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Previous studies showed that pulmonary pathological changes after hemorrhagic shock are similar to those after continuous (2 hours) serotonin infusion. Both conditions produce congestive atelectasis, interstitial and intra-alveolar edema and hemorrhage, and red cell aggregation. Studies in 25 dogs compared pulmonary hemodynamics during 2 hours of hemorrhagic hypotension (40 mm. Hg) with methysergide (serotonin antagonist), without methysergide, and with serotonin (75 mcg. per kilogram per minute) alone. During serotonin infusion in normovolemia, both pulmonary artery (PA) and pulmonary vein wedge (PVW) pressure rose. The pulmonary arteriolar and small pulmonary venous (SPV) constriction were statistically and physiologically significant. Pretreatment with methysergide prior to hypovolemia prevented the SPV pressure rise. Lung changes, grossly, microscopically, and by cinemicroscopy, were greatly reduced by administration of methysergide. These results suggest that serotonin—possibly released by the hypoxic intestine, hypoxic brain, or unstable platelets—plays a significant role in the pulmonary changes secondary to hypovolemic hypotension.

Antegrade and retrograde pressures and flows have been measured in the coronary arteries distal to an obstructive lesion and the retrograde flow and pressure correlated with the arteriographically determined degree of stenosis and extent of collateral circulation. Antegrade pressure and flow were roughly proportional to the estimated degree of proximal obstruction, with little change being noted below 70% obstruction. Below 90% obstruction, minimal collateral flow was demonstrable either by arteriogram or by retrograde flow measurement. Retrograde pressures proved to be surprisingly low, usually being about one-third of the systemic pressure and almost never over 30 mm. Hg. Retrograde pressures were relatively independent of the degree of proximal stenosis or of arteriographically demonstrable collateral circulation. Retrograde flows likewise proved to be surprisingly small, even though the method of measurement allowed for absolutely maximal backflow. Retrograde flow, however, did correlate well with the degree of collateral circulation demonstrated in the arteriograms. Patients with the preinfarction syndrome had the lowest antegrade flows and retrograde flows, which were usually too small to be measured.

Excision of bullous cysts combined with pleural abrasion and tracheostomy appear to be the only surgical procedures available which afford significant improvement. The necessity of preoperative evaluation and meticulous preparation cannot be overemphasized.

Hemodynamic, respiratory, and pathological changes that occur during experimental fat embolism with free fatty acid have been evaluated in mongrel dogs. Most important were the elevation of pulmonary artery and pulmonary artery wedge pressure combined with sustained falls in the pulmonary pressures distal to the pulmonary capillary bed, indicating obstruction at the capillary bed. Systemic blood pressure fell. Decreasing dynamic pulmonary compliance, hypoxemia, and metabolic acidosis have also been consistent. These changes reflect the severe damage to the pulmonary capillary bed secondary to the fatty acid embolus. Results of pathological examination of the lungs revealed marked interstitial and alveolar edema. As the experiment progressed severe erythrocytic clumping and almost complete cessation of pulmonary capillary blood flow became obvious. The proposal that fatty acids are the underlying cause of the findings in tat embolization has been examined.

Results of gas endarterectomy of the right coronary artery were evaluated in 29 consecutive patients. There were one surgical and two early postsurgical deaths. All three had postmortem examination, and in two there was occlusion of the gas endarterectomy. Five patients did not have repeat catheterization. Twenty-one patients were completely re-evaluated and had repeat cardiac catheterization one to sixteen months after surgery (mean eight months). Ten patients (Group A) had gas endarterectomy without a saphenous vein graft to the right coronary artery. Only one patient had significant vessel patency. Eleven patients (Group B) had the combined procedure of a saphenous vein graft anastomosed to the segment of artery that had the endarterectomy. There was excellent graft patency in seven patients (64%) and good distal flow into the segment that had endarterectomy in six of the seven patients. In conclusion, gas endarterectomy is not of value unless it can be combined with a saphenous vein graft to provide good flow to the distal vessel that had endarterectomy. Results with the combined procedure suggest that even with a severely diseased artery, gas endarterectomy can often provide continuing distal runoff for the graft.

Sixteen months' experience with intraaortic balloon pumping in a cardiac surgical unit is reported. Eight patients presented in cardiogenic shock and required immediate pumping prior to cardiac catheterization and operation. Sixteen patients undergoing elective cardiac procedures had pumping in the immediate postoperative period because of myocardial depression. Twenty of these 24 patients were able to be restored to cardiovascular stability. Mortality and morbidity in these patients are discussed as well as complications of intraaortic balloon counterpulsation. Our current methods of balloon insertion and deployment are presented.

Two hundred fifty-five determinations of the protamine sulfate test, the staphylococcal clumping test, and the tanned red blood cell hemagglutination inhibition immunoassay were performed on 30 patients undergoing cardiovascular surgery. The level of serum fibrin-fibrinogen degradation products rose in all patients and reached the highest levels between the fifth and ninth postoperative day. After the first postoperative day, a fibrin-fibrinogen degradation product increase of greater than 10μg/ml within 24 to 48 hours was associated with clinically recognized thrombotic complications in only two out of five patients. Isolated levels of serum fibrin-fibrinogen degradation products as high as 67μg/ml could not be correlated with clinically evident thrombotic disease or serious complications of surgery. Increased excretion of urinary fibrin-fibrinogen degradation products was associated with, but not predictive of, acute ischemic renal failure.

Mechanical complications that cause heart failure after acute myocardial infarction may be corrected early by surgery. The development of effective cardiac assistance by intra-aortic balloon pumping (IABP) has proved invaluable in resuscitating patients in over-whelming cardiac failure, maintaining them during diagnostic evaluation, and affording long-term (up to two weeks) postoperative support. Four of five patients with acutely expanding ventricular aneurysms, two of six patients with acute mitral regurgitation, and one of two patients with acute ventricular septal defects are living and well. Ten of these 13 patients required IABP. Seven of the group, which was totally refractory to medical therapy, are long-term survivors as a result of this combined supportive, diagnostic, and surgical approach. Usually the heart can be repaired successfully. Patients are lost primarily from the ravages, prior to surgery, of over-whelming cardiac failure on other organs.

Iatrogenic injury to the thoracic duct followed percutaneous cannulation of the left internal jugular vein. The case was managed successfully by supraclavicular ligation of the thoracic duct. We feel cannulation of the right internal jugular vein is preferable to cannulation of the left internal jugular vein.

If middle-class parents are to act in accord with their values, they must take explicit account of subjective and emotional factors, including the possible effects of punishment. They give considerable evidence that they so do. For example, when asked if there are any ways in which they would prefer to act differently toward the child, they are likely to cite the desirability of fuller understanding. When the child does poorly in school, they often try to be supportive, while working-class parents are likely to respond negatively. Of course, parents can rationalize. It is easy to believe that behavior which is at the moment infuriating ought to be punished. One gains the impression, however, that although middle-class parents may punish when angry, they try to restrain themselves-as they apparently do when they believe their children's actions to be wild play.12 The working-class orientation, on the other hand, excludes or minimizes considerations of subjective intent, and places few restraints on the impulse to punish the child when his behavior is out of bounds. Instead, it provides a positive rationale for punishing the child in precisely those circumstances when one might most like to do so.

THIS report deals with the treatment of pulmonary embolism by the application of the partially occlusive Mortez 1 clip to the inferior vena cava in 62 patients over a five-year period. The effectiveness of the clip in controlling recurrent pulmonary emboli was evaluated. The patency of the inferior vena cava has been determined in 31 of 43 patients surviving six months or more, and the degree of venous insufficiency has been examined. The Moretz clip is but one of many nonligation techniques described which offer the theoretical advantage of inferior vena caval patency while protecting the patient against a fatal pulmonary embolus. 1 There have been many reports dealing with the various methods of achieving this using a filter, 2 plication with suture, 3 or staples, 4 or with a clip, with 5 or without compartmentalization. 1 It seemed apparent that more information was needed to evaluate the long-term caval