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A comparison of the effects of anesthetic doses of morphine—1 to 3 mg. per kilogram of body weight—and halothane—0.1 to 1.5%—was obtained by determining the blood requirements intraoperatively and 24 hours postoperatively of 105 patients, 45 of whom underwent elective aortic or mitral valve replacement with the remaining 60 undergoing aortocoronary bypass grafting procedures. Of the 51 patients receiving morphine, those who underwent aortic or coronary artery operations needed significantly more blood postoperatively; all required more blood postoperatively than did the 54 patients receiving halothane. Three of the patients who had coronary artery operations and 2 who underwent mitral valve replacement died during or within 24 hours of operation and thus were not included in the final study. We believe, therefore, that, when compared with halothane, morphine produces an increase in total vascular capacitance and that increased intraoperative and postoperative replacement of blood or other colloids is required in order to maintain myocardial filling pressures and outputs.

In an attempt to ascertain the value of mediastinoscopy in peripheral lung lesions, records of 157 patients undergoing cervicomediastinal exploration (CME) at Wilford Hall USAF Medical Center were reviewed. Among patients with benign lesions, CME was positive in 90.6% of those who had central lesions and 58.3% of those with peripheral lesions. It was positive in all 7 patients who had peripheral lesions with associated mediastinal nodes on roentgenogram and negative in all 5 who had peripheral lesions without nodes. In the patients with malignant lesions, CME was positive in 72.9% of those who had central lesions and 58.1% of those with peripheral lesions. It was positive in 24 of 27 patients who had peripheral lesions with associated mediastinal nodes and negative in 15 of 16 patients with peripheral lesions without nodes. Although we recognize this to be a selected series, CME does appear to be valuable in patients with central lesions and peripheral lesions with mediastinal nodal involvement on roentgenogram. It does not appear to be as useful in those with peripheral lesions who do not have central nodal involvement.

A new technique consisting of the subcutaneous insertion of molded Silastic implants in patients with pectus excavatum deformities is presented. This method of correction should be considered for patients who are devoid of cardiac and respiratory symptoms and for those in whom the only operative indication is cosmetic. The surgical technique is simple, the complication rate is low, and patient tolerance is good. The cosmetic appearance at one year appears excellent.

A reproducible canine model of stone heart (irreversible left ventricular rigor) is described. During the studies, perfusion of the coronary circulation with various concentrations and compositions of magnesium sulfate solutions did not significantly influence the development of stone heart. Approximately 90 minutes of normothermic, ischemic arrest appeared to be the turning point for the transition of left ventricles from a flaccid state to one of rigor. In spite of left ventricular rigor, right ventricles remained flaccid and could be defibrillated. Ultrastructural studies showed that mitochondria were destroyed in left ventricles in rigor while right ventricular mitochondria were preserved even after two hours of normothermic, ischemic arrest. In either ventricle, glycogen granules were dissipated after two hours. The increased incidence of left ventricular rigor after two hours of normothermic, ischemic arrest compared with one hour of ischemic arrest was highly significant.

Ten patients with biopsy-proved eosinophilic granuloma of the lung were followed for periods of as long as nine years. The disease occurs as an isolated lung lesion or in association with bone lesions. The roentgenographic pulmonary findings are either diffuse nodularity or a fine reticular pattern. Symptoms are few, and pneumothorax is frequent. Scalene node and liver biopsies are usually not fruitful, and the diagnosis must be made by open or needle lung biopsy. Consistently abnormal laboratory tests are impaired single-breath carbon monoxide diffusing capacity and elevation of the alpha 2 globulin protein fraction of serum. Treatment usually is not required; however, if deterioration occurs, the patient may benefit from corticosteroid therapy.

A patient with spontaneous chylothorax associated with a lymphogenous thymic cyst and multiple lymphangiomata of bone is reported and literature on the association of chylous effusion with mediastinal lymphangioma and lymphangiomata of bone reviewed. We offer further support for the concept that this syndrome represents a generalized abnormality of the lymphatic system.

Larsen, G. L., Armstrong, R. G., Stanford, W., and Cline, R. E. (1973).Thorax, 28, 641-643. Granular cell myoblastoma of the oesophagus. During evaluation of symptoms of oesophageal reflux in a 40-year-old man, a filling defect of the distal oesophagus was seen on the oesophagogram, and this was noted to be a submucosal mass at oesophagoscopy. He also had an oesophageal hiatus hernia. The lesion proved to be a granular cell myoblastoma, a rarity in the oesophagus, only 11 previous cases having been reported. Symptomatology evaluation and management of granular cell myoblastoma of the oesophagus are discussed. As with other submucosal lesions of the oesophagus, preoperative biopsy through an intact mucosa is to be avoided because of danger to the patient from haemorrhage or perforation and subsequent inflammatory reaction making surgical resection and microscopic diagnosis difficult.

Three cases of recurrent tracheoesophageal fistula have been added to the 64 reported in the literature. Recurrence is suspected in patients with a previous repair who develop recurrent pneumonia, asthmatic attacks, or choking spells. The diagnosis can be established by barium swallow roentgenography or, in difficult cases, by staining of the esophagus by contrast medium introduced into the trachea. Prevention is best accomplished by an accurate repair without tension, by strict adherence to aseptic techniques, and by using fine, nonabsorbable suture material. The interposition of a pleural flap between the trachea and esophagus diminishes the chance of an initial recurrence and is very useful at the time of reoperation for a recurrent fistula.

The rapid infusion of a refrigerated, buffered albumin electrolyte solution combined with simultaneous exsanguination (total-body washout) is designed to remove the circulating neurotoxic substances that are associated with hepatic coma. This technique thereby permits time for liver regeneration by delaying the patient's death due to progressive encephalopathy. This safe, simple procedure also promptly controls bleeding problems, helps to stabilize blood pressure, and promotes diuresis. No serious complications have been observed, and the procedure now seems indicated when conventional forms of therapy fail to control progressive hepatic coma.

Bilateral adjacent neurogenic tumors of the mediastinum were excised in a 20-year-old man through a single left thoracotomy. The presence of bilateral lesions was indicated by the discrepancy betweeen excised tumor and the mass on x-ray examination. Two distinct histologic patterns resulted in one mass representing a ganglioneuroma, and the second, a neurofibroma.

Giant left atrium is an unusual finding in mitral valve disease. The chief question about the enlarged atrium is whether to reduce its size by partial excision of its wall. Simple mathematical considerations suggest that partial excision offers no significant hemodynamic benefit.