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formerly recommended by some authors is to be discouraged. Aspiration drainage of the cyst is dangerous and does not allow removal of the cyst. Following aspiration, the cyst fluid results in multiple implants of the larvae. 9 •25 The technique for removal of the cyst depends upon its location. Even though one prefers to remove it completely, excision of the pericyst is not mandatory, especially if it is adherent to vital structures. Before removal, the cyst should be sterilized by injection of 10 ml of 10 percent formaldehyde. The cyst can then be removed. In case of a complicated cyst when complete removal of the cyst is impossible, curettage of the remaining cyst wall is recommended, followed by irrigation of the pleural space. If the cyst is ruptured before the injection of Formaldehyde, careful irrigation of the area and the pleural space is advised. At the time of surgery for mediastinal hydatid disease, one should examine the other thoracic organs for hydatid cysts. In our case, other studies should be done to rule out hydatid disease in other organs. Since there is the possibility of other as yet unrecognized cysts or larvae, surgical treatment should be followed by periodic treatment with hydatid antigen (biologic treatment'"'). REFERENCES

1 MAGATH T.B.: The present status of hydatid disease in North America, Arch. Int. Hidatidosis, 11:193, 1950. 2 MAGATH T.B.: The epidemiology of hydatid disease in Canada and the U.S.A., Arch. Int. Hidatidosis, 5:55, 1941. 3 BLAXSLEY, J.: Datos de la Direcci6n de Enfermedades Transmisibles. Secretaria de Salud PUblica Argentina, (in press). 4 LOPEZ, A.: Radiodiagn6stico del quiste hidatidico del mediastino, Rev. Centro Est. Med. Rosario, 2:455, 1922. 5 VILLEGAS, R: Quiste hidatidico del mediastino, Bol. Trab. Soc. Cirug. Bs. As., 13:567, 1929. 6 CHRISTMANN, F.: Quiste hidatidico del mediastino posterior, Arch. Clin. Quir. La Plata, 7:173, 1939. 7 LAGOMARSINO, E.: Quiste hidatidico del mediastino, Rev. Cir. de Buenos Aires, 19:444, 1940. 8 RAXoWER, J., AND MILWIDSXY, H.: Hydatid pleural disease, Amer. Rev. Resp. Dis., 90:623, 1964. 9 PAOLUCCI, R, AND TOSSA'ITI, E.: Mediastinal Cyst, ]. Int. ColI. Surg., 13:472, 1950. 10 IVANISEVICH, 0., AND RIVAS, C.: Equinocococis Hidatidica, ed. Buffarini, Buenos Aires, 1962. 11 MARTINEZ, J.L.: Tumores del mediastino, Actas Congo Arg. Cirug., 1:18, 1960. 12 NINO, F.: Parasitologia, ed. Lopez, Buenos Aires, 1965. 13 I'EROSIO, A.: Hidatidosis cardiomediastinica, Prensa MM. Argent., 10:669, 1963. 14 EJDEN, J., AND LANARI, A.: Metodos inmunol6gicos aplicados a la hidatidosis, Medicina, 21: 165, 1960. 15 VINAS, E.: Quiste hidatidico del mediastino, Rev. Med. Uruguay, 2:163, 1901. 16 SANTAS, A., EGUES, J., AND FERNANDEZ, A.: Quiste

17 18 19 20 21

22 23 24

25

hidatidico del mediastino, Bol. Trab. Soc. Cirug. Bs. As., 40:488, 1956. RIVAROLA, J.: Quiste hidatidico del mediastino, Bol. Trab. Soc. Cirug. Bs. As., 40:490, 1956. BREA, M.: Quiste hidatidico del mediastino, Bol. Trab. Soc. Cirug. Bs. As., 40:855, 1956. BREA, M., AND MARTINEZ, F.: Quiste hidatidico del mediastino, Bol. Trab. Acad. Arg. Cirugia, 28:342, 1944. BREA, M., AND RELLAN, A.: Quiste hidatidico del mediastino, Dia Medico, 29:1997, 1957. TAIANA, J., SCHIEPA'ITI, E., AND VILLEGAS, A.: Equinecococis toracica de infrecuente localizaci6n, Clin. T6rax, 7:147, 1955. MARTiNEZ, J.L.: Quiste hidatidico del mediastino, Bol. Trab. Soc. Cir. Bs. As., 40:511, 1956. BADANO, A., AND PICO, A.: Quiste hidatidico del mediastino, Rev. Arg. Cirugia, 5:183, 1962. GILARD6N, A., DE RUGGERo, F., AND ELIZALDE, J.: Quiste hidatidico del mediastino, Bol. Trab. Soc. Arg. Cir. Bs. As., 26:205, 1965. CALCAGNO, B.: Terapeutica biol6gica de la hidatidosis, Bol. Trab. Soc. Cir. Bs. As., 23:481, 1939.

Reprint requests: Dr. Buenos Aires, Argentina

Garcia

Marcos, Cordoba 2149,

Cineangiocardiographic Visualization of a Left Atrial Myxoma Cesar A. Vera, M.D.,· Charles P. Bailey, M.D .. F.C.C.P.,·· and Louis F. Bishop, M.D., F.C.C.P., t

A case in which a left atrial myxoma was diagnosed during life and successfully removed at open heart surgery is described. Diagnosis was made possible by the existence of a high index of suspicion applied to a patient with clinical findings of obstructive mitral valvular disease who presented certain atypical features. The routine use of left ventriculography (RAO) is urged in patients undergoing hemodynamic studies on a presumptive diagnosis of mitral stenosis. This enables ODe to evaluate the mobUity of the mitral valve and sometimes to delineate the left atrial chamber by means of a "whiff" of regurgitation.

With the advent and perfection of open-heart surgery, the early diagnosis of intracardiac tumors no longer is only of academic interest. Of such tumors, 50 percent are cardiac myxomas.' Cardiac myxomas are benign tumors- which occur mainly in the atrial chambers, especially in the left. Often they are attached only by a pedicle which allows "free" floating and a "piston" type of movement to or even through the mitral valve thereby producing intennittent interference with its • Assistant Director of the Cardiovascular Laboratory and Assistant Attending Cardiologist, St. Barnabas Hospital, Bronx, New York. ··Director, Department of Thoracic and Cardiovascular Surgery, St. Barnabas Hospital, Bronx, New York. [Senior Board of Cardiologists, St. Barnabas Hospital, Bronx, New York.

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function and variable hemodynamic flndings. They closely simulate more ordinary types of mitral valvular disease. Syncopal episodes and capricious variability in the murmurs are not uncommon. Intermittent bouts of dyspnea without orthopnea frequently is complained of. A history of systemic arterial embolism and constitutional symptoms such as fever, asthenia, weight loss with or without abnormal laboratory flndings (anemia, leukocytosis, elevated sedimentation rate, hypergammaglobulinemia and elevated transaminases) are encountered more rarely. All of these features, except the latter, were present in the case reported herein. CASE REPORT

A 42-year-old obese white woman was admitted to the Department of Thoracic and Cardiovascular Surgery of the St. Barnabas Hospital in New York City on January 30. 1968. Three years prior to her admission to this hospital, she began to note variable shortness of breath, and later weakness, palpitation and dizziness which were brought on whenever she leaned forward, stooped, made certain shifts in body posture, or reclined on her left side. The condition grew worse despite the administration of digitalis and diuretics. Two definite syncopal attacks occurred and on one of these occasions, she was seen by one of us (L. B.) who advised her to be hospitalized for a comprehensive cardiac evaluation. Physical examination revealed basal expiratory wheezing during exercise and a palpable liver margin on deep inspiration. There was an unusually loud, almost snapping, first sound at the apical area. In this area, could be heard a short intermittent diastolic rumble following what was thought to be an "opening snap." The pulmonic second sound was accentuated and noticeably split. The apical murmur increased in intensity during exercise and when the patient assumed the lateral recumbent position. The electrocardiogram indicated right ventricular hy-

FIGURE 1. Thirty-five mm cineangiocardiogram of the left ventricle (RAO) showing a persistent filling defect in the left atrium delineated by a residual "whiff" of dye during diastole. pertrophy. Chest x-ray films suggested right ventricular enlargement. Right and left cardiac catheterization and left ventricu Iography were performed on January 31, 1968 (Table 1). A pulmonary angiogram and transseptal catheterization wen' carried out on February 2, 1968. The preliminary diagnosis of tight mitral stenosis with severe pulmonary hypertension. based chiefly upon a measured mitral diastolic gradient of 20 mm Hg and a right ventricular pressure of 120/6-12 mm Hg was questioned during analytic examination of the left ventriculogram. This study disclosed the mitral valve motion to be free and unrestricted. The presence of a regurgitant "whiff" of contrast material taking place through the lower pole of the valve (RAO) enabled us to delineate a persistent but mobile filling defect within the left atrium (Fig 1). The second procedure was complicated by three episodes of ventricular fibrillation each successfully treated by electrical (D-C) defibrination. Because of suspicion of cardiac tamponade, she was operated on the same day (night) using cardiopulmonary bypass. A yellow "gelatinous" ovoid mass measuring 6 by 4 cm was found attached to the ventrocephalad portion of the rim of the foramen ovale (Fig 2) and was removed. Her postoperative course was uneventful.

Table I-Cardiac Catheterization Data STUDY PRESSURES (mm Hg) Right Atrium Right Ventricle Pulmonary Artery Pulmonary "capillary" wedge Left atrial pressure" Left ventricle Ascending aorta Cardiac output (L/min/sq. m) Pulmonary vascular resistance (dyne sec. em 5 ) Mean mitral gradient (mm Hg)

At Rest

During Exercise

14/2 (8) 120/6-12 120/40 (75)

130/5-20 130/45

V-3O; Y-2O (23) 11017-13 110/65

115/65

Slit/min. 400

20 mm Hg

°February 2, 1968-V-50; Y-25 (30)

DIS. CHEST, VOL. 56, NO.2, AUGUST 1969

FIGURE 2. Exposed left atrial myxoma.

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DISCUSSION Since the first removal of an intra-atrial myxoma by Crafoord" in 1954, 62 such patients were reported. The increased awareness in recent years of the existence of this clinical entity has resulted in a marked improvement in the percentage of cases correctly diagnosed preoperatively. This has increased from an initial level of 28 percent to 60 percent or more and the number of cases discovered for the first time in the course of surgical exploration has been reduced correspondingly from f57 percent to 29 percent.v" The propensity of atrial myxomas to masquerade as intrinsic valvular disease or as subacute bacterial endocarditis" has presented a formidable challenge to our most sophisticated diagnostic modalities. In our own case, the lesion presented a combination of clinical features and findings which with the original cardiac catheterization report might well have been ascribed to tight mitral stenosis. The awareness of the diagnostic possibility of left atrial myxoma led to further hemodynamic and cinecardioangiographic studies which confirmed the presence of a mobile intraatrial tumor. The clinical and hemodynamic findings in this case were in no significant respect different from those in other cases already described':": (1) Belatively recent onset of symptomatology and rapid progression. (2) History of syncopal episodes (two) related to a significant change in position. (3) Intermittent presence of a diastolic murmur typical of mitral stenosis, but without a presystolic component. (4) The absence of atrial fibrillation and radiographic evidence of left atrial enlargement. (5) No history of rheumatic fever or any of its equivalents. (6) Disproportionate pulmonary hy-

pertension (120 mm Hg). (7) A left atrial pressure pattern (Fig 3) similar to that previously reported in cases of left atrial myxoma's" presenting a prominent "V" wave with a rapid "Y" descent. Pitt and co-workers,"? have suggested that the repetitive movement of the (pedunculated) myxoma into and through the mitral valve produces an intermittent rise in the left atrial pressure ("Y' wave) followed by sudden decompression ("Y" wave) when the mass retreats into the atrium in the absence of Significant mitral insufficiency. The part played by cinecardioangiography in this case is demonstrative of the important contribution it can make to final diagnosis in the majority of suspected cases. This radiographic technique has been employed since 1952 to delineate the existence of cardiovascular filling defects, but its routine use in cases of suspected mitral stenosis has not previously been advocated.' By use of the technique of cineventriculography, the mobility and pliability of the mitral valve as well as the vigor of the ventricular contractions can be evaluated prior to surgery. In this particular case, we were able to rule out the presence of any significant intrinsic disease of the mitral valve by observation of its natural unrestricted movements during both diastole and systole. At the same time, a small amount of contrast material regurgitating from the left ventricle into the left atrium followed a peculiar trajectory which consistently outlined an underlying concave area or "subtraction defect" in the cardioangiogram. This was interpreted as representing a pedunculated tumor (Fig 1), which was delineated later with even greater clarity by pulmonary angiography. A direct measurement of the left atrial pressure was obtained by transseptal puncture.

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FIGURE 3. Left atrial pressure curve. Notice large "V" wave and a rapid descent of the "Y" wave.

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LEFT ATRIAL MYXOMA

165

We believe that the routine use of left ventriculography in patients submitted to cardiac catheterization for evaluation of suspected mitral stenosis is of significant value not only as a mechanism for analysis of the mitral valve motion, but also in some cases, providing indirect visualization of the left atrium due to minimal regurgitation of contrast material. This phenomenon was described by Stems and Penny.11.12 REFERENCES

1 PRICHARD, RW.: Tumors of the heart, Arch. Path., 51:98, 1951. 2 ZUIDEMA, G.D., BURKE, J.F., VILLEGAS, A.H., AND SCANNELL, J.G.: Surgery of atrial myxoma, New Eng. J. Med., 264:1016, 1961. 3 CRAFOORD, C.: Panel discussion of late results of mitral commissurotomy, Saunders, Philadelphia, 1955, p. 202. 4 CAREY, J.M., GREER, A.E., HONICK, G.L., BRESSIE, J., AND ZUHDI, N.: Myxoma of the left atrium; Review and report of three successful surgical cases, Ann. Thorac. Surg., 1:736, 1965. 5 DIFFERDING, J.T., GARDNER, RE., AND ROE, B.B.: Intracardiac myxomas with report of two unusual cases successful removal, Circulation, 23:929, 1961. 6 GLEASON, J.O.: Primary myxoma of the heart: A case

7

8

9

10

11

12

simulating rheumatic bacterial endocarditis, Cancer, 8: 839,1955. MAY, LA., KIMBALL, K.G., GOLDAM, P.W., AND DUGAN, D.l: Left atrial myxoma; Diagnosis, treatment and preand postoperative physiological studies, J. Thorac. Cardiovasc. Surg., 53:803, 1967. FISH, RG., TAKARO, T., AND CRYMES, T.: Left atrial pressures pulses in the presence of myxoma, Circulation, 20:413, 1959. OGNIBENE, A.J., AND NELSON, W ..P: Atrial myxoma, comments on hemodynamic alterations: Report of a case, Dis. Chest, 52:699, 1967. PITT, A., CRILEY, J.M., PITT, B., AND SCHAEFER, J.: Left atrial myxoma: hemodynamic and phonocardiographic consequences of sudden volume changes caused by tumor movement, Circulation, suppl, III, 33-34: 188, 1966. STERNS, L.P., EUOT, RS., VARCO, RL., AND EDWARDS, lE.: Intracavitary cardiac neoplasms: A review of 15 cases, Brit. Heart J., 28:75, 1966. PENNY, J.L., GREGORY, J.J., AYRES, S.M., GIANNELLI, S.. JR., AND ROSSI, P.: Calcified left atrial myxoma simulating mitral insufficiency: Hemodynamic and phonocardiographic effects of tumor movement, Circulation, 36: 417,1967.

Reprint requests: Dr. Vera, St. Barnabas Hospital, Bronx, New York 10456

LASTING PRINCIPLES OF EDUCATION It is generally agreed that in spite of the derivative in his system, the development of pedagogical theories has been profoundly and decisively influenced by Rousseau (1712-1778) particularly in respect to all child-centered methods which assume a difference between the child's and the adult's view of the world; and stress the value of first-hand experience or learning by doing, and the child's right to enjoy his childhood. The line of historical inHuence is visible at least in the principles of most educational reformers since Rousseau, from Basedow and Campe in eighteenth century Cer-

many to Pestalozzi of Switzerland; and on through the nineteenth centurv to Froebel, and thence to Maria Montessori. And it is still reasonable to argue that one current of educational idealism, which preaches individualism and freedom, owes much to certain parts of Rousseau's teaching. Whether later theorists have always understood the whole of his thinking with regard to Individual Iibertv, is less certain. Broome, J. H.: Rousseau; A Study of His Thought, Edward Arnold, London. 1963

MEDICAL CYBERNETICS SIMPLIFIED The cybernetic act is a regulation. Even though the human organism possesses information channels and regulatory organs, it finds itself limited in overcoming aggression from the external environment. This depends, first of all, on the fact that the organism is very badly informed concerning events in the innermost parts of altered tissues, which is due to a defect in information channels. On the other hand, the organism disposes of

DIS. CHEST, VOL. 56, NO.2, AUGUST 1969

very few pathways through which reactions can be transmitted to these tissues. The work of the physician, cybernetically speaking, consists in reinforcing these information channels with a How from patient to physician (clinical and laboratory data) and a How from physician to patient (therapy). Masturzo, A.: Cybernetic Medicine, C. C Thomas, Springfield, 1965