859

unclamped at this stage to prevent over-distension of thearrested heart.After a satisfactory beat has been established and care has

been taken to ensure that there is no air in the left side of the

heart, the vent is removed. In case 3, with multivalvulardisease, aortic valve replacement was successfully achieved, butthe mitral valve was grossly calcified, fibrotic, stenosed, andincompetent. Because of difficulties in the exposure the mitralvalve could not be replaced; hence only a valvotomy underdirect vision could be performed, which resulted in mitralincompetence.

’

ResultsOf the 5 patients in the series, 4 are alive and well after

their operations. The first 2 were operated upon sevenmonths ago, case 4 five months ago and case 5 four monthsago. Case 3 died 5 days after surgery, from heart-failure.At necropsy the aortic valve was shown to have been

successfully replaced. The mitral valve was grosslydiseased and incompetent, and there was evidence ofsevere left and right heart-failure.Pressures measured across the prosthetic valve, obtained

by needle puncture just after discontinuing bypass, areshown in table iv. There was no evidence of aortic

incompetence and no significant gradient across the valve.The preoperative and postoperative phonocardiogramsand pulse pressures are shown in fig. 5.Anticoagulants were not used in any of these cases after

operation and, to date, there has been no evidence ofclotting or of embolism. All 4 surviving patients are freeof cardiac symptoms.

Conclusions and SummarySuccessful operations for -acquired aortic valve lesions

depend on:(1) a technique which will allow a long but safe total body

perfusion;(2) adequate protection of the myocardium during bypass;

and(3) complete correction of the lesion.

In our hands this has been rendered possible by:(1) the use of haemodiluted high-flow perfusion with

moderate hypothermia;(2) perfusing both coronary arteries with cold oxygenated

blood and preventing ventricular distension;(3) by total replacement of the aortic valve with a reliable

prosthesis.A prosthesis based on the same principles as the

lenticular mitral prosthesis has been devised and tested inour laboratory. The absence of a cage, and ability toinsert the mobile portion of the prosthesis after completingthe insertion of the fixed ring, greatly facilitate the correctimplantation of the prosthesis. In addition, the valvedesign produces only slight gradients across the prosthesis.

All 4 patients in whom the aortic valve alone wasaffected recovered after surgery, and no longer havecardiac symptoms. The 1 patient with multivalvulardisease, in whom only the aortic lesion was corrected,succumbed. Correction of all valvular lesions at a singleoperation when multivalvular defects are present isessential for survival. To date, up to seven months aftersurgery, there has been no clotting or formation of emboli,and all 4 surviving patients have returned to normalactivity.A further aortic valve replacement has been performed

since, and this 6th patient is well and has suffered nosetbacks since operation a month ago.We wish to thank Prof. J. H. Louw of the department of surgery,

University of Cape Town, for his constant support and encourage-ment ; the technical staff of the J. S. Marais Surgical ResearchLaboratory; and the staff of the Cardiac Clinic, Groote Schuur

Hospital, for- their assistance; Dr. J. G. Burger, medical superinten-dent of Groote Schuur Hospital, for permission to publish details ofthe cases; and the University of Cape Town, the Council for Scientificand Industrial Research, the City Council of Cape Town, and theTeaching Hospitals’ Board, for financial support.

REFERENCESBarnard, C. N., Goosen, C. C., Holmgren, L. V., Schrire, V. (1962) Lancet,

ii, 1089.— Schrire, V., Goosen, C. C., Holmgren, L. V. (1963) S. Afr. med. J.

37, 97.Beall, A. C., Morris, G. C., Cooley, D. A., DeBakey, M. E. (1961)

J. thorac. Surg. 42, 497.Harken, D. E., Taylor, W. J., Lefemine, A. A., Lunzer, S., Low, H. B.,

Cohen, M. L., Jacobey, J. A. (1962) Amer. J. Cardiol. 9, 292.Hufnagel, C. A., Conrad, P. W. (1962) New Engl. J. Med. 266, 72.

— Villegas, P. D., Nahas, H. (1958) Ann. Surg. 147, 636.Kay, E. B., Mendelsohn, D., Suzuki, A., Zimmerman, H. (1961) J. Amer.

med. Ass. 176, 1077.— — Zimmerman, H. (1962) Amer. J. Cardiol. 9, 284.

Kerwin, A. J., Lenkei, S. C., Wilson, D. R. (1962) New Engl. J. Med. 266, 852.Larson, R. E., McGoon, D. C. (1961) Surg. Forum 12, 242.

— — (1963) J. surg. Res. 3, 104.Lillehei, C. W., Barnard, C. N., Long, D., Sellers, R. D., Schimert, G.,

Varco, R. L. (1961) in Conference on Prosthetic Valves for CardiacSurgery (edited by K. A. Merendino); p. 527. Springfield, Ill.

McGoon, D. C. (1961) Proc. Mayo Clin. 36, 88.— Mankin, H. T., Kirklin, J. W. (1963) J. thorac. Surg. 45, 47.— (1963) Surgery, 53, 373.

Muller, W. H., Warren, W. D., Dammann, J. F., Beckwith, J. R., Wood, J. E.(1960) Circulation, 21, 587.

Murray, G. (1956) Angiology, 7, 446.Prochazka, J., Jedlicka, J., Hudler, L., Endrys, J. (1961) Rozhl. Chir. 40, 608.Roe, B. B., Najarian, J. S., Moore, D. (1957) Ann. Surg. 145, 388.

— Burke, M. F., Zehner, H. (1960) J. thorac. Surg. 40, 561.Ross, D. N. (1962) Lancet, ii, 487.Starr, A., Edwards, M. L., McCord, C., Griswold, H. E. (1962) Unpublished.

BLOOD-LOSS IN GENERAL SURGICALPATIENTS

A. J. S. GARDINERM.B. Aberd.

RESEARCH FELLOW

H. A. F. DUDLEYCh.M. Edin., F.R.C.S.E.

SENIOR LECTURER *

DEPARTMENT OF SURGERY, UNIVERSITY OF ABERDEEN

DESPITE many reports and papers, there is little informa-tion on the loss of blood during general operationsperformed according to standard British practice. Thisis largely because of inadequacies in the measurement ofblood-loss (Gardiner and Dudley 1962). In the past twoyears the use of an accurate device has permitted us todetermine the blood-loss of a large number of patientsoperated upon almost exclusively by one surgical team.

MethodThe instrument for extraction-dilution analysis and its

use have already been described (Roe et al. 1962).Recoveries of the blood lost have been repeatedly checked

TABLE I-GASTRIC OPERATIONS

and are always greater than 99%. The machine is accuratewithin ± 3%. Standard anxsthetic techniques were usedwithout hypotension, except for the occasional inclusion* Present address: Department of Surgery, Monash University, Prince

Alfred Hospital, Melbourne, Australia.

860

TABLE II-GALLBLADDER AND BILIARY-TRACT OPERATIONS

of halothane which resulted in the systolic pressure fallingto levels between 85 and 100 mm. Hg. Halothane was notused to reduce bleeding.

Results

Operations on the stomach and duodenum, the biliarytract, the colon and rectum, the breast, and the prostategland are considered separately.

In formal primary operations for peptic ulcer (table I),whether these involved dissection of the duodenum andresection of the stomach or merely nerve section and drain-age, the blood-loss never exceeded 340 ml. and averaged125 ml. for drainage procedures and 225 ml. for resections.The small number of patients who underwent antrectomy

TABLE III-OPERATIONS ON THE COLON

plus vagotomy was partly accounted for by a tendencyto avoid dissection of the difficult duodenum (Dudley andAnderson 1962). Blood-loss was continuously monitoredin the patients undergoing these operations. The verticalmidline or paramedian incision produced an average lossof 55 ml. or up to a third of the total blood-loss.Somewhat unexpectedly, secondary operations for

stomal ulcer or conversion from Polya to Billroth I type ofreconstruction did not occasion greater losses in the smallnumber of patients studied, and in 6 patients the loss neverexceeded 325 ml. (table I). In total resection for cancerthe losses were larger, ranging from 380 to 645 ml.

(table i).Removal of the gall-bladder with or without exploration

of the duct (table 11) produced an average loss of 120 ml.,

TABLE IV-OPERATIONS ON THE BREAST

although bleeding from the gallbladder bed raised the lossin one instance to 380 ml. Palliative operations for

malignant jaundice resulted in an average loss of 120 ml.Anterior resection and hemicolectomy for large-bowel

cancer (table ill) gave surprisingly low figures in the range105-240 ml. In radical perineal dissection the loss rosesharply, and synchronous combined excision for cancergave rise to losses of up to 930 ml. and never less than395 ml. The more limited perineal dissection in rectal

excision for ulcerative colitis produced a correspondinglylower loss of blood.

Radical mastectomy for cancer (table iv), like abdomino-perineal excision, caused consistently large losses of bloodby contrast with the minor losses in local excision.

Although the range was up to 600 ml., the average was340 ml.Minor dissections such as herniorrhaphy, appendicec-

tomy, colostomy, and exploratory laparotomy producedsmall losses, but nephrectomy can be regarded as" moderate " with an average of 245 ml. and a range of140-350 ml. (table v). The opportunity to measure blood-

TABLE V-MISCELLANEOUS MINOR OPERATIONS

loss in the more extensive operations is, of course, morelimited, but table vi shows the massive losses that mayarise during the dissection of great vessels, when bleedingis already present, or in oesophagectomy in attempts todissect the tumour away from the aorta. In such complexinstances only an objective record can ensure accuratereplacement of lost blood.

Operations on a vascular organ such as the prostategland produce moderate to severe blood-loss, but in thetwo operations of transvesical prostatectomy the patientswere severely hypertensive (table vn).

TABLE VI-MISCELLANEOUS MA]OR OPERATIONS

Discussion

These figures are for the most part surprisingly low,and, were we not confident of the accuracy of the method,they would be suspect. They emphasise again that withgood anxsthesia, accurate dissection, and the avoidance ofbloody mobilisation of diseased structures, such as theduodenum, loss of blood in standard operations shouldrarely approach half a litre. Surgeons have becomeaccustomed to the idea that they underestimate blood-loss,particularly when large quantities are shed. Our findingssuggest that this is unlikely under favourable circumstances.We believe that these figures are of interest for three

TABLE VII-OPERATIONS ON THE PROSTATE GLAND

861

further reasons. First, they provide further evidence toreverse the tendency, perhaps already in decline, towardsindiscriminate transfusion of blood in every majoroperation. A reserve of blood to cover gastroduodenaloperations is now no longer demanded from the bloodbank, although we still group the patient and hold hisserum in readiness for the unforeseen emergency.Secondly, a firm decision must be reached on the likelihoodof having to replace blood on a large scale in some patients.A patient whose blood-volume is already marginal mayconceivably be harmed by a relatively small loss of blood,and such losses, moreover, may delay convalescence in away that’ is not obvious from gross clinical indices. If thisis so, a case could be made for blood-transfusion depart-ments to package a proportion of their blood in 250 ml.units rather than in 500 ml. units.

Finally, we believe that our figures show the need formore careful analysis of the cause of hypotensive episodesduring and after operations before ascribing them to lossof blood. We do not suggest that blood should be with-held when it is clearly indicated, but that acceptance ofhypovolaemia should be avoided unless there is objectiveevidence obtained by an accurate technique such as wehave described.

REFERENCES

Dudley, H. A. F., Anderson, W. A. (1962) J. R. Coll. Surg. Edinb. 7, 206.Gardiner, A. J. S., Dudley, H. A. F. (1962) Brit. J. Anœsth. 34, 653.Roe, C. F., Gardiner, A. J. S., Dudley, H. A. F. (1962) Lancet, i, 672.

XANTHOMA TUBEROSUM MULTIPLEXCOMPLETE RECOVERY

WITH CHOLESTEROL-LOWERING DIET

VIDAR JENSENM.D. Oslo

DISTRICT MEDICAL OFFICER, NORDLI, NORWAY

IN May, 1961, I was consulted by a 30-year-old manwho since the age of 14 had had an increasing number offirm yellow-white nodules in the skin of his palms, fore-arms, elbows, feet, legs, knees, and groins. In the pre-vious 3-4 years the palms of his hands had become com-pletely covered with nodules, and these had become soprominent and confluent (and also slightly tender) thatthey interfered with his work as a customs official. Hewas keen on outdoor life and shooting, but for the pastfew years he had had to use gloves to chop wood and tohold a gun. It was also difficult for him to use bootsand to go for long walks, because of the many tendernodules on the soles of his feet and over the calcaneus.The man was slim, and appeared to be otherwise completely

healthy; and on examination I found no other abnormality.The patient said that he had no significant previous illness.None of the nodules had ever disappeared, they had alwaysincreased in number and extent. The nodules were yellowishwith an average diameter of from 4-5 mm. to 10-12 mm.

arranged in groups in the skin under the epidermis, firm,slightly prominent, confluent in many places, and the palmsof the hands were completely covered. There were no noduleson the face, scalp, neck or trunk, and the patient had noxanthelasma on the eyelids. I judged the total number ofnodules on the hands and forearms alone to be between 200and 300.

I excised an isolated nodule and sent it to the NorwegianRadium Hospital, with a tentative diagnosis of leprosy. Themterim report was that the microscopic appearances could fitm with fibroxanthoma, but, since they were also possiblyconsistent with leprosy, additional investigations were

necessary; had the patient hypercholesterolxmia ? A blood-sample was therefore sent to the central clinical chemistr)laboratory at the Central Hospital in Trondheim and the

serum-cholesterol was reported as 590 mg. per 100 ml.estimated by the method of Schoenheimer and Sperry. For

comparison the average value in blood-donors in Trondheimin the age-group 45-54 years was given as 240 mg. per 100ml. (Dr. Jacob C. Lund). This result, together with theadditional information that the patient did not know of theexistence of skin nodules, xanthelasma, cardiac infarct, or

angina pectoris in his relations and that he himself had neverhad any anginoid symptoms, was reported to the pathologistin the Norwegian Radium Hospital.The final diagnosis was xanthoma tuberosum multiplex

(Dr. Kirsten Osen).The patient was advised to go into hospital for investigation,

but was unwilling to do so. I then advised him to avoid animalfats completely, to avoid margarine or butter on his breadcompletely, not to eat pork or fatty meat, cheese or other milkproducts, or eggs, but to confine himself to vegetable oils

(soya, maize, and sunflower-seed oil) for all cooking (includingbaking), and to use plenty of herring, fish, and fish-oils andto take a large dessertspoon of cod-liver oil every day.The patient’s previous diet had been the crofter’s normal

fare in these parts with no excessive consumption of animalfats.

I was surprised when he reappeared 9 months later (May16, 1962) to tell me that the disease that had bothered himto an increasing extent for the last 12-15 years was now com-pletely cured. He had kept to the diet. His skin was nowsoft and free from’ blemishes everywhere. The serum-

cholesterol was 318 mg. per 100 ml. The patient said that hehad noticed a definite decrease in size of the nodules afterabout 6 weeks, and after 4 months all the nodules had

disappeared.A year later the serum-cholesterol, taken at the same time

of day and estimated at the same laboratory, had gone downto 274 mg. per 100 ml. The patient’s skin was still soft

everywhere and completely normal, without the least sign ofnodules or remains of nodules.The patient said that he had decided to continue with the

strict diet for the rest of his life, and did not consider this anuisance. He also said that he now felt in better form thanever before.At follow-up 1112 years after the start of dietary therapy the

serum-cholesterol was 237 mg. per 100 ml., and on May 4,1963, it was 256 mg. per 100 ml., estimated at the same

laboratory. The skin over his whole body showed no tracesof the nodules.

Discussion

According to Anderson (1961) xanthoma tuberosummultiplex has hitherto often been regarded as a neoplasticlesion, but there is now general agreement that it shouldbe classified with xanthomata of the skin and thereforerelated to xanthoma dissemination and xanthoma dia-beticorum. The lesions in these two disorders, however,are usually much smaller and of more uniform size. Theserum-cholesterol is not raised in xanthoma dissemination,whereas xanthoma tuberosum multiplex, because of thecoincident hypercholesterolaemia, must be regarded as

an anomaly of fat metabolism and thus as a systemicdisease. The heart, blood-vessels, and liver may beaffected (Muller 1938, Alvord 1949, Beaumont 1950,Anderson 1961.) Sudden cardiac death has been reportedin children with xanthoma tuberosum multiplex in whompronounced coronary atherosclerosis was found at

necropsy (Rigdon 1950). The sites of predilection inxanthoma tuberosum multiplex are the skin on theextensor surfaces of the extremities, the palms of thehands, and soles of the feet, and often the tendon sheathsas well. The condition usually advances slowly over

many years.The xanthomata are characterised by microscopically

localised accumulations of lipoid deposits, histiocytes con-