wood

Congenital Heart Disease.—I

The size of the pulmonary arteries, measured intraoperatively, was correlated with operative mortality in 90 patients who underwent the Fontan operation. There was no significant difference in the cross-sectional area of the right and left pulmonary arteries/body surface area (PA index) between survivors and nonsurvivors. There was no significant difference in mortality rates between patients with a PA index greater than 250 and those with a PA index less than 250 mm2/m.2 Survival was observed with cross-sectional area as low as 188 mm2/m2. Circulation 72 (suppl II), II-93, 1985. IN 1971, Fontan and Baudet described a new surgical technique used successfully in the treatment of two patients with congenital tricuspid atresia. Since then, the Fontan operation and its various modifications have been used extensively for the surgical treatment of this lesion23 and other more complex malformations.4 5 Since initial use of the procedure, Fontan and associates6 have established criteria for selection of patients with tricuspid atresia, which, in their hands, have yielded good clinical results. Included among the various clinical, hemodynamic, and anatomic criteria was the requirement that the pulmonary valve anulus and pulmonary arteries be of normal size. In this light, Nakata et al.7 presented data suggesting that if the combined cross-sectional area of the right and left pulmonary arteries as determined from the angiocardiogram was less than 250 mm2/m2, the Fontan operation should not be done. It is important that the relationship of pulmonary size to the results of the Fontan operation be defined as accurately as possible to avoid the excessive risk of performing a Fontan procedure in patients whose pulmonary arteries are too small and to avoid withholding the operation in patients whose pulmonary arteries are of adequate size. To evaluate further the relationship of pulmonary artery size to results of the Fontan operation, we retroFrom the Department of Pediatrics, Indiana University School of Medicine, Indianapolis, and the Mayo Clinic and Mayo Foundation, Rochester, MN. Address for correspondence: Donald A. Girod, M.D., Pediatric Cardiology, 702 Barnhill Dr., Indianapolis, IN 46223. Vol. 72 (suppl II), September 1985 spectively studied 90 cases of tricuspid atresia, univentricular heart, and other complex anomalies in which direct intraoperative measurements were made of the pulmonary arteries. These measurements were correlated with operative mortality. In this report, we present the results of this study and discuss their surgical implication.

Da Costa's Syndrome (or Effort Syndrome). Lecture II.

It is this sign above all others which has drawn attention to the heart, yet it is one of the commonest psychosomatic effects, occurring in every one of us under the influence of sufficient emotion. It h1as been recorded by all observers, and in my ownI series of 200 cases the pulse rate averaged 82 beats per minute (48 to 136) during casual examination in the day-time, compared -with 66 beats per minute (48 to 100) in 50 controls. During sleep, however, it is normal, averaginig 60 to 65 in Huines series (1918). It is customary to speak of the great lability of the pulse, which is said to accelerate unduly with change of posture, with effort, and with adrenaline. The evidence for this, however, is open to criticism. -Statements declaring that there is undue acceleration of the pulse rate on change of posture may be challenged directly, because the published figures do not show it, even those given by authors who make this yery statement. Thus in 36 children with effort syndrome Bass and Wessler (1913) found the difference between the lying anid standing pulse rates to average 7 beats per minute, which was the exact figure obtained by Lincoln (1928) in 320 controls aged between 3 and 13. In adult patients published figures are well within published control figures; they are hardly worth quoting, because little attention has been paid to the behaviour of the pulse on standing up. Douglas and I have found that the initial acceleration lasts for but nine to fifteen seconds in about two-thirds of patients and controls, and is followed by abrupt slowing. It is therefore necessary to count the pulse for the first ten seconds only, after the patient stands up, if the true speed at this time is wanted. In comparing patients with controls we took three readings: (1) during the first ten seconds as described; (2) during the second quarter-minute; (3) at the eind of the first minute. The results are recorded in Table IX, and show no essential difference. It is coIn-

Da Costa's Syndrome: Aetiology. Lecture III.

Practical points in the ordering, regulation, and measurement of feeds for bottle-fed babies are discussed, and methods of minimizing the risk of quantitative errors are indicated. The employment of feeds providing 20 calories per fluid ounce for all infants, unless there is some special contraindication, is strongly urged on the ground that thereby (a) there is a much-reduced -risk of quantitative mistakes for the infant, (b) feeding is greatly simplified for doctors and nurses, and (c) labour is lessened in childrens wards or day nurseries. Tables are given for the instruction of nurses in infant feeding. These can be adapted and shortened by the doctor in accordance with the type of feeding he habitually uses. It is hoped that feeding standardized to the extent here suggested may be widely adopted at the present time, for it offers a way of coping with the difficulty of ordering feeds for large numbers of babies brought into reception areas on feeds of every description. [The concluding part of this paper-giving practical points in the regulation of feeds during the neonatal period-will appear next week.]

Blast Injury to Abdomen by Depth Charge.

Ventilation.-When asphyxiated by failure of respiration or circulation these nerve cells gradually die-usually in a few minutes, but they may remain viable for an hour, rarely more. When they are dead all hope is gone. As they die, the elastic tone of the muscles-which they maintain-progressively declines. When the diaphragm has in this way lost all its tone the lungs contract by their own elasticity; they pull the diaphragm right up and become deflated (as in the warm cadaver). At this stage (1) Schiifers method has become impotent because the elastic recoil of the diaphragm (for inspiration) has gone; (2) Silvesters method will still produce some ventilation owing to elasticity in the thorax independent of its pectoral muscles; (3) the rocking method will effectively shift the flaccid diaphragm up and down independently of tone, and hence should save cases in which loss of tone had gonm too far for the Schafer method to revive. Circulation.-The heart muscle itself does not die quickly, for after drowning it can be revived by perfusion with oxygenated saline solution-a babys heart after several hours. The diagram shows how well the head-down tilt perfuses the coronaries. But in shock (hypotonia of muscles) the heart may also fail from mere emptiness because insufficient venous blood gets back to it through veins and capillaries unsupported by tone of muscles. Hence in drowning cases (always shocked) it is important to encourage venous return, as by the compression of abdominal veins which occurs in Schafers method or, far more potently, by the rocking method-as already explained. To fill the heart and respiratory centres with blood a head-down slope of about 10 degrees (1 in 6) should be chosen (as on a beach) for manual resuscitation when possible. To fill an empty heart is a quick way to restart it beating. When you tilt steeply to empty out wate, you incidentally fill the heart and change the coronary blood. Warmth.-This is indispensable in shock treatment generally-e.g., by hot-water bottles and blankets; also by impervious coverings, to prevent heat loss from evaporation and cold winds. Nerve cells are paralysed by cooling but revive at once on re-warming. With a crippled circulation the indispensable nerve cells in the upper spinal cord will quickly cool and their blood vessels constrict. Hence it may prove very important to warm the back of the neck by a rubber bag early in the resuscitation.

Cardiology for Beginners

Of all the organs of the body the eye is unique in the opportunities it provides for detailed clinical examination. Because of its ready accessibility and the transparency of its tissues the living structures can be studied in minute detail; changes which might be sacrificed in the mutilating techniques of the histologist may be rendered apparent, or minutiae which are not amenable to differential staining may be revealed by differences in optical properties. In this way the early signs of disease or the finer points of diagnostic or prognostic significance are determined in the eye with a certainty unobtainable in other organs. Not only is this of value to the ophthalmologist in determining the presence of local disease, but to the general clinician and the pathologist the opportunities thus provided by biomicroscQpy are equally great. Ophthalmology as a specialty has taken full advantage of these possibilities, and in the slit-lamp-the combination of focal illumination and an erect-image microscope-it has at its disposal a very efficient technical instrument. The late Alfred Vogt, of Zurich, who introduced the technique of obtaining brilliant and uniform optical sections of the ocular tissues with this instrument, has been the most enthusiastic exponent of the method, and by his unflagging industry and unusual clinical acumen has made immense contributions to ophthalmology in the third and fourth decades of this century. His observations were collected and systematized in his Atlas, the first edition of which appeared in 1921. The present volume is the third part of the greatly expanded second, edition. It contains an account of the iris, ciliary body, and conjunctiva, and includes an important contribution on the lens. The author minutely describes all the classical conditions, with an abundance of case histories lavishly illustrated, and makes in addition many new observations and new associations. This volume will long remain a classic of ophthalmology and is quite indispensable to those wanting detailed and authoritative references to the subjects of which it treats. A feature of the book is the emphasis on genetics and hereditary conditions, one of Vogts major interests. In this respect he has made a long-term study of the eyes of twins. His conclusions are of great interest-for example, that the microscopical details of the iris and their behaviour in old age are predetermined in the germ-plasms. Moreover, in the supplement to the study of the lens, based on an imposing amount of evidence of the same nature whereby identical changes shared by monozygous twins are considered to be hereditary while variations are due to exogenous influences, he concludes that senile cataract is a phenomenon of ageing determined hereditarily on an exact parallel with greying of the hair or wrinkling of the skin. He follows out the interesting suggestion that the influence of medicaments on the formation of cataract can best be controlled by administering the medicament to one twin, the other being used as a control. The three volumes of this Atlas probabiy constitute a reference work unique in medicine. It is a monument of accurate and detailed observation, lavishly produced, beautifully illustrated, and much of the thought is original. It is expensive to buy; but it is worth it. It is indeed a fitting memorial to one of the greatest clinical observers of our generation.

Erythrocyte Sedimentation Rate in Infective Hepatitis and Malaria

In his lucid and balanced survey of the problems confronting us concerning infective hepatitis Witts (1944) writes: A major difficulty in the pre-icteric stage is the differentiation from clinical malaria . . . and a simple laboratory test for infective hepatitis would be an immense help. It is the purpose of this short paper to show that in the erythrocyte sedimentation rate we already have such a test at our disposal, subject to its usual limitations, especially as an aid in the differentiation mentioned. The behaviour of the E.S.R. in 35 unselected cases of infective hepatitis was normal during the first week or ten days, whether there was fever or not. It rose slowly and steadily during the period of biliuria, to reach a maximum commonly between 15 and 30 mm. in one hour (Wintrobe). During the stage of recovery, when the urine was free from bile, the E.S.R. returned slowly to normal, a minority of cases showing further acceleration before this occurred. These conclusions were supported by sporadic readings in other cases, especially the fact that the E.S.R. was normal or low in the febrile or pre-icteric phase, and below 10 during the first week. The accompanying Graph depicts average readings on each day of the disease up to the twelfth day. The numeral above each reading indicates the number of cases from which an average was obtained. This graph does not distinguish febrile from afebrile cases. The behaviour of the E.S.R. in malaria is in sharp contrast. The Graph shows the average difference during the first 12 days, the malaria graph being constructed in the sameway as that just described for infective hepatitis. As no essential difference was observed between M.T. and B.T. cases, nor between fresh attacks and cases of relapse, they have all been shown as one group. The general trend was confirmed by single readings in other cases. The diagnosis rested on a positive blood smear in every instance, and treatment with quinine, gr. 10 t.d.s., was started as soon as it was made. It is not known whether this

The Coronary Circulation

No neurologists in recent years have made such extensive contributions to the study of localization of function in the human cerebral cortex as Dr. Penfield and his collaborators. They have availed themselves to a remarkable degree of the opportunities provided in the course of the surgical exposure of the brain, and in a series of papers over the last ten years they have recorded many important observations. These observations provide the main substance of the book which has now been written by Dr. Penfield and Dr. Rasmussen. Clearly it is in relation to sensory localization that this exploration of the human brain offers the most fruitful field of study, for the human patient is able to record the nature of his own sensations and thus provide evidence not possible in animal experimentation. At the same time, the method has peculiar difficulties of its own. The conscious patient undergoing an extensive craniotomy for the removal of part of the brain is obviously not in the most favourable condition to provide accurate reports, and it may be questioned how reliable are the answers which he can give to the surgeons questionings. In those cases reported by the authors in which a cortical lesion is combined with a definite psychosis the situation evidently presents much more serious difficulties. For this reason the reviewer feels the need for caution in accepting conclusions such as that which states that memories are stored in the temporal cortex. But, while it may seem desirable to urge caution in accepting some of the authors interpretations of cortical action (which perhaps tend to be too facile), there can be no question of the value of the records they present. Without doubt they provide a most important addition to the physiology of the human cerebral cortex. W. E. LE GROS CLARK.