Abstracts of Papers 145

drop in blood pressure, there was a corresponding acceleration of the heart rate of only 10 beats/min. The orthostatic hypotension was idiopathic in 21 cases (16 men and 5 women). In 41 cases orthostatic hypotension was associated with a condition known to result in autonomic nervous dysfunction. Of these conditions, diabetic neuropathy (11 cases) and tabes dorsalis (5) were the most frequent. Symptoms in- cluded lightheadedness upon standing (34 observa- tions), syncope (27), weakness (23) and aggravation of the symptoms in the morning, after exercise or in hot weather (23). Anhidrosis was observed 32 times and impotence 11 times. The orthostatic hypotension was idiopathic in 7 of the 10 cases in which symptoms were markedly disabling.

The incidence of idiopathic orthostatic hypotension (approximately one third of all cases of orthostatic hypotension), its predominance in men (two thirds of the idiopathic cases) and the frequent marked severity of symptoms and resulting disability (one third of the idiopathic cases) are stressed.

*63. Practical Aspects of the Diagnosis and

Treatment of Lymphedema, ALEXANDER SCHIRGER, M.D. and JOHN A. SPITTELL, JR., M.D., Rochester, Minn.

Lymphedema is not an uncommon entity in cardio- vascular practice. Its correct diagnosis is important because, when it is mistaken for edema of systemic origin or confused with deep venous insufficiency, inadequate or even improper treatment may result.

Furthermore, the differential diagnosis between idiopathic (primary) and secondary lymphedema of the lower extremity is important, since the latter may reflect a significant underlying disease. Of 211 patients with lymphedema of the lower extremity seen in a seven year period, 131 had idiopathic lymphedema (123 lymphedema praecox, 8 congenital lymph- edema), and 80 had secondary lymphedema.

Idiopathic lymphedema affected women 10 times more often than men, and swelling began before the age of 40 years in most patients. Half the patients had bilateral lymphedema, and a fourth had com- plicating lymphangitis.

In contrast, secondary lymphedema affected men as often as women, rarely started before the age of 40 years and seldom affected both legs except when caused by infection. The most common cause was recurrent lymphangitis, often associated with tri- chophytosis. Under this circumstance, an infectious episode always preceded the onset of permanent swell- ing. The second most common cause of secondary lymphedema was neoplastic disease, prostatic car- cinoma predominating in men and lymphoma in

VOLUME 15, JANUARY 1965

women. In several cases, lymphedema was the first manifestation of the neoplasm.

Once a diagnosis is established, proper treatment can be undertaken. Although lymphangiography aids in differential diagnosis between idiopathic and secondary lymphedema, diseases often can be dis- tinguished by historical features and physical findings.

Treatment consists of elevation of the affected extremity, mobilization of fluid with aid of a thiazide diuretic, use of proper and adequate elastic support, and antibiotic therapy when there is infection. In selected cases, surgical ablation of lymphedema tissue is warranted for cosmetic or mechanical reasons. Awareness of the rare complication of lymphangio- sarcoma is necessary, since only with prompt surgical therapy can a cure be gained.

*64. Serum Cholesterol as an Acute Phase

Reactant, MYRON R. SCHOENFELD, M.D., New York, N. Y.

Serial studies have been made of the serum choles- terol changes in acute and chronic somatic and psychic stress states and in dysproteinemias. It was found that the serum cholesterol was strikingly depressed during the active phase of all somatic diseases tested such as myocardial infarction, strokes, bronchopneumonia, lung abscess, empyema, pul- monary tuberculosis, typhoid fever, acute nonspecific gastroenteritis, acute cystitis, acute and chronic pyelonephritis, surgery, acute and chronic gastro- intestinal or vaginal bleeding, congestive heart failure. Hypocholesterolemia developed within 24 to 72 hours, tended to be proportional to the severity of the stress, and often was present even with seemingly mild disease. A fall of 40 to 200 rng.% below the patient’s normal control value was consistently ob- served. This meant that, in the severest cases, the serum cholesterol reached levels as low as 40 to 80

mg.% The cause of this hypocholesterolemia is thought to

be qualitative and quantitative changes in the serum proteins which mediate their effect in two ways: (1) by a decrease in their chemical capacity to carry cholesterol, and (2) by a decrease in their capacity to bind thyroxine, which, in turn, causes a reciprocal increase in the serum-free thyroxine and depression of cholesterol biosynthesis and an acceleration in its degradation. This same explanation is believed to account for the frequent occurrence of hypocholes- terolemia in multiple myeloma and related dyspro- teinemic states.

On the other hand, severe psychic stress engendered by fear or pain increases the serum cholesterol 50 to 100 mg.% above the patient’s control level within 12 to 24 hours. This has been observed in acute

146 Abstracts of Papers

coronary insufficiency without infarction, during

cystoscopy or proctosigmoidoscopy, and in fearful

patients just prior to surgery or other forbidding

diagnostic procedures. The cause of this hyper-

cholesterolemia is not entirely clear, though perhaps

the adrenal hormones and a release of cholesterol

from the brain itself play important roles. This inter-

esting difference in behavior of the serum cholesterol

with somatic and psychic stress has proved to be a

useful guide in helping to decide which cases of acute

coronary insufficiency have developed into myocardial

infarction.

65. “Silent” Rheumatic Heart Disease, BERNARD

L. SEGAL, M.D., WILLIAM LIKOFF, M.D., F.A.c.c.,

ALBERT KASPAR, M.D., HRATCH KASPARIAN, M.D.

and PAUL NOVACK, M.D., Philadelphia, Pa.

The murmur has long been recognized as the

conventional hallmark for valvular heart disease.

Seventeen patients with aortic regurgitation, 4

with mitral regurgitation, 4 with tricuspid regurgita-

tion and 3 with mitral stenosis were examined fre-

quently over long intervals. No murmurs of valvular

regurgitation or stenosis were heard or recorded by

external phonocardiography at any time at rest,

after exercise or after metaraminol (Aramine@)

infusion. A clinical diagnosis of associated valvular

lesions led to their investigation.

Cineangiography showed grade 2 and 3 aortic

regurgitation (grading 1 to 4), grade 2 mitral re-

gurgitation and grade 2 tricuspid regurgitation.

Left heart catheterization demonstrated a severe

gradient (18 to 25 mm. Hg) across the mitral valve

in the patients with “silent” mitral stenosis. Intra-

cardiac phonocardiography demonstrated the mur-

mur of aortic regurgitation in the left ventricle in 2

patients with no transmission to the chest wall.

Ventricular rates were not rapid; cardiac outputs

varied from 3.5 to 5.7 L./min. and the end-diastolic

pressures in both left and -ight ventricles were nor-

mal.

Serious aortic, mitral and tricuspid regurgitation

can occasionally occur in the absence of an audible

regurgitant murmur; also, severe mitral stenosis with

pulmonary hypertension is sometimes “silent.”

66. Secundum Type Atria1 Septal Defects: Early

and Late Results of Surgical Repair Utilizing

Extracorporeal Circulation in 250 Patients, ROBERT

D. SELLERS, M.D., RANDOLPH M. FERLIC, M.D.,

L. P. STERNS, M.D. and C. WALTON LILLEHEI, M.D.,

F.A.c.c., Minneapolia, Minn.

The isolated secundum type of atria1 septal defect

accounts for 10 to 15 per cent of the congenital

cardiac lesions that are amenable to correction by

open cardiac surgical methods and was the first

intracardiac lesion to be successfully repaired under

direct vision (inflow stasis and hypothermia). To

data, relatively few studies have been made of the

early and late results in a large series of patients with

this defect treated by extracorporeal circulation.

Our experience at the University of Minnesota Medi-

cal Center includes over 350 patients, 250 of whom

have been operated upon since 1956. The pump

oxygenator was used exclusively.

In this group of 250 patients the age varied from

under 12 months to 65 years. There were 8 hospital

deaths (3.2% operative mortality) and 1 late death

(0.40/, late mortality). Six of the 8 were infants oper-

ated upon because of severe distress.

All of the patients had preoperative catheterization

studies and 75 have had postoperative catheteriza-

tions. Of the patients studied following surgery, 95

per cent have had complete correction of their lesion

and restoration of their circulatory system to normal.

Preoperatively six of the patients had severe pul-

monary hypertension with systemic pulmonary artery

pressures. In these, closure was achieved by utilizing a

one way silastic valve which will be described. Par-

ticular emphasis has been placed upon the late follow-

up results in this high-pressure group as well as in

the other older patients.

67. Postcardioversion Ventricular Tachycardia,

JAMES A. SHAVER, M.D., FRANK W. KROETZ, M.D.,

RUBEN TENICELA, M.D., JOHN F. LANCASTER, M.D.

and JAMES J. LEONARD, M.D., Pittsburgh, Pa.

In our series of 84 synchronized countershocks in

67 patients, ventricular tachycardia (VT) occurred

in the immediate postcountershock period in 3 pa-

tients having chronic atria1 fibrillation (AF). During

cardioversion, 2 patients, postmitral commissurotomy,

developed recurrent episodes of VT. One patient

had three successive bouts, each terminated by

countershock, ultimately stabilizing to the previous

AF. In a second patient 6 such arrhythmias

were terminated by six countershocks. Stable sinus

rhythm occurred only after the infusion of 750

mg. procaine amide during the final three episodes.

A third hypertensive patient developed VT which

reverted to the previously present AF after a single

countershock. Every patient received quinidine sul-

fate prior to cardioversion. All received cardiac

glycosides, but in only the third case could possible

digitalis intoxication be implicated. Light sodium

pentothal anesthesia was used. In each patient,

following the initial countershock, normal sinus beats

were observed prior to spontaneous development of

VT, thereby ruling out improper synchronization of

THE AMERICANJOURNALOF CARDIOLOGY