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FILE NAME Kent KNT DATE 1955 DOC KNT134 DOCUMENT DESCRIPTION Journal Articles - The Journal of the American Medical Association 19515955  ~ ele Annual Meet Atli antn ic Cg ity June 6-10 1955 This issue Exceeds 165.000 Coses THE JOURNAL OF THE American Medical Association APRIL 9 1955 ORIGINAL ARTICLES CORRELATION OF FIELD SIZE AND CANCEROCIDAL DOSE IN RAY TREATMENT OF SKIN CANCER X. D. A. Allen M.D. and J. H. Freed MD Denver TREATMENT OF PSYCHOTIC STATES WITH CHLOR ROMAZINE Dougles Goldman M.D. Cincinnati CHLOROPHYLL SOLUTION IN DEODORIZATION OF ADVANCED CARCINOMA OF HEAD NECK N. Chilton York Zegarelli and A. K Kutscher D.D.S Robin Rankow V. G.D.S , DDS , D.S New D. Pies D.D.S. NEONATAL TORTICOLLIS Kieswetter W B. C. E. Koop M.D. M K. Philadelphia Helson M.D V. S. Pallodine M.D. and JAUNDICE CAUSED BY CHLORPROMAZINE THORAZINE L. R. Loftus M.D A. Huszengo M.D M. Stauffer H. Rome M.D and J. C. Cain M.D. Rochester Minn M.D. PEDIATRIC RESEARCH IN THE AGE OF THE COMMON MAN AND EXCEPTIONAL CHILD C. A. Janeway M.D. Boston THE PSYCHOLOGICAL FACTORS IN_MEN IN_MEN SEEKING SEX TRANSFORMATION F. G. Werden M.D and J. T. Manh Ph.D. Los Angeles CLINICAL NOTES CHLORPROMAZINE IN THE TREATMENT OF EMOTIONALLY MALADJUSTED CHILDREN . Garshi R. L. M. M.D D.. Danville , Pa USE OF A. FLUDROCORTISONE ACETATE IN DERMATOSES C. V Robinson M.D. Baltimore . SPECIAL ARTICLE EDUCATIONAL METHODS Chicago POSTGRADUATE TEACHING , SPECIAL REPORTS Chemical Laboratory A STUDY OF CIGARETTES CIGARETTE SMOKE NICOTINE AND TARS IN MAINSTREAM SMOKE AND FILTERS 1271 1274 . 1279 1281 1286 1289 .1292 1298 1300 1302 1305 1305 1311 EDITORIALS Ulcerative Colitis A Holien the Pension Umbrella Prevention of Rheumatic Fever 1332 1313 1313 ORGANIZATION SECTION Abstract of Minutes of Meetings of Board of Trustees 1314 Statement by Dr. David B. Allman Before Subcommittee of House of Represento- tives March 10 1955 Statement by Dr. Leo H. . Bartemeser 1315 Before Subcommittee of House of Representatives March 10 1955 1315 Bibliography on Absenteerim Among Workers 1316 REGULAR DEPARTMENTS Medical News 1317 Correction 1321 Meetings and Licensure Magazine Report Deaths Foreign Letters 1321 1324 1325 Brazil Symposium on Cirrhosis England Industrial Health and Acci dents Use of Oxytetracycline in Preventing or Delaying Isoniazid Resistance Sterilization Techniques Octord Medical School Artificial In- 1328 semination Health of the British Army Physicians and Radio Perform onces Wrappers Jig Health of London infection After an injec tion Death of Sir Arthur Keith Legal Aid for Patients 1328 Switzerland World_Health World_Health Organizo tion : Turkey : 1330 Cerebrospinal Cerebrospinal Hydatid Meningitis Water-Water- Friderichsen Syndrome Cortin cal Necrosis of the Kidneys Ascaris Tumor 3331 Correspondence Hypotensive Reaction Following Use of Pentolinium Tartrate Preservation of X.Ray Films Practice of Medicine Drugs and Anginal Syndrome ^ ncidence of Multiple Sclerosis 1332 Government Services Veterans Administration Health Service Council Administration Administration Council on Medical Service Medical Care for the Indigent in Illinois 1335 Economic Bureau of Medical Research Status Current of Jenkins Bills Medicine ~ Dickinson Ph.D. Chicago 1339 Medicine and the Low Selection of Medical Staff in Govern mental Hospitals . . 1342 Medical Literature Abstracts 1344 Book Reviews sek 1354 Queries and Minor Notes . Insulin and Sugar Treatment of Frac- tures Inflation of Eustachion Tubes Normochromic Normocytic Anemia Easy Bruising in Women Sinus Treat ments Diabetes Hyperthyroidism and Tuberculosis Itch Powder Prolonged Bronchitis Seborrhea Stimulation of Growth Multinodular Goites Cataracts During Pregnancy Medicated Cleansing Tissues Ultrasonic Energy Hypopro teinemia Dermatitis and Scabies Anal Loss for Compensable ContractureInjuries Menstrual Periods Called During Pregnancy Tongue Sucking Frozen Shoulder Milk Allergy 1356 WASHINGTON NEWS VA Funds Military Training Mentol Health Survey Loans for Health Facik ties Miscellany Ad- Page } National Organizations of Medical Interest Tonics and Sedatives The Bright Side Indes to Advertisers Adv Page 18 Adr Page 58 Adv Page 78 Adv Page 81 Volume No. 13 , Published Weekly at 535 North Dearborn Street Chicago 10 Illinois SubscriSupbscription tion 15 Single Copy 45 cents Sixth Nelson's Textbook modern textbook or worid worid recognized excellence designed to help you treat event Mitess su children are steersstuth steersstuth specm.cally than ever of Pediatric HYC ( iir:) Vol 157 No. 15 CHEMICAL LABORATORY 1309 COMMENT Postgraduate medical education has many unique problems that dictate a need for unusual methods tech- niques and teachers The small discussion or seminar though employed only occasionally in postgraduate medical education was ranked highest by physicians as a postgraduate learning method Individual supervised clinical casework lectures and panels and demonstrations were considered next most effective Tbe present disproportionate prevalence of didactic methods in postgraduate education points to the need for a re- versal of present policy to increase the use of participative methods Nevertheless didactic methods have 2 larger place in postgraduate education than in undergraduate medical education since the physician foun- dations upon which to anchor the knowledge he receives If didactic methods are to continue to play such an im- portant part in postgraduate medical education a more thorough investigation of indirect methods using the mass communication mediums is warranted since these could result in more economical use of faculty as well as student time Of these mediums television shows the greatest promise ns It apparent that no one method or plan is likely to be the sole answer to postgraduate medical education Peda- gogic ideals often come into conflict with practical considerations The solution lies in a realistic adjustment of the educational objectives to the limitations of the situa- tion but with full recognition of the fact that the com- promises required may result in less than optimal learning potentials Postgraduate education can also serve as a proving ground for new medical educational methods and techniques if careful evaluation procedures are employed The teachers in postgraduate medical education are largely drawn from the ranks of undergraduate graduate and postgraduate medical schools In order to do effec- tive postgraduate teaching they must spend considerable time in preparation for each session and even more in travel One of the major needs of postgraduate medical education is to enlarge the teaching force drawing on such sources as the staffs of large hospitals research cen- ters physicians in smaller towns and residents It is equally important that definite proportions of medical- school faculty time be assigned to postgraduate teaching with the full recognition that this is one of the instructors primary duties not a secondary chore Faculty time could be much more efficiently used by the development of a organized and coordinated system of all postgraduate activities within each region Intrathoracic Surgery recent years intrathoracic surgery has become so safe that excision of a pulmonary lesion is usually the indicated treatment when surgical therapy is contemplated Resection has reached this preferential position as a result of| improved technical methods the wide spectrum of protection afforded by antibiotics the improvement in anesthesia that permits the pleural cavity to be open for long periods without bazard the development of procedures to determine ventilatory function and finally the better understanding of pre- and postoperative management These have provided the foundation on which thoracic surgery rapidly grew to maturity one of the most spectacular records in the annals of surgical Cranston W. Holman M.D. Principles of Pulmonary Resection The American Journal of Surgery January 1955 CHEMICAL LABORATORY This is the fourth report on cigarettes cigarette smoke and filters by the Chemical Laboratory of the American Medical Association The first report concerning filter cigarettes oppeared in The Journal July 4 1953 page 917. The second laboratory report concerning cigarettes ~ laimingto contain tobacco of low nicotine content appeared in THE Journal July 11 1953 page 1035. The third report on cigarette holders appeared in THe Journal Feb. 20 1954 page 678. The work reported in this series was done by Mr. Robert R. Stark of the Chemical Laborato Walter Wolman Ph.D. Director A STUDY OF CIGARETTES CIGARETTE SMOKE AND FILTERS 4. Regular Cigarettes Klog Cigarettes and Additional Filter Cigarettes The Chemical Laboratory of the American Medical Association has examined a number of the largest selling brands among the regular and king cigarettes as well as a number of brands of filter cigarettes that have appeared on the marker since the Laboratory's original report on filter cigarettes Reports on e effects of cigarette smoke on the health of habitual smokes have prompted the introduction of many new brands of filter cigarettes during the past several months The methods of analysis and experimental conditions for smoking have been described in a previous report Briefly 47 mm of both the standard and king cigarette were smoked 67 of a standard 70 mm cigarette and about 55 of a king cigarette using 35 ml puffs of two seconds duration taken once a minute In addition king cigareties were smoked 62 mm to a 23 mm butt the same length butt as a 70 mm cigarette smoked 47 mm ; The results of the experiments are given in tables 1 and 2 Table 1 lists the type of cigarettes tested the type of filter used if any the physical characteristics of the cigarettes and filters and the percentage of moisture and nicotine found in the tobacco Letters assigned to brands reported in previous papers have been retained as the first letter for the same brands in this report The addition of the letters k and f to the letter sym- bolizing the brand name designates king and filter respectively Table 2 gives the results obtained from the smoking of the cigaretles In table 2 column 2 the figures are obtained by multiplying the average number of puffs required to consume the designated length of cigarette smoked by the volume of each puff 35 ml and represent the average volume of smoke drawn into the absorption train This mainstream smoke represents the smoke that would reach the smoker's mouth Column 4 of table 2 shows the weight of nicotine in the smoke from intact cigarettes and column 3 gives the weight of nicotinien the smoke obtained from the cigarettes in which the filter was removed The percentage reduction in nicotine in the mainstream smoke effected by the filter is listed in column 5 and is based on the difference between columns 3 and 4. In column 9 of table 2 the weights of the tars appearing in the mainstream smoke per cigarette are given for the intact cigarettes and column 8 gives the weights of lars in the smoke obtained from the cigarettes in which the filter was removed Column 10 lists the per- centage reduction in tars effected by the filter based on the difference between columns 8 and 9 mainstream The figures for nicotine and tars in the mainstream smoke listed in columns 3 and 8 were obtained from the short cigarettes resulting from the removal of the filters and are higher than would be obtained from intact tobacco cigarettes of regular or king length since tobacco itself is a rather good filter If the filters of the filter cigarettes were to be replaced by an equal length of tobacco this tobacco would filier out a certain amount of the nicotine and tars passing through it This filtering 1. A Study of Cigaretes Cigarette Smoke and Cigarettes a report of the Chemical Laboratory I 920 July 4 1953 Filters 1. A MA MA Filter 1521917 ve 1310 CHEMICAL LABORATORY cigarettes effect of tobacco is illustrated io table 2 by the king from which 15 mm of tobacco was cut and the resulting 70 mm cigarettes were smoked 47 mm The amount of nicotine and tars appearing in the smoke was considerably greater than the amount obtained from the intact 85 mm king cigarettes smoked 47 mm If a king cigarette is smoked 62 mm instead of 47 mm to the same 23 mm butt length as a regular 70 mm cigarette smoked 47 mm 31.9 more tobacco is consumed however the nicotine and tars found in the mainstream smoke are higher J.A.M.A. April 9 1955 to the mainstream smoke without the fillers and with intac~- cigarette respectively Under comparable conditions the proportion of nicoline transferred from the tobacco of the smoked portion of the cigarette to the mainstream smoke is rather constant A factor contributing to differences in the smoking of the filter cigarettes was the variation in the filters of the individual cigarettes There were differences in porosity of the filters but the greatest variation was in the length of the separate filters The filters of brand M cigarettes ranged from 10.4 to TABLE Moisture Nicotine Content and Physical Characteristics of Cigarettes Colama I Brand R D Type of Filter Weer een a eeeeset evens Lf Tada tee rem enentttnnensnsar esses esuterans K Lk tk MC Aik Nfk Bik of Cellulose = Cellulase Asbestos acetate fibers rrrrry acetate fibers fumlauted with paper Activated charcoal with Date Date SSaammppllee Obtalped Feb. 1934 Aug. 1933 Feb. 1954 Aug. 1954 Mar. 1954 June 1954 Sept. 1834 April 1954 Jan. 1954 July 1954 Ort 1934 Nov. 1954 S 1 Average CigCairgeatrteettoef Cu. Average Weight Filter ofTip Gin 1.038 vores 1.096 . 1.088 aeaee 1.003 1.072 1.215 1.297 tree a van 1,109 0.178 1.288 1.965 1.199 1.976 0.181 0.120 . 0.14 ; 6 Total of CiCgiagreatrtee tte Mm 70.0 69.9 70.0 70.0 69.8 1.8 14.8 59.9 65.0 14.0 87.0 61.0 Average Length of Filter Tip 3536 baw tees bene 13. 13.0 15.0 113 3.1 7 Average Cireum of CigarCeitgtaerette Cigarette 50.4 20.5 20 20.2 26.2 26.2 25.T 26.0 15.1 15.3 25.8 23.8 25.9 8 Moisture Tobacco Tobacco Tobacco 11.95 11 . 11 10.03 10.54 11.89 11.57 31.30 10.09 11.78 10.41 13.03 9 Nicolloe la Tobacco MolatureFree BasiBasiss % 1.51 2.08 1.99 2.00 2.11 1.29 1.80 1.76 1.00 2.12 1.59 1.59 1.30 TABLE Analysis of Smoke from Cigarettes Colama 1 Hy 3 4 $ a i 4 " 10 Nicotine in Tobacco Xe Brand Weight Weight of Toliaceo Actually Smoked Dry Weight Gal Average Volume of Main stream Smoke per Cigarette MI Weight of Nicotine Found la Malostren Smoka per Cigaretta Mg Wich Filter Tip Removed lotact Reluc loo of Neoting lo Mainrenan Sminke % Actually Sinoked That is Transferred to balbstresan Smoke % With Filter Reinovert = Intact Weight of Tats Founit to Mainstrenin S~-naike per Cleurette Mr. With Filter Reinoved Intact Reduetlos of T'art la Maio siren bmoke % H 7 mm smoked Unida ton see 1.31 a D 47 mm smoked I 47 mm smoked 0.031 75 ae 1.65 - 0.1002 SGN coe 2.34 a a 180 . 8 - 18.2 9 10.6 a see . 4 47 wam smok~ j 0.145 171 ate 3.13 a a 9 ae 36.0 I 47 mm smoked 0.623 344 sone 2.17 - : 5 . 372 a Lk 7 mm s^nked s^nked 0.577 KLU tees 2.55 . 7 : 31.0 a 3.54 3 62 mm smoked aes 0.702 32 sees . Cigarette cut to 70 min 21.0 ae 47 min smoked 0357 ay tee 2.31 # aes 154 o ia 47 min smoked 0.009 177 1.08 : 52 13.G ~ 4.80H 1.90 18 8 min smoked . 437 : ly as Olgarette cut to 70 mitu 47 mm smokad 0.009 50 see 1.39 : ** be] ae 13.6 a MI 47 mm smoked 0.033 15 2.13 1.00 80 ** M4 10.9 21.3 x = 377 11..6875 af 7 mm poked 42 mm smoked 0.074 0.853 481 2.44 wees 80 19 14 16.1 11.3 0 : :: : **** 15.4 Nor 17 m smoked 400 * smoked 0.830 521 8.70 RS2 2 mm ee 0.014 = :: 13 14.0 12.1 i) ates 1.90 :: 14 os 17.1 ve Cigarette cut to 10 mm , 47 pm smoket 0011 294 sees 2.ST : a * tee 12.7 : 0.305 Btx 47 mm smokej Et mm amoked 0.745 34 ** 311 . 18 2.96 ... n ; . 1.1 "3 00 E 18 . 134 Cigarette cut to 70 inal 47 cm snaked 0.77 248 vee 2.12 os : IS . 10.3 . 00 = 47 mm emoked we - Pal CHI 04.11 15807 371 484 t.s ate 1.70 2.G1 ... 18 : 142 sat rT) . : 14 way 160 ae Cigarette cut to 70 inm 7 mm smoke~ 011 375 2.0 14 vans HI than can be accounted for by the extra weight of tobacco smoked As the cigarette is puffed and the smoke travels through the cigarette the tobacco filters out a portion of the nicoline and tars At each succeeding puff therefore the remaining to- bacco becomes richer in nicoline and tarry material As this enriched tobacco is burned during subsequent puffs a portion of the deposited nicotine and lars is transferred to the main- stream smoke It is plain that one cannot have the added pro- tection of the extra length of tobacco and at the same time have a 21 longer smoke as some ads for king cigarettes have claimed . 1 Columas 6 and 7. Table 2. show the percentage of the total 17.1 mm long with an average of 13.1 mm brand A fillers ranged from 10.7 to 16.0 mm long with an average of 13.0 mm brand N filters ranged from 12.3 to 17.8 mm long with an average of 15.0 mm brand B filters ranged from 8.8 to 14,5 mm long from with an average of 11.5 mm and brand O filters ranged 9.5 to 17.0 mm with an average of 13.2 mm These differences are of liide significance when the efficiency of the filter is about the same as the tobacco it replaces but as the efficiency of the filter increases beyond this point the variations become increasingly evident Chemical examination showed that the brand M filter was not -cellulose as claimed by the carton insert Additional tests indicated that it was cellulose Vol 157 No. 15 CHEMICAL LABORATORY 1311 > At the present state of filter development filtering eff mouth The \ ciencies in the range of those found in brands A B M and O. the importance of this information lies in the fact that seem to be the optimum for ^ commercially successful product amounts of these constituents that reach a are smoker's mouth proportional to the amounts assimilated by the striking a sort of balance between effectiveness and a smoke 100 determinations of the amounts smoker The thinned to please many habitual smokers The early history of the brand 8 filter seems to indicate this These made because of the assimilated cannot easily be biological variations among individuals filters early brand B the differences in their smoking habits and removed about 60 of the nicotine and tars from the mainstream smoke but smokers apparently found 100 difficult The amounts of nicotine and tars that reach a smoker's mouth can be approximated in the to draw through the tight filters and the smoke too thin to be laboratory by the use of a smoking satisfying Consequently the brand B filters were modified to , machine that simulates human smoking under trolled conditions The nicotine and carefully can their present state of effectiveness rars in the mainstream smoke the smoke that reaches the smoker's mouth have beco selling From the series entitled A Study of Cigarettes Cigarette determined by this laboratory for the and brands for which special claims have been made cFiogarreetatsees Smoke and Filters data of greatest pertinence to the physician of comparison and reference these data have been gathered together in the following r^'sum^'and are previous studies are accumulated in the presented in graph form for ease of reference brought together in figures , 2 3 and 4 Figures 1 and 2 show the amounts of nicotine and NICOTINE AND TARS IN MAINSTREAM SMUKE SMUKE tars re- spectively that were found in the mainstream smoke of the The recent rise in the popularity of king and cigarettes tested Using standard cigarettes brand D. filter figures cigarettes may be caused partly by the feeling that these 3 and 4 show the average nicotine and tar contents in the types of cigarettes are giving a measure of health protection to the mainstream smoke based on the first five cigarettes smoked smoker This feeling has been encouraged by advertisers who through various cigarette bolders The capital letters used to cigarettes have dwelt on the real or fancied importance of such features identify the brand names of the correspond to the letters used in the earlier papers CETS e anT asst ea OR a ad . = at ESS ERAN SASS MN SRR 3 t rm = 4. i e ' ry a Nicotine Mg Fig Nicotine in mainstream smoke of cigarettes Gray bars represent cigarettes smoked 47 mm Crass hatched bars represent size cigarettes moked 62 mm Tars Mg Fig Tars in mainstream umoke of cigarettes Gray bars represent cigarettes smoked 47 mm Cross hatched bars represent king cigarelles smoked 62 mm 4 x * 6 4 i a 3 Fix } Nubline in Nicoune Mg smoke drawn through cigarette holders as the efficiency of the filter the type of filter material and the length of the cigarette Seldom has the information that is of prime importance to the amounts of smoke constituents that advertiser given the the smoker naniely reach the smoker's wt Fig 4 Lars in smake drawn through cigarette noiders 1 A Study of Cipareties Cigarette Smoke and Filters 1. Filter Cigarettes a 152 920 July 4 report of the Chemical Laboratory J. A. 195 2. Special Nicotine Cigarettes M. ibid 132 1035- 1036 July 1 195 3. Cigartile Holders ibid 154 678 Feb 1954 4. Regular Cigaretes King Cigarettes and Additional 917- 20 . Filter Tip Cigarettes biu 137 3109 April @ 1933 hoot Clinical Meeting + Boston Nov 29 Dec. 2 1955 This Issue Exceeds 155,000 Copies THE JOURNAL OF THE American Medical Association NOVEMBER 26 1955 ORIGINAL ARTICLES CIRRHOSIS OF THE LIVER TREATED WITH PROLONGED SODIUM RESTRICTIONS .1257 C. 5. Davidson M.D. Boston IMPROVED APPROACH FOR POSTERIOR UPPER THORACIC SYMPATHECTOMY 1261 H. J. MacKay M.D. Seattle SCIENTIFIC BASIS FOR THE SURGICAL TREATMENT OF CORONARY ARTERY DISEASE 1264 C. S. Beck M.D. and D. S. Leighninger M.D. Cleveland J. DIFFERENTIAL DIAGNOSIS OF CHEST DISEASES 0... 0.0... cee cece cece vide vide .1272 A. L. Banyai M.D. Milwaukee PROBLEM OF ECZEMA 200.0 Ralph Bookman M.D. Los Angeles cc ce cee cece cee tee ene tebe teb reece .1275 .1275 THE GENERAL PRACTITIONER AND THE DISCHARGED MENTAL HOSPITAL PATIENT.1278 PATIENT.1278 \ K. E. Appel M.D. and Albert Scheflen M.D. Philadelphia , PAIN IN THE NECK AND SHOULDER COMMON CAUSES AND RESPONSE TO THERAPY 0c c cece eneRESPONSE RESPONSE RESPONSE RESPONSE bbb eben eee. 1282 E. M. Krusen M.D. Dallas Texas FURTHER EVALUATION OF HEATING BY MICROWAVES AND BY INFRARED ; AS USED CLINICALLY cc INF RARED INFRARED bneeees 1286 .. M. Martin M.D. and J. F. Herrick Ph.D. Rochester Minn CLINICAL NOTES SPECIAL REPORTS Council on Pharmacy and NEW AND NONOFFICIAL REMEDIES Chemistry ccc e cece cee eeenevebeneees 1290 Government Services Air Force Public Health Service Selec- tive Service System Veterans Admin- istration .1319 .1319 .1319 Deaths .1320 Foreign Letters Brazil Pulmonary Syphilis Schistosomal Myelitis ............00..0,, 1323 England Lung Cancer Polluted Air and Smoking First Seven Years of National Health Service Hypophysectomy for Diabetes Hernior- rhaphy as an Outpatient Procedure Osler Memorial at Oxford National Health Service in Northern Ireland Influenza in the United States and Great Britain Compulsory Hospital- ization for Tuberculosis Harmful Effects of Exhaust Fumes Tuberculosis Due to Resistant Organisms Radioactive Cesium James Parkin- son Magnetic Call System 1323 Finland Drug Addiction in Finland..1325 Finland..1325 France Delirium Tremens Heparin for Cold Abscesses Oxytetracycline for Rheumatic Fever ...0...00....... 1325 Italy Problems of Oncology Law of the Heart 2.000000 08. 1325 Sweden BCG Vaccination Appendec- tomy at Gynecologic Operations Medical Jubilee 2 ............. 1326 Uruguay Poliomyelitis ............. 1326 Correspondence Medicolegal Office The Concer Patient ...0..000.00.0...0..008. 1327 Medical Literature Abstracts ......... 1328 Book Reviews .........0............. 1333 Queries and Minor Notes Acne and Chronic Hepatitis Dental Caries Infant Feeding and Circumcision Convulsions of Childhood Buck- wheat Poisoning Monocular Diplopia Foods Rich in Arginine Penicillin Prevention of Blocking of Indwelling Catheter 41335 41335 the Board of Trustees .1302 of Poliomyelitis Vaccine 1303 .1303 .1304 Medical MetingLegislation Medical Conference on LegislatLioengislation .1305 The Boston Meeting Legislation Meeting Legislation 1305 Federal Federal , .1305 .1305 COUNCIL ON DEFENSE NATIONAL Survey Physicians Separated Results of of Active Military Service from Active Military Service .1306 REGULAR DEPARTMENTS News .1310 CMoerdrieccatlion nn eee .131 .1 6 316 .1316 Meetings ee eeaee Licensure e ete e eee n .1316 .1316 Examinations and Licensure 1317 Television Report 1318 WASHINGTON NEWS Poliomyelitis Vaccine Grants Commission for Health Officers Burton Program Public Health Grants LongTerm Yeteron Care i Rehabilitation Security Records Social cellany Service Interns Security for Administration Records Mis- . Adv Page 13 State Medical Associations Adv Page 18 Tonics and Sedatives .Adv Page 52 The Bright Side Adv Page 58 Books Received .Adv .Adv Page 72 Index to Advertisers Adv Page 74 . Volume 159 No. 13 Published Weekly at 535 North Dearborn Street Chicago 10 Illinois Subscription 15 Single Copy 45 cents Pediatric Orthopedics 16 most A practical Symposium in the November Number of the Pediatric Clinics of North diagnosis and treatment of the most com- mon orthopedic disorders in children Full contents inside <<... SAUTE 4D. nwot......4. .. ll at frequenth J.A.M.A. Nov. 26 1955 SCIENTIFIC BASIS FOR THE SURGICAL TREATMENT OF CORONARY ARTERY DISEASE Claude S. Beck M.D. and David S. Leighninger M.D. Cleveland To understand the scientific basis for the surgical 3. Of all the people who die of coronary artery disease treatment of coronary artery disease it is necessary to about 90 die because the heart becomes electrically analyze information obtained by experiments on dogs One of us C. S. B. and his associates have done about unstable The hearts in these people are capable of continued function under slightly altered circulatory con- 5,000 operations on the coronary blood vessels in the last 23 years and these are the basis for this presenta- ditions and these are the patients who can be helped by surgical operation The remaining 10 of the patients tion There are several variables inherent in this work who die from coronary artery disease have extensive and it is appropriate here to state that these must be myocardial degeneration and these patients die in circu- properly taken care of otherwise erroneous conclusions will be made A report on much of this experimental latory failure Little or nothing can be accomplished by surgical operation in these patients fig ) 4. The work has been published in THE JOURNAL In these experiments the reduction in coronary artery inflow was transfer of this information from the laboratory to the human patient is being made without conflict in the produced by placing ligatures around the coronary ar- science teries In the human arteriosclerosis produces reduction in coronary artery inflow The net result is reduction in arterial inflow This is not a study of arteriosclerosis Even if this disease could be produced experimentally in adequate numbers of dogs the occlusion probably could ELECTRICALLY STABLE AND UNSTABLE HEARTS An electrically stable heart is a uniformly well oxygenated heart Emphasis is placed upon the uniformity of oxygen tension throughout the myocardium fig 2A not be localized nor could the degree of occlusion be controlled with the precision demanded by the experiment and as a method of investigation it would be inferior to the ligature The surgical treatment of coronary artery disease is Electrically Unstable Electrically Unstable Electrically Stable Heart Heart Without Infarct Heart With Infarct 100 With Faial nduFar ilue re 90 Ds 80 vee based upon four considerations 1. Operation adds 4.7 cc of blood per minute 282 cc per hour to an area of myocardium made ischemic by complete ligation of the artery that normally feeds this muscle This quantity of blood is of little or no significance if it is delivered to myocardium that is fed by a normally patent artery or if the artery is occluded by fourths of its diameter But if the artery is totally occluded then this quantity of blood is protective When the circumflex ,70 deaths 60 50 of 40 ...,,, ... ,,,,,, cent 30 Per 20 ...,,, 10 ...,,, 0 eres Fe tad pbafy te | artery is ligated in a normal dog the average amount of blood available to the muscle beyond the ligature is 3.8 cc per minute Operation adds 4.7 cc to this quantity making an average total of about 8.5 cc per minute 2. This quantity of blood accomplishes three favorable results It reduces mortality following test coronary artery occlusion it likewise reduces the size of the infarct in these dogs that live following the arterial occlusion and it provides time for additional blood to Fig third of all victims of coronary artery disease have no infarct either old or recent according to Yater In this group column , the hearts became electrically unstable Approximately 10 of all victims die of circulatory fallure In this group column 3 the currents incidental to progressive occlusions were never strong enough to fibrillate the heart and stability was maintained from one occlusion to another until failure supervened Of the remaining 57 column 2 both muscle damage and instability were present and in many of these specimens the destruction of muscle was not so great but that continued function would have been possible were it not for the electrical potentials that destroyed the coordinated mechanism In the first group there was no muscle damage and continued function was of patients possible in this group provided the heart remained electrically stable run into this low pressure area of occlusion from adja- cent high pressure areas of myocardium In a few days Stability persists when the oxygen tension is reduced this ischemic but viable myocardium begins to contract provided the reduction is uniform throughout the myo- In 24 dogs the average amount of blood available to the cardium A uniformly cyanosed heart is also a stable myocardium beyond the ligature was 62 cc per minute heart as indicated by observations made in our labora- tory on about 60 dogs in which the intratracheal tube From the Western Reserve University Hospitals Read before the Section on University School of Surgery General and Medicine and the Abdominal at the was clamped off for periods of six to nine minutes The heart in these experiments became increasingly cy- 104th Annual Meeting of the American City June 8 1955 Medical Association Atlantic anosed it dilated the beat became weak and then it This work supported by grants from the United States Public Health Service and the Cleveland Area Heart Society The burs used in the number 1 operation are made by Kapp Surgi- stopped in standstill In none of these experiments did the heart fibrillate When oxygen was again delivered | cal Works 2004 St. Clair Ave. Cleveland 1. Beck C. S. and Leighninger D. .: Operations for Coronary Artery Disease J. A. M. A. 156 1226 Nov. 27 1954 into the lungs and the heart massaged a few times a strong vigorous beat was restored Thus the mechanism Ht Fig Dog hearts illustrating four conditions of myocardial oxygenation with direct epi- cardial electrocardiograms demonstrating measurement of electrical potentials A and C are the same heart the one is uniformly well oxygenated and the other is uniformly and severely cyanosed These hearts are electrically stable as shown by the isoelectric T segment in each condition B and D are electrically unstable because the oxygen tension in each heart is not uniform throughout The T segment is depressed over the pink or oxygenated myocardium and elevated over the blue or cyanosed myocardium These differences in potentials are often strong enough to fibrillate the heart The term current of differentials is introduced to replace current of injury which is obviously incorrect A uniformly cyanosed heart is not an injured heart - _ Vol 159 No. 13 CORONARY DISEASE AND LEIGHNINGER 1265 remained coordinated as the heart changed in color from pink to blue and back again to pink Direct epicardial electrocardiograms taken from the surface of the uni- formly pink and the uniformly cyanosed beart are shown in figure 24 and C. The heart becomes electrically un- stable and may fibrillate when the oxygen tension is not uniform throughout the myocardium Thus a cyanosed area surrounded by oxygenated myocardium or a oxygenated area surrounded by cyanosed myo- cardium are conditions that produce electrical instability These conditions are produced experimentally by ligation of one or more coronary arteries in a oxygenated heart and by delivery of pink arterial blood through a catheter in a coronary artery in a deeply cy- anosed heart The appearance of these two types of trigger and the electrical potentials from the surface of these hearts are shown in figure 2B and D. These differences in electrical potential from pink and blue areas measure 5 to 20 mv They are produced at the precise plane of contact between blue and pink and pink and blue muscle They are produced by differences in oxygen tension and we use the term oxygen differential to refer to this phenomenon The term current of injury has been commonly used to refer to currents produced by ligation of a coronary artery but this term is probably not correct The terms stable and unstable heart are also of recent origin and seem to have a place in cardiac nomenclature No doubt the amount of current and the voltage produced under experimental conditions vary in different dogs The same current may fibrillate the heart in one dog and fail to do so in another In different dogs and under different conditions there appears to be a dif- ference in what might be referred to as the threshold for fibrillation The threshold for fibrillation is lowered . by hypothermia in the absence of coronary artery oc_ clusion and in a series of experiments in which the de- scending ramus of the left coronary artery was ligated the heart fibrillated in every experiment whereas under normal temperatures the incidence of fibrillation was 50 . Electrical instability leads to fibrillation and death in a large number of people The classic example of this occurs in the man who goes out and shovels snow and in a few moments is dead The exercise improves oxygenation of myocardium everywhere except in an area supplied by a coronary artery that is not normally patent ; although it may not be completely occluded In some , instances the arterial disease is slight Under these con- ditions an oxygen differential is produced that in turn ; produces sufficient current to fibrillate the heart Had ; this man remained indoors without this vigorous exer- = cise the circulation of red blood into the myocardium would have been less brisk the heart under conditions of rest would have been less pink and the oxygen differential probably would not have produced sufficient current to have fibrillated the heart To society the loss produced by these currents is incalculable These cur- rents occur in people who could live productively provided small alterations were present in the coronary s artery circulation third of all victims of coronary artery disease have no damage in the myocardium either old or recent and many of the remaining thirds have heart muscle that probably could continue to func- about tion for years were it not for these currents In 10 of the victims of coronary artery disease these cur- disease heart rents were never severe enough to fibrillate the the patient continued to live and the occlusive advanced to the point where extensive damage and fail- ure occurred It appears then that oxygen differentials of a fatal nature can be produced in the absence or in the presence of myocardial destruction It also appears that myocardial destruction can proceed to the stage of failure without producing currents strong enough to fibrillate the heart The production of currents and the destruction of muscle are both related to oxygen but they are different biological processes The purposes of surgical operation are to reduce these currents and to preserve viability of muscle although the occlusive proc- ess may proceed later on even to the point of cardiac failure SURGICAL OPERATIONS The principles for aiding a crippled coronary circulation were previously presented in The Journal.,, AC- cording to our experience the most important aid is provided by the presence of intercoronary arterial communications so that a red blood cell entering the descending ramus or one of its branches can get over to the circumflex ramus or one of its branches where it fulfills a more important function The addition of blood from outside sources is less effective than the distribu- tion of blood that is already in the coronary system We tried to add blood to the heart in many different ways one of which was to enter it through the coronary sinus system of veins in a retrograde direction This method provides the greatest amount of protection of all methods that we tested but retrograde flow tapers off in the dog after six to eight weeks and is replaced by a protective set of intercoronary channels Whether retrograde flow tapers off in the presence of coronary inflow disease in the human patient cannot be stated at this time Other sources of flow from the outside such as from parietal pericardium mediastinal fat lung internal mam- mary arteries chest wall omentum spleen and intestine grafted upon the heart are yet to be measured Considerable work on this subject has been done and anatomic channels large enough to carry blood have been demonstrated between graft and coronary arteries but so far measurements of flow have not been done No doubt these measurements will be made because methods measurement are available and some of these surgical procedures may be found to be effective For the present we have laid aside the operation that diverts arterial blood into the coronary sinus system of veins because the term condition of the circulation in the human heart will not be known until a number of speci- mens are examined This operation is technically dif- ficult It requires two stages It has a definite mortality 2. Brofman B. L Leighninger D. S. and Beck C. .: Electrical Instability of the Heart A New Concept in Coronary Artery Disease to be published 3. Selman M. W. and Brofman B. L The on Survival Rates Following Coronary Occlusion 707 May 1955 Effect of in Dogs Hypothermia Surgery 37 4. Andrus E. C. and others Coronary Artery Disease M. Ano District of Columbia 20 313 June 1951. Yater W. M. Beck C. S. Leighninger D. S. and Brofman B. L Symposium on Coronary Arterial Disease Am Rev. Tuberc 71 904 June 1955 1266 CORONARY DISEASE AND LEIGHNINGER J.A.M.A. Nov. 26 1958 and also some effects from the arteriovenous fistula produced by the operation However as stated above it produces the greatest amount of benefit and we might apply it in those patients who still have pain after the number 1 operation has been used The Number 1 Operation number 1 operation consists of the following steps 1. The lining of the parietal pericardium and the surface of the heart are 22222207 22222207 22222207 NORMAL 67 DOGS MINUTE 22222207 MINUTE * MINUTE 22222207 MINUTE 22222207 PER PER 22222207 CC CC 22222207 : : IN IN N BACKFLOW BACKFLOW to+ BACKFLOW * BACKFLOW BACKFLOW 0 ween, eee * 4-2 oe *Xes BECK NO.1 OPERATION 41 DOGS * 7 + 26 ale x * -24 * 22 -20 -20 i 18 -16 * x * 14 | * a | * * * * ** 20 10 att ** Ts . a eX * ee * : 2 ~*% eee CONTROLS le 1 . 2 3 6 9 TIME IN MONTHS 0 12 Fig Mautz backflow measurements in normal control dogs and in dogs upon which number 1 operation was done Average in 67 normal dogs was 3.8 cc per minute and in 41 dogs in which the number 1 operation was done was 8.5 cc per minute This increased backflow was present one year after operation Star indicates that elec- trocardiographic evidence of protection was present and solid circle indicates it was absent This operation has been well tested in the mental laboratory The protection of the expert number operation in terms of mortality and size of infarct been reported In normal dogs the mortality following complete ligation of the descending ramus of the left coronary artery at its origin in one step was 70 In 43.4 dogs in which the number 1 operation was done and sometime thereafter the same artery was ligated mortality was 26.6 This is a reduction of produced by the operation The hearts in each group that survived test artery ligation were examined and the size of the infarct measured In the hearts that were protected by operation the infarct was 60 to 70 specimens smaller than in the control group In some there was no gross infarct and this was never observe~ in a specimen of the control group Backflow.The Mautz method of backflow yields important information and was used in many experiments This method consists of ligation of either the circumflex ramus or the descending ramus of the left common coronary artery One of these vessels is ligated i proximally and cut distal to the ligature The amount of blood from the cut artery is the backflow A third measurement of protection which has also been re- ported consists of the response made by the circulation after test artery ligation provided the animal lived and the heart muscle was not destroyed by the ischemia Backflow measurements made in an artery that was oc- cluded one day were 10.8 cc per minute two days 42.0 cc three days 68.0 cc and six days 20.0 cc the average up to four months in 24 dogs was 62.1 cc per minute The important consideration here is the fact abraded or roughened by special burs This produces mechanical trauma which in turn produces inflamma- tion and intercoronary arterial channels We experi- mented with necrotizing chemicals for the removal of NORMAL EKG A. AVR epicardium but no satisfactory chemical agent has been found and strong chemicals such as carbolic acid should not be used 2. Application of 0.2 gm of coarsely ground asbestos is made to the entire surface of the AFTER LIGATION CIRCUMFLEX ARTERY heart This produces mild inflammation which persists for a period of months and which in turn produces intercoronary arterial channels We experimented with many BACKFLOW - CC PER MINUTE B. C. D. E. different inflammatory agents and asbestos is the most 10 CC 6 CC CC 2 CC : effective agent 3. The coronary sinus is occluded to a diameter of 3 mm Ligation of this veiins not beneficial when the arterial circulation in the heart is normal be- cause it reduces arterial inflow but when a major cor- * onary artery such as the circumflex is occluded then * e e ligation of the sinus affords protection against loss of coordinated mechanism and it also provides greater absorption of oxygen from the blood in the occluded vascular bed Ligation also aids in the development of intercoronary arterial channels 4. Parietal pericardium and mediastinal fat is applied to the surface of the heart This grafted tissue stimulates the development of intercoronary arterial channels and in some instances probably becomes the source of additional blood to the heart EKG EVIDENCE OF PROTECTION | * - PRESENT $j ( @ - ABSENT Fig Relationship between electrocardiogram and Mautz back, flow that 4.7 cc per minute of additional blood provided by operation carried the dog over the crisis of the arterial occlusion and also preserved the viability of myocardium Under these conditions additional blood ran into the Gregg 5. D. E Coronary Circulation in Health and adelphia Lea & Febiger 1950 Disease Phil- Following Mautz 6. culation Exper Biol F. R. and Gregg D. E The Dynamics of Collateral Chronic Occlusion of Coronary Arteries Proc & Med 38 797 June 1937 - - Cir Soc ischemic pressure myocardium from adjacent myocardium where the pressure was higher and later on this ischemic but viable myocardium had sufficient blood supply to restore contractility to this area of myocardium Vol 159 No. 13 CORONARY DISEASE AND LEIGHNINGER 1267 Recent measurements obtained by one us D. S. L. are presented in figure 3. In 67 normal dogs the average backflow was 3.8 cc per minute After the number 1 operation was done the backflow in 41 dogs was 8.5 cc _ per minute or an increase of 4.7 cc This increase in backflow was found one year after operation so that the improvement is probably of a permanent nature The relationship between backflow and electrocardio- gram is shown in figure 4. Any quantity of blood added to that which is already present is protective When the total quantity of backflow is 6 to 10 cc per minute the electrocardiogram shows T segment depression less than 2 mm and is indicated by a star When the total backflow is 2 to 4 cc per minute it shows greater T segment depression or the heart may fibrillate and this is indicated by a solid circle The various components of the number 1 operation were measured and these are shown in figure 5. Each component contributes something to the backflow Thompson 7 advocated the introduction his own The next step is the intravenous administration of 10.5 mg of tubocurarine chloride The Wolfe mechanical respirator is used and is recommended 5 Nitrous oxide and oxygen liters of each making a flow A of 10 liters per minute are given little ether is given but usually curare and nitrous oxide maintain the anes- thesia The amount of ether used is about 2 to 3 oz 60 to 90 cc per patient We do not use rebreathing The drugs used are as follows pentobarbital Nembutal sodium 0.2 mg given the night before operation digitoxin Crystodigin 0.1 mg given just before the patient is moved to the operating room and desace- tyllanatoside C Cedilanid 0.2 mg given intravenously if the heart rate is over 110 beats per minute This is repeated if necessary or 0.4 mg may be given in one dose This digitalis preparation for intravenous use is an important aid in slowing the heart rate and its use should not be overlooked It requires 20 minutes to become effective Atropine in doses of 0.2 to 0.4 mg into of 4 to 6 gm of talc into the pericardial pericardial pericardial cavity for the treatment of coronary artery disease and backflow in such experiments is given in figure 6. The average backflow in 20 dogs was 4.8 cc per minute This figure is 1.0 cc greater than the average normal but is 3.7 cc less than obtained in the number 1 operation Vineberg* im- planted the internal mammary artery into the myocardium of the left ventricle for the treatment of coronary artery disease This artery is ligated and severed but an intercostal branch is left open The artery is placed in a tunnel in the myocardium with the expectation that branches will de- velop from it and these branches will con- nect with the smaller branches of the coronary arteries Backflow measure- ments were made and the results are shown in figure 6. The average backflow in 20 dogs was 3.9 cc per minute This BECK NO.1 OPERATION 40 Dogs 28 26- COMPONENTS of BECK NO.1 OPERATION Individual Components 28 Dogs Combinations 15 Dogs -28 26 24- MINUTE . 24 MINUTE MINUTE 2 ** * * * per CC 2 CC 4] * . in "1 ata | fad BACKFLOW * BACKFLOW *] *,* oe . * * > BACKFLOW ]**#** * 2 wT * . . * * * * t. . * . 22 20 , 16 f14 a 12 eee 10 B r^' x4 2 Complete Operation Ligation Sinus complete partial Abrasion " Asbestos pe' Abrasion Abrasion Asbestos Asbestos Sinus 3mm S~nus 3mm Fig Mautz backflow and various components of number 1 horizontal line indicates the average normal backflow Broken lines indicate backflow in each procedure Each procedure adds something to : operation Solid average backflow operation did not increase backflow measurements over the normal and the measurements were about the same with the mammary artery occluded by clamping or not occluded In these experiments there was no increased backflow even from intercoronary arterial channels When the artery was severed the proximal end bled freely but the distal end yielded either no blood or less than one drop per minute Vineberg stated that the implant should be made into ischemic myocardium for anastomoses to develop and that was not done in these exepxepreriimmeenttss OPERATION ON PATIENTS is given intravenously for nodal rhythm Procainamide Pronestyl hydrochloride 100 mg diluted 10 times in saline solution is given intravenously for ventricular extrasystoles Tachycardia and T segment changes in the electrocardiogram are treated by stopping the operation for several minutes and oxygenating the lungs well The lungs should come up well and then relax with each respiration If the blood pressure falls mephentermine Wyamine sulfate 7.5 mg is given intravenously and twice this amount is given intramuscu- larly The patient is given 0.6 mg of atropine sulfate and 10 mg morphine sulfate half hour before being moved to the operating room and in the operating room is given 50 mg of diphenhydramine Benadryl hydrochloride intravenously together with 0.4 gm of thio- The patient is placed on his right side with the left side up If the blood pressure falls below 90 mm Hg the operation is not started Time is taken to observe the blood pressure If the pressure remains below 90 mm Hg for the next hour the operation is not done pental Pentotha sodium and 60 mg of succinylcholine chloride He is given 100 oxygefonr three to six min- utes and he is then intubated with a properly fitting cuffed endotracheal tube Ether and oxygen are then given and respiration is assisted until he breathes on Experience 7. Thompson S. A. and Plachta A Fourteen Years with Cardiopexy in the Treatment of Coronary Artery Disease J. Thoracic Surg 27 64 Jan. 1954 Implantation 8. Vineberg A Munro D. D Cohen H. and Buller Years Clinical Experience with Internal Mammary Artery W Four in the Treatment of Human Coronary Artery Insufficiency Including Additional Experimental Studies J. Thoracic Surg 29 Jan. 1955 1268 CORONARY DISEASE AND LEIGHNINGER J.A.M.A. Nov. 26 1955 and the patient is acceptable for operation By experience we learned to regard as a rule not to be broken The incision is placed between the sixth and seventh ribs extending from a point about 8 cm from the midline in front to a point about 6 cm from the midline in back " VINEBERG " THOMPSON 26 20 DOGS 20 DOGS 22200 22200 4 MINUTE MINUTE 22200 MINUTE 22200 MINUTE | per 22200 per 4 CC 14 CC d in 12 e BACKFLOW BACKFLOW 10 . BACKFLOW 00 BACKFLOW 4 BACKFLOW 6 . 4 s . A renga ; 2 e _ e gate . . * a he * e st e '. e : a hemostat separating the sinus slightly from its bed A curved needle that contains silk is passed directly into the right auricle parallel to the sinus This curved needle is then turned 90 degrees so that the point comes out of the auricle just superior to the sinus fig 9 The circumflex artery lies close to the passage of the needle but with care it can always be missed The ligature is a tied around the sinus plus stilet 3 mm in diameter The stilet is removed and partial occlusion of the sinus is accomplished fig 10 This ligation is done after the surface of the heart is abraded fig 11 and also after 0.2 gm of coarsely ground asbestos is applied to the surface of the heart fig 12 The mediastinal fat is then brought into contact with the heart over as wide an area as possible and the pericardium is loosely closed fig 13 A drainage tube is placed in the left pleural cavity and attached to a water If a cartilage is broken it is carefully wired together The sixth and seventh ribs are sutured with a wire The soft parts are closed with silk The patient is given oxygen intra- nasally or is placed in an oxygen tent for 24 hours and ambulation is started The patient is discharged in about two weeks INDICATIONS FOR AND LIMITATIONS OF OPERATION Operation is indicated in the treatment of coronary artery disease Any patient in whom the diagnosis of this disease is established is a candidate for operation 0 Fig Mautz backflow measurements in two groups of dogs In one group the Vineberg procedure was done Average backflow was 3.9 cc per minute in normal dogs it is 3.8 cc per minute In the other group the Thompson procedure was done Average backflow was 4.8 cc per minute which is 1 cc greater than normal fig ) The ribs are spread apart by a retaining retractor for a distance of 12 to cm The pericardium is opened by an incision from apex to base about 4 cm to the right of the left phrenic nerve Traction sutures are placed in the pericardium and held up by the weight of a hemostat The lining of the parietal pericardium is abraded everywhere by special burs Another incision is made parallel to the first incision but to the left of the nerve and a third incision splits the pericardium at right angles down to the coronary sinus Traction sutures are applied to the cut edges of the pericardium fig 8 Exploration of the myocardium and coronary vessels is carried out The common left coronary artery is lightly palpated by the right index finger This vessel is nor- mally patent thickened but pulsatile or it may be calcified The descending ramus is palpated as is also the first part of the circumflex ramus The branches of these vessels are observed as to pulsation beading or streaking The myocardium is observed for the presence of an infarct The infarct is observed for size location and paradoxical pulsation The coronary sinus is observed A point is selected between the middle and posterior veins of the ventricle The epicardium just below the sinus is nicked with scissors and a small opening is | made and the tissues are gently spread with the point of Fig Left side of chest is opened by incision between the fifth and pericardial sixth or sixth and seventh ribs as indicated in the inset The incisions are indicated by the broken lines provided the disease has not advanced to the point where the risk of operation is too great Diagnosis will not be discussed The problem is to determine the stage of the disease when the operation should or should not be - Vol 159 No. 13 CORONARY DISEASE AND LEIGHNINGER 1269 done Patients with signs of failure nocturnal dyspnea and marked enlargement of the heart are almost auto- matically excluded Patients with slight or moderate en- - largement of the heart without failure are accepted Operation is delayed in patients with rapidly increasing pain and disability because these symptoms may indicate progress of the disease and an impending infarct If decision for or against operation is difficult it is advisable to delay decision for several months after which reappraisal is made Patients with status anginosus have been accepted We prefer not to accept patients addicted to drugs but in several patients this habit if present was broken Operation is indicated early in the course of the disease rather than late The experience usually has been that the disease is worse at the operating table than anticipated progressive in patients in the 20's and 30's than those in the 40's 50's and 60's The youngest patient operated upon was 27 years of age and the oldest 71 The operation has limitations that if properly understood will make its beneficial effects more readily acceptable It does not treat coronary arteriosclerosis it Sutures Fig Placing a suture around the trating the left atrium in a direction coronary sinus B needle pene- Needle is then turned in parallel and close to the sinus a clockwise direction 90 degrees to emerge just superior to the sinus Temporary traction sutures are in the fat to sinus expose treats alterations in inflow produced by the disease It therefore does not reduce the disease in the arteries nor does it stop its progress It may become more marked after operation A similar statement may be made about the myocardium Operation does not re- palpated Fig Pericardium opened for observation of coronary arteries myo- cardium and coronary sinus Common left coronary artery and circumflex ramus of left artery cannot be seen but can be palpated Right coronary artery cannot be seen or After an infarct has occurred a period of four to six months is given before operation is done This delay serves several purposes It affords time for intercoronary channels to develop after the low pressure bed has been established by the occlusion and clinically it gives the patient time to level off so that his condition can be compared before and after operation Also electrical instability accompanies occlusion and an anesthetic plus manipulation of the heart at operation may lead to ventricular fibrillation This instability becomes less after the scar has formed and has become electrically inert Another reason for delay applies to patients in whom one occlusion is followed by another These patients a have progressive arterial disease and they are not candi_ dates for operation The disease is more likely to be Fig Partial ligation of the coronary sinus on a stilet 3 mm in diameter as in A B and removed after the ligature is tied as in D. The ligature is tied C and the stilet is store an infarct to functional myocardium however it does reduce the size of the infarct or even prevent the formation of an infarct if another artery becomes oc- cluded It is possible for the symptoms to become worse in a patient who has shown clinical improvement after operation This is brought about by the progress of the arterial occlusion so that it is possible for the patient to be in worse condition clinically sometime after opera- tion yet the operation has saved the patient's life The patient may die of coronary disease sometime after operation but the experience so far seems to indicate that the operation prolongs life Fig Epicardium removed by special should not be used for this purpose burs Necrotizing d ane chemicals RESULTS OF OPERATION The results of operation can be determined by three measurements as follows 1 symptoms before and after operation using the patient as his own control 2 ability to work and to exercise again using the patient as his own control and 3 prolongation of life after operation The first two items are shown in figure 14. Approximately 90 of the patients have less anginal pain or no anginal pain after operation Several patients were operated upon who did not have any pain before operation and these are not counted in these results Some patients state that the angina is better three days after the operation This improvement may be mental but early changes in the circulation as shown by experiment do occur When such mild therapy as a small quantity of whiskey or a glyceryl trinitrate nitroglycerine pill can reduce angina it is not inconceivable that a few drops of blood to ischemic muscle could also give relief As a rule the patient operated for coronary artery disease complains less of incisional pain than does the patient operated upon for mitral stenosis and the in- cision in each is almost the same Some patients do not show improvement for several months after operation The explanation for this cannot be given A small percentage of the dogs failed to show increased backflow after operation About 10 of the patients do not show any improvement after operation and this aspect of the problem requires further investigation Some of our patients are classified as salvage These patients have severe arterial disease in the com~ mon left coronary artery or in each of the major branches . of this artery They also have extensive infarcts some J.A.M.A. Nov. 26 1955 times with aneurysm of the myocardium In these patients not only is the operative risk high but it is often difficult for us to understand how they can be helped by the operation and yet some of the best clinical results are obtained in this salvage group The best results are almost unbelievably good In some patients pain and disability are completely re- lieved Such almost miraculous results are occasionally seen in patients without operation and the explanation is the same as in the operated patients Each patient develops a good set of intercoronary channels one without operation the other after operation and the occlusive disease does not get worse The result is the same Indeed operation accomplishes what nature can do but fails to do in a sufficiently large number of patients In about 90 of the patients the ability to work is improved Many of the patients return to jobs that they could not do before operation It is gratifying to see this type of result however the patient is advised before operation that there is a good probability he will be better after operation but that he will not be cured of his disease It is difficult to make definite statements concerning the prolongation of life after operation The arterioscle- rotic process in the coronary arteries follows a variable and unpredictable course These variable factors were eliminated in the experimental work because by use of the ligature the arterial occlusion was a known factor In the dog it would be undesirable to reduce coronary artery inflow by the arteriosclerotic process even if it Fig Sprinkling of an inflammatory agent 0.2 to 0.3 gm coarsely ground asbestos over the entire surface of heart : were possible to do so This study of coronary artery oc- clusion would not exist if it were not for the fact that controlled occlusion by the ligature was used It is a fact | that a surgical operation can be done on a normal dog 3 heart and sometime thereafter a coronary artery can be ligated completely and in one step and the dog has a Vol 159 No. 13 CORONARY DISEASE AND LEIGHNINGER 1271 better chance to continue to live than it would had the operation not been done It is desirable to present information on the patients concerning arterial occlusion and mortality subsequent to operation but it is scarcely possible to do this with this subject It is desirable to measure this aspect of the work by operating on alternate patients and determining mortality in both groups but this is for the future SUMMARY AND CONCLUSIONS the data available at the present time Our medical Uniform distribution of oxygen to myocardium pro- cardiologist Dr. Bernard Brofman is working on this subject and our belief is that arterial occlusion occurs after operation and the clinical evidence is often not adequate to make a diagnosis This is favorable for the duces an electrically stable heart lack of this uniformity produces an unstable heart Differences in electrical PAIN NO PAIN - 45 operation It is likewise our belief that the operation pro- a longs life but to prove this statement on basis requires two identical groups of cases statistical Lindgren reported mortality in a group of 88 patients who were & > acceptable candidates for sympathectomy for angina pectoris but the operation was not done in these patients because of nonmedical reasons The mortality was 17 LESS PAIN = 45 % TOTAL - 90 % oO ABILITYABILITY TO WORK BETTER ABLE TO WORK NO LIMITATIONS BETTER ABLE TO WORK SOME LIMITATIONS 35 % 55 % TOT-A90L% 9 out of 10 Back to Work and Relatively Free of Pain Fig Clinical results in 103 patients who could be evaluated six months or more postoperatively potentials of the heart are produced by oxygen differentials The term current of injury is probably not correct A uniformly cyanosed heart is not an injured or an unstable heart With the number 1 operation for coronary artery disease operative mortality has been reduced to 6.6 The more important component of this called operative mortality is the disease rather than the operation Operation relieves symptoms in 9 out of 10 patients So far the trend of experience seems to indicate that operation prolongs life Operation adds 282 cc of blood per hour to ischemic myocardium and this blood is present at the crisis of arterial occlusion This is com- parable to a transfusion of arterial blood into ischemic muscle There is no experimental evidence to indicate that medical therapy adds or subtracts a single drop of JANUARY 1 1954 MAY 6 1955. TOTAL PATIENTS - 75 eas THORACOTOMY ALONE ox 2 PATIENTS 2.8 OPERATIVE AND EARLY POSTOPERATIVE - PATIENTS 4.0 F TOTAL 6.6 FROM DISCHARGE UP TO 15 MONTHS 1 PATIENT - 1.3 Fig Pericardium partially closed Mediastinal fat is used to cover it the heart as much as possible Here is brought beneath the bridge of pericardium containing the pericardiacophrenic artery and vein In most instances it is attached to the right border of this bridge of tissue the first year and 13 the second year for a total of 30 for two years These figures may be compared to - our experiences but the two groups probably are not strictly comparable The operative and postoperative mortality with the number 1 operation in 75 patients was 6.6 This mortality rate is lower than our previous figures In the last 49 patients operated upon at Mount Sinai Hospital Cleveland the mortality was 2 or about % The mortality in 136 patients occurring from the time of discharge from the hospital up to one year was 6.6 and in 83 patients from one year to two years was 4.8 If these figures are added together the total operative and two year postoperative mortality is 11.4 , which is lower than Lindgren's figures without operation We expect life to be prolonged by operation and this is the most important purpose of our extensive studies on LATE MORTALITY SUBSEQUENT TO DISCHARGE ALL CASES TO JUNE 1954,53 136 - PATIENTS FROM DISCHARGE UP TO ONE YEAR DEATHS . 4.6 # PATIENTS - FROM ONE YEAR UP TO TWO YEARS = 4 DEATHS 4.6 TOTAL - 11,4 ^ MORTALITY IN PATIENTS TREATED SURGICALLY OPERATIVE - 6.6 OURING FIRST YEAR - 6.6 DURING SECOND YEAR - 4.0 TOTAL - 18.0 % plaleddiodalaancaitld MORTALITY IN 88 COMPARABLE PATIENTS TREATED MEDICALLY DURING FIRST YEAR - IS DEATHS - 17 ( } LINDGREN DURING SECOND YEAR - 11 DEATHS 13 TOTAL - 30 % Fig Mortality in several groups of patients blood to ischemic areas of myocardium In view of this limitation the patient with coronary artery disease should be told there is a more effective treatment Operation should be done early in the course of the disease before irreparable damage occurs in the myocardium 2065 Adelbert Rd 6 Dr. Beck 9. Lindgren .; Angina Pectoris A Clinical Study with Special Refer- ence to Neurosurgical Treatment Acta med scandinav supp 243 138 1 1950