INVITED COMMENTS
`
`Early history of aortic surgery
`Jesse E. Thompson, MD, Dallas, Tex
`
`In the past 50 years, we have witnessed the most
`spectacular period of growth and development in
`the long and fascinating history of vascular surgery.
`As in all things, the basis for today’s modern vascu-
`lar surgery rests on achievements from the past. As
`Thomas Carlyle wrote, “History is the essence of
`innumerable biographies.”
`
`ANEURYSMS
`Studies of Egyptian mummies have revealed that
`atherosclerosis and arterial calcification were rela-
`tively common 3500 years ago.1 The Ebers Papyrus
`is among the earliest medical writings and is thought
`to have been prepared around 2000 BC. The writer
`clearly identified arterial aneurysms, probably
`peripheral aneurysms, and recommended the fol-
`lowing treatment: “Treat it with a knife and burn it
`with a fire so that it bleeds not too much.”2
`Antyllus, a Greek surgeon of the 2nd century AD,
`has left the earliest record of attempted therapy of
`aneurysms. Although his writings have been
`destroyed, his ideas are recorded in the works of
`Oribasius, who lived in the 4th century AD. According
`to Oribasius, Antyllus said, “We decline exceptionally
`big aneurysms, but we will operate as follows on
`aneurysms in the extremities, the limbs and the
`head.” Antyllus applied ligatures to the arteries that
`entered and left the aneurysm and then cut into the
`aneurysm sac, evacuated the contents, and packed the
`cavity. Antyllus did not resect the aneurysm sac. He
`stated, “Those who tie the artery, as I advise, at each
`extremity, but amputate the intervening dilated part,
`perform a dangerous operation. The violent tension
`
`From the Department of Surgery, Baylor University Medical
`Center.
`Presented at the Twenty-first Annual Meeting of the Midwestern
`Vascular Surgical Society, Chicago, Ill, Sep 12–13, 1997, as an
`Honored Guest Lecturer.
`Reprint requests: Jesse E. Thompson, MD, 3705 Stanford Ave,
`Dallas, TX 75225.
`J Vasc Surg 1998;28:746-52.
`Copyright © 1998 by The Society for Vascular Surgery and
`International Society for Cardiovascular Surgery, North
`American Chapter.
`0741-5214/98/$5.00 + 0 24/9/89989
`
`746
`
`of the arterial pneuma often displaces the ligatures.”3
`This good advice was given 1800 years ago.
`Few advances were made in the treatment of
`aneurysms during the ensuing millennium. Ambroise
`Paré (1510-1590) advocated the application of a
`proximal ligature to aneurysms but did not believe
`the sac should be opened because of the danger of
`severe and fatal hemorrhage. Paré also described a
`ruptured aneurysm of the thoracic aorta and wrote,
`“The aneurysms which happen in the internal parts
`are incurable.”1,2 Andreas Vesalius (1514-1564) was
`a friend and colleague of Paré and apparently was the
`first to describe thoracic and abdominal aortic
`aneurysms.4
`Matheus Purmann operated on an antecubital
`space aneurysm in 1680, and he ligated the artery
`above and below the aneurysm and removed the sac.
`In medieval times the antecubital fossa aneurysm
`was quite common as a complication of bloodletting
`by puncture of the median basilic vein.2
`With John Hunter (1728-1793), surgery began to
`emerge as a scientific discipline on the basis of anato-
`my and physiology. Hunter’s contributions to vascular
`surgery were basic. In addition to his clinical observa-
`tions, he studied the development of collateral circula-
`tion of occluded main arteries, which led to his
`method of treating aneurysms. On December 12,
`1785, he ligated the superficial femoral artery high in
`the thigh in the area now known as Hunter’s canal to
`treat a popliteal aneurysm. The patient did well; the
`aneurysm shrunk to a hard knot, and the limb sur-
`vived. The specimen from Hunter’s first case is locat-
`ed in the Hunterian Museum in London. This case
`represented the first major innovation in the treatment
`of popliteal aneurysm after the Antyllus operation of
`the 2nd century. Hunter’s method lasted until the
`operation of Rudolph Matas was developed in 1888.5
`The discussion now brings us to Astley Cooper
`(1768-1841), one of the great English surgeons of
`the late 18th and early 19th century. Cooper made
`contributions in many fields of surgery, but his name
`is linked permanently to advances in vascular surgery.
`In 1817, he was called to see a man in extremis with
`a leaking iliac aneurysm. Cooper decided that the only
`possible treatment was ligation of the aorta above the
`
`TMT 2089
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`JOURNAL OF VASCULAR SURGERY
`Volume 28, Number 4
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`Thompson 747
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`aneurysm. He managed to get his finger around the
`aorta through a small transperitoneal incision, and he
`passed a single ligature around the vessel with an
`aneurysm needle. The ligature then was tied. The
`patient’s right leg remained viable, but the left leg was
`totally ischemic, livid, and cold, and the patient died
`40 hours later. This was the first recorded case of lig-
`ation of the aorta for aneurysm. The specimen of
`Cooper’s operation is preserved in the Department of
`Surgery at St. Thomas’s Hospital in London.6
`During the next 100 years several attempts were
`made to ligate the aorta, but all the patients died,
`until April 9, 1923, when Matas successfully ligated
`the abdominal aorta in the treatment of an aneurysm.
`The patient survived the operation but died 18
`months later of pulmonary tuberculosis.7 By 1940,
`Dan Elkin8 was able to identify only 24 recorded
`cases of ligation in the world literature to which he
`added one of his own. In only five of these cases was
`the operation a success.
`Rudolph Matas9,10 (1860-1957), of New Orleans,
`was a pioneer in the field of vascular surgery. He made
`many contributions to all areas of surgery, but he is
`best remembered in vascular surgery for his operation
`of endoaneurysmorrhaphy. He first performed this
`operation May 6, 1888, on a patient with a large trau-
`matic brachial artery aneurysm of the left arm. After
`ligation of the proximal and distal arteries, an incision
`was made into the aneurysm, and the clot was
`removed. The orifices of the blood vessels that entered
`the sac then were sutured from within, which pre-
`served the collateral blood supply to the extremity.
`This operation markedly reduced the incidence of gan-
`grene and amputation that followed the procedure in
`a high percentage of patients who underwent the
`Hunterian ligation for popliteal aneurysm. This princi-
`ple is still used.
`An interesting note is the experience of William
`Osler11 in his 16 years at the Johns Hopkins
`Hospital from 1889 to 1904. Osler saw only 17
`cases of abdominal aortic aneurysm, an average of
`one per year.
`Over the years a number of methods have been
`used in efforts to treat aortic aneurysms. These
`methods were designed either to cause thrombosis of
`the aneurysm or to fibrose the wall to prevent rup-
`ture. The methods included needling, wiring, proxi-
`mal banding, ligation, and cellophane wrapping.
`In 1864, Moore, a British surgeon from Middle-
`sex Hospital, introduced wiring of aneurysms by
`inserting either silver, iron, steel, or copper wire in an
`effort to thrombose the aneurysm. In 1879, Alfonso
`Corradi from Pavia attached Moore’s wires to a bat-
`
`tery in an attempt to induce coagulation. The results
`were dismal, with only an occasional reported cure.11
`The principle persisted, however, and was brought to
`its culmination by Blakemore, of New York.
`Blakemore advocated progressive constrictive occlu-
`sion of the abdominal aorta with a rubber band
`wrapped with polythene film proximal to the
`aneurysm, followed by insertion of wire and elec-
`trothermic coagulation with 100 volts of direct cur-
`rent. In fact, Blakemore’s final major presentation of
`this method was given December 10, 1952, before
`the Southern Surgical Association. (Interestingly, in
`the discussion after Blakemore’s paper, DeBakey
`reported his first two cases of resection of aneurysm
`with homograft replacement that had been done in
`the month before Blakemore’s presentation.12)
`At Johns Hopkins, William Stewart Halsted
`(1852-1922) attempted proximal aortic ligation
`with either silver or aluminum bands. These patients
`usually died because the metallic bands cut through
`the aortic wall and fatal hemorrhage occurred. In
`1910, Halsted operated in Kocher’s clinic in Bern,
`Switzerland, and put a metallic band on an aortic
`aneurysm above the renal arteries. The patient
`apparently was cured but 6 weeks later died of rup-
`ture at the site of banding.13
`On October 19, 1944, Crafoord and Nylin14 in
`Sweden reported the first successful end-to-end
`anastomosis of the aorta after resection of an aortic
`coarctation. Robert Gross,15,16 of Boston, per-
`formed his first successful coarctation resection and
`anastomosis on July 6, 1945. Shortly thereafter, on
`May 24, 1948, Gross17 successfully replaced a
`longer segment of a resected coarctation with a pre-
`served arterial homograft with methods devised by
`Charles Hufnagel for the preservation of human
`homografts. The stage was set for the rapid develop-
`ments that were to follow.
`Now we take a short bypass into arteriography.
`On November 8, 1895, Wilhelm Konrad Roentgen
`first observed the new rays that would become a cor-
`nerstone of our diagnostic armamentarium. Roentgen
`received the Nobel Prize in 1901 for this discovery. In
`1923, Barney Brooks18 initiated clinical angiography
`by injecting sodium iodide and studied the femoro-
`popliteal system. In 1927, the first cerebral arteriog-
`raphy was performed by Egas Moníz, of Portugal. In
`1929, Reynaldo dos Santos, another Portuguese
`physician, was the first to report translumbar aortog-
`raphy, and he envisioned this method as valuable to
`studying diseases of the arteries. These pioneering
`achievements have evolved into today’s sophisticated
`methods of visualizing all the vessels in the body.19
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`748 Thompson
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`JOURNAL OF VASCULAR SURGERY
`October 1998
`
`Table I. Early cases of elective resection of
`abdominal aortic aneurysm with homograft
`replacement
`
`Case
`
`Schafer & Hardin20
`Dubost et al21
`Julian et al22
`Brock23
`DeBakey & Cooley24
`Bahnson25
`
`*Case resulted in death of patient.
`
`Date of case
`
`Mar 2, 1951*
`Mar 29, 1951
`Oct 25, 1952
`Nov 5, 1952
`Nov 6, 1952
`Feb 14, 1953
`
`Table II. Early cases of ruptured abdominal aortic
`aneurysm successfully treated by resection with
`homograft replacement
`
`Case
`
`Bahnson27
`Gerbode58
`Cooley & DeBakey59
`Javid et al60
`
`Date of case
`
`Mar 13, 1953
`Before 1954
`Apr 26, 1954
`Dec 21, 1954
`
`On March 2, 1951, Schafer and Hardin20 resect-
`ed an abdominal aortic aneurysm with a bypass
`shunt and replaced the aorta with a human homo-
`graft. The patient survived the operation but died 29
`days later of hemorrhage from a leak in the native
`aortic wall. The first successful resection of abdomi-
`nal aortic aneurysm with graft replacement was per-
`formed on March 29, 1951, by Charles Dubost in
`Paris. He used an extraperitoneal thoracoabdominal
`approach with resection of the 11th rib. The graft
`used was the thoracic aorta taken 3 weeks previous-
`ly from a 20-year-old woman. The patient’s left
`common iliac artery then was anastomosed to the
`side of the graft.21 After Dubost’s landmark proce-
`dure, reports of successful operations appeared in
`quick succession by Julian,22 Brock,23 DeBakey and
`Cooley,24 and Bahnson25 (Table I).
`After Dubost’s report, the abdominal aortic
`aneurysm sac would be completely removed before
`the graft was placed, but this technique was some-
`times difficult and hazardous. Therefore, in 1966,
`Oscar Creech,26 of Houston, combined the endo-
`aneurysmorrhaphy technique of Matas with graft
`replacement that left the aneurysmal sac in place. This
`single step has greatly simplified aneurysm surgery.
`Ruptured abdominal aneurysms were subjected
`to resection and repair after successful elective treat-
`ment of abdominal aortic aneurysms. Henry
`Bahnson27 is credited with the first successful repair
`
`of a ruptured aortic aneurysm, performed March 13,
`1953. Other early operations are shown in Table II.
`The first successful repair of a ruptured aneurysm by
`our own group in Dallas was performed on October
`21, 1954, at Baylor Hospital.
`The arterial homografts were a great step forward,
`but problems of procurement and availability were
`major factors for limitation. The development of satis-
`factory arterial substitutes was basic for progress in vas-
`cular surgery.28 Veins had been substituted for arteries
`as early as 1906,29 but methods of graft preservation
`were perfected and artery banks were established in
`the 1940s and early 1950s on the basis of the early
`works of Carrel and Guthrie30,31 and Gross et al.17
`In 1952, Voorhees, Jaretski, and Blakemore32
`reported that a tube of Vinyon-N cloth as a plastic
`artificial substitute for an artery would remain open in
`a dog’s aorta. This observation was soon confirmed,
`and although Vinyon-N cloth did not prove to be sat-
`isfactory material, the principle was established. In
`1955 Sterling Edwards33 reported the development
`of nylon prostheses and also devised a technique of
`crimping prosthetic grafts. Nylon did not hold, but
`Teflon and Dacron grafts followed in short order.
`In 1954, DeBakey and his group began working
`on various materials for grafts. DeBakey collaborat-
`ed with Professor Thomas Edman, a Philadelphia
`textile engineer, to build a new knitting machine to
`make seamless Dacron grafts of all sizes, shapes, and
`configurations.34 Various refinements were made in
`these grafts, which culminated in the standard grafts
`in use at the present time. Szilagyi35 played an
`important role in the development of vascular grafts
`with his introduction of the elasticized woven
`Dacron graft that bears his name. His follow-up
`reports on aortic aneurysm surgery have been land-
`mark contributions. A number of investigators also
`were involved in the development of vascular grafts,
`including Deterling, Julian, and Shumacker.28
`Thoracic aneurysms have presented a challenge to
`surgeons for many years. These aneurysms can be sac-
`cular or fusiform or associated with coarctation of the
`aorta. After the lead of Moore, in 1864, the
`aneurysms were treated by wiring until more defini-
`tive measures were developed.11 In Ann Arbor in
`1941, John Alexander36 simply resected the aneurysm
`with the coarctation and sewed off the ends without
`anastomosis or graft in the case of lesions associated
`with coarctation. On June 28, 1949, Henry Swan37
`apparently was the first to resect an aneurysm associ-
`ated with a coarctation and to replace the resected
`area with a homograft. In 1951, Robert Gross report-
`ed five cases of aneurysm associated with coarctation
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`Thompson 749
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`treated by resection and graft.38 In the early 1950s,
`Bahnson39 and Cooley and DeBakey40 resected sac-
`cular aneurysms and repaired the arterial walls by lat-
`eral suture. DeBakey and Cooley41 reported the first
`case of a successful resection and graft of a fusiform
`thoracic aneurysm that was performed January 5,
`1953. Since that time, all sections of the thoracic aorta
`from the arch to the diaphragm have been resected
`successfully and replaced by grafts of various sorts.
`Thoracoabdominal aneurysms have presented an
`even greater challenge. A forgotten pioneer in the
`field of vascular surgery is the Austrian surgeon
`Ernst Jeger, who died at 30 in World War I. Jeger
`was a brilliant investigator who devised many vascu-
`lar and cardiac procedures that included a procedure
`for complicated thoracoabdominal aneurysms. In
`1913, Matas commented on Jeger’s work,
`“His contribution had a great bearing upon the future
`of aortic and visceral surgery. If it ever became practicable
`to transplant the coeliac axis, the mesenteric arteries and
`the renals from their normal origin…to other segments of
`the aorta, there was hope still left for this usually insurable
`class of aneurysms.”42
`
`Etheredge, in 1955, described resection of this
`lesion. He used a temporary shunt from the distal
`thoracic aorta to the distal abdominal aorta. A homo-
`graft then was inserted, and the visceral vessels were
`implanted into the homograft.43 In 1956, DeBakey44
`described a similar technique with a temporary bypass
`shunt. Shumacker45 modified this technique by using
`the homograft shunt as the permanent conduit,
`implanting the visceral vessels into the shunt, and
`then excising the aneurysm. In 1974, Stanley
`Crawford46 reported his experience. The earliest cases
`consisted of the insertion of a Dacron graft and the
`reattachment of consecutively involved branches to
`side-arm tube grafts that arose from the bypass graft.
`In the later cases, the graft was inserted inside the
`aneurysm with reattachment of visceral branch origins
`directly to an opening in the graft wall, which is the
`inclusion technique that we use today.
`
`ARTERIAL OCCLUSIVE DISEASE
`Rene Leriche (1879-1955) first published his
`observations on obliteration of the terminal aorta in
`1923 and stated that the ideal treatment would be
`resection of the area and reestablishment of graft
`patency. In 1940, he published a detailed description
`of the syndrome that now bears his name. He rec-
`ommended resection of the terminal aorta and com-
`mon iliac arteries together with bilateral lumbar
`sympathectomy through a retroperitoneal approach.
`
`The results of this procedure were variable and
`depended on the preoperative status of the patient.
`His final observations on this syndrome, published
`in 1948, preceded by 2 years the operation of
`Jacques Oudot, which was resection of the terminal
`aorta with homograft replacement to restore graft
`patency, a procedure that had been recommended
`by Leriche47 in 1923, almost 30 years earlier.
`A direct attack on occluded vessels was made by
`J. Cid dos Santos,48 of Portugal, in 1946. He per-
`formed the first successful thromboendarterectomy
`for peripheral occlusive disease and established this
`procedure as feasible. His first operation was per-
`formed August 27, 1946, on a left femoral artery, his
`second, on December 12, 1946, on a subclavian
`artery. Both of these cases were successful for the
`graft patency. This operation was termed disoblitera-
`tion but came to be known as thromboendarterectomy
`or just endarterectomy. By 1948, Bazy, in France, had
`performed endarterectomies on 12 abdominal aortic
`occlusion cases, and Kunlin also had carried out the
`procedure in a number of cases in Leriche’s clinic.
`In 1951, aortic endarterectomy was introduced
`into the United States by E. Jack Wylie49 of San
`Francisco. Jack Cannon and Wiley Barker,50 of Los
`Angeles, were pioneers in the use of endarterectomy
`for femoral occlusive disease. Aortic endarterectomy
`was popularized by Wylie and by Robert Linton,51
`of Boston. Endarterectomy has gradually given way
`to bypass grafting, except in the carotid area and in
`certain localized obstructions in other large vessels.
`A giant step forward in the treatment of aortic
`occlusive disease was made on November 14, 1950.
`Oudot, another Frenchman, was the first to resect the
`terminal aorta for the Leriche syndrome and replace
`the aorta with a preserved 24-day-old homologous
`aortic graft with end-to-end anastomoses. Six months
`later, because of thrombosis of the right iliac limb of
`the graft, Oudot placed a crossover graft from the left
`distal external iliac to the right external iliac—the first
`extraanatomic bypass graft. Oudot, a famous moun-
`taineer, died ironically in an automobile accident at
`the age of 40.52 Resection of the aortoiliac segment
`with graft replacement first gave way to endarterecto-
`my and then gradually to aortoiliac or aortofemoral
`bypass graft, which left the native vessels in situ.
`The principle of bypass graft surgery had been
`considered in the laboratory for some years, and Jean
`Kunlin, a French surgeon who worked in Leriche’s
`clinic, performed the first long bypass graft of the
`femoral artery with a saphenous vein, on June 3,
`1948, with both proximal and distal end-to-side
`anastomoses.53 The first patient treated by Kunlin
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`750 Thompson
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`JOURNAL OF VASCULAR SURGERY
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`
`was a 54-year-old man who previously had under-
`gone an arteriectomy of the superficial femoral artery
`in the manner of Leriche. The patient’s ischemia was
`not relieved, and Kunlin decided to perform a venous
`graft with end-to-end anastomoses. However, expo-
`sure of the previous operative sites was difficult
`because of a tremendous fibrotic reaction, and end-
`to-end anastomoses could not be done. Kunlin had
`no other choice but end-to-side implantations of the
`venous graft into the femoral artery above and below
`the resected area. Thus the bypass graft procedure
`was born by serendipity. The bypass graft principle
`was extended to the aorta by Frank Cockett, of
`London. Cockett probably performed the first aortic
`bypass graft for treatment of aortic thrombosis with-
`out removing the aorta in 1955.2 This operation was
`another step forward and was less demanding than
`aortoiliofemoral endarterectomy.
`I will only mention other interesting historical
`aspects of aortic surgery because space does not per-
`mit discussion. These aspects include aortic embolec-
`tomy, aortoduodenal fistula, aortocaval fistula, dis-
`secting aortic aneurysms, extraanastomotic bypass
`grafts, and the retroperitoneal approach to the aorta,
`which first was advocated by Astley Cooper in 1817.
`In the early days of aortic surgery, a major prob-
`lem that beset surgeons was proper fluid management
`during and immediately after the operative procedure.
`At first, we and others followed the recommendations
`that were current at that time: we avoided salt solu-
`tions and almost exclusively used limited quantities of
`dextrose in water. We found a high incidence of
`shock, oliguria, and renal shutdown with this regi-
`men. An example of the results of such a regimen is
`emphasized in a 1966 report from Duke University.
`The report described 183 aortic aneurysm operations
`in which an average 2.5 L of dextrose in water plus
`blood usually comprised the 24-hour fluid comple-
`ment.54 The operative mortality rate for elective
`aneurysms was 18%. The rate of development of
`azotemia of varying degrees in patients was 47%; 11%
`of the patients died of azotemia, and 10 of the 40
`deaths were caused by renal failure.
`As a result of such problems, we began to follow
`the recommendations of Shires et al.55 We began to
`use a regimen of 5% dextrose in lactated Ringer’s solu-
`tion or balanced salt solution in fairly large amounts of
`3 to 4 L or about 600 ml/hr during the operation to
`keep the perioperative urinary output above 125
`ml/hr. These large quantities compensated for the
`sequestration of extracellular fluid to maintain an effec-
`tive circulating blood volume. With this regimen,
`
`hypotensive and renal complications of aortic surgery
`largely disappeared. In our 1968 report on the subject,
`we studied 474 cases of elective aortic surgery for both
`aneurysmal and occlusive disease, and only two
`patients died of renal failure, which was an incidence
`rate of 0.4% and an overall mortality rate of 3.2%.56
`The use of proper amounts of balanced salt solution
`during aortic surgery is now well standardized.
`Prominent individuals who have suffered from or
`have been treated for aortic disease are interesting to
`note. Albert Einstein had an abdominal aortic
`aneurysm that was wrapped with cellophane in
`1949. The aneurysm ruptured 6 years later, on April
`13, 1955. Surgical treatment was recommended,
`but Einstein rejected the surgery and remarked, “I
`want to go when I want. It is tasteless to prolong life
`artificially. I have done my share. It is time to go. I
`will do it elegantly.” On April 18, he died at
`Princeton, NJ, at the age of 76.57 By contrast, the
`Duke of Windsor traveled to Houston and had his
`aortic aneurysm repaired electively by Dr DeBakey,
`in 1965, with a very successful outcome.
`Aortic surgery thus has had a fascinating history.
`From Cooper to Matas, 106 years were needed to
`obtain a successful outcome of aortic ligation for
`abdominal aortic aneurysms. However, more
`progress has been made in the last 50 years than in
`the preceding 2000 years since Antyllus ligated,
`incised, and packed his cases of aneurysms.
`
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`Thompson 751
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`aorta with wiring and electrothermic coagulation for the
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`

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`752 Thompson
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`JOURNAL OF VASCULAR SURGERY
`October 1998
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`
`Submitted Feb 25, 1998; accepted Mar 2, 1998.
`
`