Cushing's Syndrome and Skin Pigmentation

the appendage biopsy results failed to give any indication of prognosis. In two of our cases the comment had been made at the first operation that " it would not be surprising if the rheumatic process were still active," and in these two cases the appendage biopsies showed numerous Aschoff bodies suggesting continued rheumatic activity. Another patient had several attacks of subacute rheumatism in the interval between operations. Logan et al. (1962) found that 36% of patients who had cusps completely separated anteriorly and posteriorly developed restenosis after an interval of more than five years. This was not the experience of Belcher (1960, 1962), who found that only 4% of patients who had a complete split of both commissures had restenosed when followed up for eight years. Furthermore, he is convinced that an inadequate first operation is of prime importance in causation, and he has not known of restenosis in any case in which he has used the dilator. Can these diverging views be reconciled ? Before expressing an opinion several variable factors require to be considered, such as the critical assessment of operation notes, completeness of follow-up studies, criteria accepted for the diagnosis of restenosis, and the time interval between operations. Our findings tend to support those of Belcher (1960, 1962). In 27 of the 32 cases the primary operation was undoubtedly inadequate. No case had a complete separation of both anterior and posterior commissures. We believe that after every valvotomy there is some re-fusion at the outer ends of the commissurotomy, and this is certain to occur. It would seem logical that a poor split followed by this inevitable restenosis would in most cases lead to a recurrence of symptoms. On the other hand, a similar amount of restenosis in a case having had a wide split would not decrease the size of the valve orifice by the same proportion. When we examined the decrease in valve size in the interval between operations we found that it amounted to 1 to 1.5 cm. in 23 (72%) cases, 2 cm. in 4 (12.5%), 2.5 cm. in 4 (12.5%), and 3 cm. in one case (3%). This possibility of inevitable reduction in value size, say from 1 to 1.5 cm. , would explain our finding that stenosis recurred most often in cases in which the primary valvotomy was inadequate. When restenosis occurred in patients believed to have had a reasonable split the process had been more extensive (2 to 3 cm.). Is this theory of inevitable partial re-fusion compatible with the common experience that many patients who have had an inadequate valvotomy make good progress and have no recurrence of symptoms for many years? We believe that in some cases it is possible that a degree of restenosis may occur without giving rise to symptoms, for it must be borne in mind that in some patients the actual valve stenosis may be the main or only feature, while in others the effects of prolonged back pressure and myocardial damage are so extensive as to bear a much greater influence on the result of any valvotomy carried out. In other words, there are two groups of patients-the one in which the size of the valve orifice is the dominant feature, and the one in which other factors are of equal or of more importance. Wood (1954) stressed that in the latter group the size of the valve orifice in mitral stenosis bore no relation to the hability to develop symptoms such as pulmonary oedemza and auricular fibrillation. Summary