Digitalis delirium: psychiatric considerations. Digitalis is a ubiquitous drug in modern clinical medicine and digitoxicity is one of the more common iatrogenic disorders. Psychiatric problems are often overlooked as manifestations of digitalis excess and may range from mild disorientation, lethargy, or restlessness to full blown delirium. In this paper we discuss two patients who presented to a psychiatric inpatient unit and were later found to be digitoxic. Psychiatrists are advised to consider digitalis as a possible cause of mental abnormalities and are reminded that psychiatric signs may be the first indication of a potentially lethal drug toxicity. Psychiatric patients may also be at special risk for the development of digitoxicity because of erratic drug taking, electrolyte imbalance or increased autonomic tone.


The liaison psychiatrist in cardiovascular rehabilitation: an overview. Depression, anxiety and fear of recurrence following myocardial infarction often lead to disability in excess of actual cardiac impairment in a large number of patients. The high social, economic and emotional cost of psychogenic cardiac invalidism has stimulated the development of cardiovascular rehabilitation programs throughout the country. The liaison psychiatrist can play a critical role in the rehabilitation effort. This paper describes the psychological impact of the rehabilitation process in combating psychogenic cardiac disability. The conflicts of the post-infarction patient and their management by the rehabilitation team are presented from the perspective of the team psychiatrist. Cardiovascular rehabilitation as described is a productive area for psychiatric liaison, through individual consultation, group therapy sessions and team meetings which address the psychosocial issues of convalescence.


Teaching family psychodynamics in a family practice center: one experience. This paper describes a method of teaching family psychodynamics in a new family practice center. Initially, there were difficulties in engaging staff because of inappropriate teaching methods and personal and professional identity conflicts. Ultimately, a sequential program of video playbacks, live interviews and case conferences was developed. The residents' four-month rotation in psychiatry proved essential for developing comfort with psychological and familial aspects of psyical illness.


Xenon-133 muscular flow measurements in surgery for arterial disease of the lower limbs. Muscular flow measurements were carried out in 34 patients with peripheral chronic arterial occlusive disease using the 133-xenon clearance method. The reactive hyperemia technique was preferred to the walking test. All the patients were investigated by angiography and 46 limbs were available for assessment. Control flow measurements were done after treatment in the following groups: arterial reconstruction in ten limbs of nine patients, unilateral lumbar sympathectomy in three and medical therapy in seven. Follow-up was from three to 12 months. The findings of flow measurements were of limited value in identifying the distribution of the arterial disease, but they provided a reliable means to predict the results of direct arterial repair in various procedures. They also proved to be a valuable method to assess the results of surgery. This does not seem to apply to lumbar sympathectomy or conservative treatment.


Changing concepts in thoracic and cardiovascular surgery in the last twenty-four years: 10,000 thoracic and cardiovascular operations. On July 27, 1977, the ten thousandth operation was performed by the author in commemoration of the twentieth anniversary of the Department of Thoracic and Cardiovascular Surgery, Sapporo Medical College, Sapporo. Changing concepts in modern or postwar thoracic and cardiovascular surgery during the past two decades are discussed.


Results of operative treatment of Fraley's syndrome. Relying on their own observations, the authors describe nine patients in whom Fraley's syndrome was diagnosed and treated operatively. In six of them, calycopyeloneostomy was performed. In three of the patients, because of complications, the upper pole of the kidney was excised together with the changed calyx. In noncomplicated cases the calycopyeloneostomy with a transposition of the artery beyond the cervix of the upper calyx allows to retain the active parenchyma of the upper pole of the kidneys.


Esophageal reflux after gastrectomy: a hazard after Billroth-I subtotal gastrectomy. One hundred and seventy-six patients were evaluated for esophageal reflux after gastrectomy. Apart from proximally and totally gastrectomized cases, the conventional Billroth-I type of distal subtotal gastrectomy destroys many esophageal reflux preventive mechanisms. The Roux-en-Y type of repair should be adopted for the prevention of reflux.


Preoperative work-up in breast surgery.

Preoperative work-up in breast surgery. Our patients who are to undergo breast surgery are placed into one of four groups with a number of subdivisions. Each has a variable amount of preoperative work-up depending on the patient's age and constitutional status, the degree of suspicion as to the malignancy of the lesion, the type of anesthesia (local or general), the place where the biopsy is being done (in-patient or out-patient)and on the type of informed consent signed by the patient. Breast x-rays are used on a judicious and selective basis and thermography and ultrasound are used routinely.


The use of tissue adhesive "Chirurcoll-Polfa" in surgical fixation of the kidney. Experimental and clinical investigations were carried out on the application of tissue adhesive "Chirurcoll-Polfa" in surgical fixation of the kidney. It was found that the adhesive gives firm tissue adhesion without causing inflammatory reaction, and can be safely used in operations for fixation of the kidneys.


Treatment of testicular hypofunction with gonadotrophic hormones. The paper reports on the response to gonadotrophic hormone treatment in cases of male infertility. The report includes 119 cases treated between 1971 and 1975. The evaluation of the results of gonadotrophic hormone treatment led to the following conclusions. Treatment with Praedyn has been relatively successful and the rate of success was directly dependent on the number of applied ampoules. Pergonal 500 brought a considerable improvement in all the treated patients. A meaningful comparison of the effect of Praedyn and Pergonal 500, respectively, was not possible because of the relatively small number of patients treated with Pergonal. Treatment with gonadotrophic hormones, especially Pergonal 500, seems to be indicated in cases of oligoasthenospermia, hypogonadotrophic hypogonadism (or secondary hypogonadism) and at least a short-dated correction of the spermiogram to normal can be expected in approximately one fourth of cases. A long-term testosterone (Agovirin) administration has a beneficial effect on the qualitative aspect of the treatment in that it enhances sperm motility.


Operative management of variocele by high retroperitoneal ligation of the spermatic vein. High retroperitoneal ligation of the internal spermatic vein has been performed in 30 cases of varicocele. Renospermatic reflux had been demonstrated by preoperative phlebography in every case. Retrograde pressure brought to bear on the spermatic vein from the renal vein has been ascertained by intraoperative measurements of the pressures in the internal spermatic vein. On the ground of the results, high ligation of the spermatic vein is regarded as suitable for the surgical management of varicocele in case of renospermatic reflux.


Selection for surgery and long-term results in renovascular hypertension. From 1960 to December 1977, 251 patients with renovascular hypertension (RVH) were observed; 219 were operated upon. Long-term results were assessed in 130 patients. Selection for surgery follows three steps: 1) screening of patients with renal artery disease, which is done by angiography; 2) diagnosis of RVH, which is reached mainly by differential renal function studies and renal vein renin measurements (ancillary methods are intravenous pyelography and sequential scintigraphy; the significance of renin measurements is discussed); and 3) prediction of the results of surgery and choice of technique. An original dynamic test of the authors is employed and reconstruction of the renal artery is the procedure of choice. This is done in the majority of cases by aortorenal bypass grafts using dacron prostheses. Techniques and complications are discussed and comparison with venous autograft is made. Hospital mortality was 3.2%. Overall long-term results were favorable in 78%. Long-term mortality was 6% and occurred mainly in patients who remained hypertensive. Results in atherosclerotic patients are compared with those obtained in fibrous stenoses. Results of renal artery reconstructions were far better than those of nephrectomies and lead us to restrict indications for such a procedure.


Washout urography in the diagnosis of renal hypertension. Washout urography was used as a screening test for 100 hypertensive patients. Eleven patients had renal hypertension. These were 4 cases of unilateral renal artery stenosis, 6 cases of unilateral pyelonephritis and one case of bilateral pyelonephritis with atherosclerosis of the right renal artery. The increase in size of the affected kidneys after Lasix injection was much restricted relatvie to the normal contralateral kidneys. The test proved valuable for screening cases of renovascular hypertension and unilateral pyelonephritis.


Seasonal variations in urinary excretion of calcium and magnesium in healthy subjects and patients with renal calculus and chronic renal failure. Renal excretion of calcium in healthy subjects and in patients with renal stones increases in the summer, as compared to the winter values. In patients with chronic renal failure calciuria shows no seasonal variations. No essential difference in the monthly excretion of magnesium in 24-hour urine has been found between healthy persons and patients with renal stones.


Effects of 1alpha-hydroxyvitamin D3 on serum calcium and immunoreactive parathyroid hormone in patients with chronic renal insufficiency. Six patients with chronic renal failure on regular dialysis treatment were given low doses (0.5--1.0 microgram/day) of 1alpha-hydroxyvitamin D3, monitoring the serum calcium, inorganic phosphate, immunoreactive parathyroid hormone concentration (IPTH) and alkaline phosphatase activity. The serum calcium rose in all patients after 7 days' treatment, in some subjects to hypercalcemic range; this effect persisted 6--14 days after withdrawal of 1alpha-hydroxyvitamin D3. The elevated serum IPTH rose in the first days of treatment, but later decreased to normal values. It is suggested that active vitamin D metabolites are necessary for normal response of parathyroid glands to variation in serum calcium. Low-dose 1alpha-hydroxyvitamin D3 treatment appears to be a promising method of correcting hypocalcemia and secondary hyperparathyroidism in chronic renal failure. Careful control of serum calcium is necessary, as hypercalcemia may occur even after minute doses of 1alpha-hydroxyvitamin D3.


Asymptomatic kidney tumors incidentally diagnosed in two patients. In the years 1962--1975, at the Urological Department of the District Hospital in Warsaw, 1607 patients were operated on because of nephrolithiasis. In two cases coexistence of nephrolithiasis with renal tumour was demonstrated during operation. Physical and preoperative X-ray examinations suggested neither tumour nor metastatic foci in these two patients. The coexistence of nephrolithiasis and tumour of the kidney is a rarity (in our material 0.12%). Lumbotomy carried out because of nephrolithiasis makes possible a precise evaluation of the kidney condition and early discovery of tumour producing no clinical symptoms or X-ray changes.


Bilateral renal dysplasia (case report). Bilateral renal dysplasia is a very rare condition, unlike unilateral renal dysplasia. We came across three cases. In one of them there were other multiple congenital anomalies. In all the cases the ureters and renal blood vessels were rudimentary. The condition is incompatible with life. The different theories explaining this congenital anomaly and the incidence of the disease are being discussed.


Horseshoe kidney and its therapeutic problems. (A review of seventy-one clinical cases). A review of 71 cases of horseshoe kidney accounting for 0.12% of the total number of patients seen at the Department of Urology, Semmelweis University Medical School, Budapest, over 25 years is presented. The incidence of the abnormality has been found twice as high in males as in females. The proportion of surgical cases has been 57.8%, in agreement with published data. The radiodiagnostic investigations, particularly the functional diagnostic studies, are dealt with in detail. Their decisive importance in the considerations for or against surgery is emphasized.


Sensitizing activity of 9,13-dicis retinal in bleached photoreceptors of the skate. 9,13-dicis Retinal was externally applied to photoreceptors of isolated skate retina that previously had been desensitized by bleaching irradiation. This treatment led to a significant lowering of photoreceptor threshold and to the intracellular formation of isorhodopsin II, an artificial visual pigment containing 9,13-dicis retinal as its chromophore. These results suggest that isorhodopsin II can function in situ to promote an increase in the visual sensitivity of skate photoreceptors.


Distribution of acid phosphatase, beta-glucuronidase, and lysosomal hyaluronidase in the anterior segment of the rabbit eye. Distribution of acid phosphatase, beta-glucuronidase, and lysosomal hyaluronidase in the anterior segment of the rabbit eye was studied biochemically. Acid phosphatase activity was higher in the anterior uvea and cornea but lower in the sclera. Beta-Glucuronidase activity was higher in the anterior uvea but lower in the corneoscleral tissues. Lysosomal hyaluronidase activity was higher in the anterior uvea. The inner layer of the corneoscleral junction showed the highest specific activity of beta-glucuronidase and lysosomal hyaluronidase among the corneoscleral tissues. Lysosomal hyaluronidase activity was detected in all corneoscleral tissues.


Direct delivery of anticancer agents: experimental treatment of intraocular malignancy. Two anticancer agents, one lipophilic, 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), and one hydrophilic, 5-(3,3-dimethyl-1-triazeno) imidazol-4-carboxamide (DTIC), were used to treat Brown-Pearce epithelioma in the anterior chamber of rabbit eyes. The BCNU test animals were divided into three groups: one treated by direct injection of the drug into the subconjuntival space or the anterior chamber, the second by both direct injections and intravenous administration, and the third by intravenous injection alone. The DTIC test animals were treated with only local injection into the subconjunctival space or anterior chamber. Dosage, delivery system, and effectiveness were compared following clinical observation and histopathologic examination. Direct delivery of BCNU or DTIC in subconjuntival space or anterior chamber delayed the growth of Brown-Pearce epithelioma in rabbit eye. The effectiveness of this treatment was significnatly enhanced by combining direct injection with systemic administration of a lower dose of BCNU.


Phagocytosis and surface morphology in cultured retinal pigment epithelial cells. Phagocytosis of latex spheres was studied in explant cultures of retinal pigment epithelium from rabbit, calf, and rat (normal and dystrophic). Calf and rabbit pigment epithelial cells showed a "latent period" of about 12 and 17 hr, respectively, during which latex spheres were not ingested even when the cultures were pre-incubated for up to 24 hr prior to exposure. Scanning electron microscopy demonstrated a profusion of apical processes on the surface of cells from both species that was present throughout the latent period. In contrast, rat pigment epithelial cells showed no latent period and phagocytosed latex spheres after a pulse of 1 hr. It was concluded that the latent period is not common to all species and, when present, is not due to an absence of apical processes. The surfaces of normal and dystrophic pigment epithelial cells showed abundant apical processes that did not differ from each other in morphology, number, or distribution. In cells from pigmented species (calf and rat), frequent fusions were observed between latex phagosomes and melanosomes or melanin granules.


Fluorescent pigment accumulation in retinal pigment epithelium of antioxidant-deficient rats. A yellow autofluorescent pigment, generally thought to be indicative of membrane autoxidation, was found to accumulate in the retinal pigment epithelium (RPE) of rats maintained for 32 weeks on diets producing physiological antioxidant deficiency. The largest build-up of fluorescent pigment occurred in rats fed a diet high in polyunsaturated fatty acids (PUFAs) and deficient in alpha-tocopherol (vitamin E), selenium, sulfur-containing amino acids, and chromium. These latter four nutrients have all been implicated in maintaining the antioxidant status of tissues, whereas PUFAs are pro-oxidants. Dietary supplementation with methionine and chromium significantly reduced the amount of fluorescent pigment accumulated in the RPE. Supplementation with all four nutrients further reduced the amount of fluorescent pigment to a very low level. Rats maintained on a normal laboratory diet, relatively low in PUFAs and presumably adequate in other nutrients, accumulated relatively small amounts of fluorescent pigment in the RPE. Of all tissues in the retina and choroid, the autofluorescent pigment was found to be almost entirely restricted to the RPE. The autofluorescence produced in the RPE by antioxidant deficiency was more concentrated than that produced in the testes, kidney, intestine, and heart. This suggests that the RPE is particularly sensitive to physiological antioxidant deficiencies. The increased fluorescent pigment build-up in the RPE of antioxidant-deficient rats appears to correlate with a decreased RPE melanin content. Similar changes in pigmentation have been reported to occur in human RPE with age and in dominantly inherited retinitis pigmentosa. Thus, with respect to its effect on RPE pigmentation, antioxidant deficiency appears to mimic aging and possibly some aspects of one type of retinitis pigmentosa.


Leukocytes and experimental corneal vascularization. The growth of blood vessels toward corneal burns was compared in normal rabbits and those depleted of their white cells by exposure to X-irradiation. By the fourth day following injury, new vessels were present in all control and leukopenic animals. Histologic examination failed to demonstrate infiltrating cells in the leukopenic animals. In the absence of inflammatory cells, the cornea has the capacity to undergo vascularization in response to an injury. It is suggested that the epithelium is a source of a vasostimulating substance.


Essential fatty acid deficiency and photoreceptor membrane renewal--a reappraisal. The earlier reports from this laboratory that the renewal of rat photoreceptor membranes was dependent on essential fatty acids have not been confirmed in more recent studies.


Septic choroiditis with serous detachment of the retina in dogs. The present study describes a model of multifocal septic choroiditis with serous retinal detachment after intracarotid injection of Staphylococcus aureus or Streptococcus faecalis. The fundus lesions occurred mainly in the tapetal area and, on ophthalmoscopic examination, were more extensive after S. aureus than after S. faecalis injection. On histopathologic examination there were microabscesses in the inner choroid and subretinal space, disrupting the outer retina but sparing the inner retina.


Monochromatic (red-free) photography and ophthalmoscopy of the peripapillary retinal nerve fiber layer. The appearance of the peripapillary retinal nerve fiber layer (PRNFL) is crucial in the evaluation of patients with presumed optic neuropathies as well as in the differentiation of true optic disc edema from pseudopapilledema. Monochromatic (red-free) photography performed at 2 + magnification with a Zeiss fundus camera, a filter with maximum transmission at 540 nm, and Kodak Plus-X black-and-white film provides excellent PRNFL detail. Since direct ophthalmoscopy depends upon maximum illumination, which in turn depends upon increased color temperature of the light source, use of a direct ophthalmoscope with a gas-surrounded tungsten filament light source driven at 4.5 V raises color temperature sufficiently to allow practical use of monochromatic, red-free filters for optimum PRNFL evaluation.


Electroretinography with noncorneal and corneal electrodes. The noncorneal ERG is essential for certain patients in which corneal recording is contraindicated. A preliminary report is presented investigating ERGs from three noncorneal montages and their correlation with the corneal ERG. Statistical analysis showed that an electrode at the medial canthus combined with medial viewing gave the closest correlation to the corneal ERG. Repeatability was good for all montages. The inner canthus electrode was considered preferable for noncorneal recording because it was less affected by other time-locked activity; it correlated well with the corneal ERG and can be used in conjunction with the electro-oculogram.


Extraocular muscle and Harderian gland degeneration and regeneration after exposure of rats to continuous fluorescent illumination. Exposure of adult albino rats to continuous cool-white fluorescent illumination caused extensive destruction to the extraocular skeletal muscles (EOM's) and Harderian glands. After 1 day of exposure, leukocytes and macrophages invaded the damaged area and were found among and within the myofibers. After 48 hr of exposure, myoblasts and short myotubes extending from the damaged fibers indicated that regeneration had begun. In spite of constant illumination of the animals, the EOM's continued to reconstitute, and by the seventh day of exposure, regeneration was almost complete. At this time, small loci of degeneration and leucocytic infiltration resembling those seen in the 1-day stage again occurred. Results supported the speculation that differentiated myofibers were susceptible to the damaging effects of continuous fluorescent illumination, but that myoblasts myotubes, and early undifferentiated myofibers were not. Although the tubular epithelium proliferated in damaged Harderian glands, very few other regenerative changes were observed during the 7-day exposure period. When animals with one eye occluded with a plastic contact lens and the other unoccluded were exposed to continuous illumination, the pattern of tissue destruction in unoccluded eyes was identical to that described in the above series. However, EOM's in occluded eyes were unaffected, and Harderian glands had minimal damage limited to unshielded areas at the conjunctival fornix. Glands apparently were more susceptible to injury than EOM's. Orbital tissue destruction in these animals seemingly was due directly to a radiant energy-dependent mechanism.


Anterior segment permeability to fluorescein-labeled dextrans in the rat. Permeability of the anterior segment of adult Wistar-Furth rats to fluorescein-labeled dextrans (FITC-dextrans) was evaluated by fluorescein angiography following intravenous injection of 0.2 ml of a 33% FITC-dextran solution. Permeation of each fluorescent compound into the anterior chamber was evaluated by (1) initial appearance of fluorescence in iris vessels, (2) the appearance of fluorescence at the pupil, (3) contrast between the iris vessels and their surroundings, and (4) disappearance of FITC-dextrans from the iris blood column. Permeability of FITC-dex 3 (molecular weight, 3000; effective diffusion radius, 12 A) was similar to that of sodium fluorescein in that both entered the aqueous rapidly and showed diffuse aqueous fluorescence within 3 min. As the molecular weight of the FITC-dextrans increased (m.w. of 20,000, 40,000, 70,000, and 150,000 were used), the FITC-dextrans exhibited decreased aqueous permeation, and iris vessel contrast persisted. For FITC-dex 150 (m.w. 150,000; 85 A) no fluorescence was visible in the pupil at times as long as 1 hr. Since these fluorescent compounds exhibit aqueous permeability properties based upon molecular size and thus are similar to blood proteins, they should be useful for in vivo and in vitro quantitative study of the blood-aqueous barrier in animals.


The corneal and conjunctival surface in vitamin A deficiency: a scanning electron microscopy study. A model system of acute vitamin A deficiency in the guinea pig was used to investigate changes in corneal and conjunctival morphology. Hypovitaminosis A was induced by feeding experimental animals a purified gel diet deficient in vitamin A, while a control group received a vitamin A enriched diet. By the fifth week experimental animals exhibited a significant decrease in plasma vitamin A levels compared to controls. Animals were sacrificed at intervals from 5 to 9 weeks, and the corneas and conjunctivae were examined histologically and by scanning electron microscopy. Conjunctivae from control animals showed large numbers of goblet cells, whereas 16 of 18 experimental conjunctivae were completely devoid of goblet cells. Tarsal, palpebral, and cul-de-sac epithelia from deficient animals all showed many superficial squamous cells uplifted from the surface. Also, rugae were notably absent from the palpebral and cul-de-sac conjunctivae. The corneas of vitamin A--deficient animals exhibited varying degrees of superficial epithelial cell desquamation and keratinization. In addition, reduced numbers of microprojections and membrane breakdown were observed. These morphological and clinical findings are correlated with the possible role of vitamin A in cellular physiology.


Glycosidases of the retinal pigment epithelium. The pH optima and apparent Km and Vmax values were determined for nine glycosidases of the retinal pigment epithelium (RPE) of the calf. In terms of micromoles of substrate cleaved per milligram protein per hour, the following relative order of enzymatic activities was observed: beta-N-acetylglucosaminidase greater than alpha-glucosidase = beta-N-acetylgalactosaminidase greater than alpha-mannosidase greater than beta-galactosidase greater than beta-glucosidase greater than alpha-fucosidase greater than alpha-galactosidase greater than beta-glucuronidase. The pH optimum of each of these enzymes was in the acidic range (below pH 6). All these findings refer to enzymatic activities of bovine RPE preparations obtained by the brushing procedure of Glocklin and Potts and washing as described by Berman and Feeney. Thus they may relate to those activities associated with particulate components of the RPE cell and not to the more soluble glycosidases. The distribution of the glycosidases between the washes of the cells and the final pellet of bovine RPE cells was examined. The activities of 10 glycosidases in the RPE of the embryonic chick were also examined. Neither beta-mannosidase nor beta-fucosidase activities could be detected in washed bovine RPE cells, although beta-mannosidase was detected in RPE of the embryonic chick. The presence of isoenzymes of beta-glucuronidase in bovine RPE was indicated. Specificity by beta-glucuronidase of bovine RPE for synthetic substrates was observed.


Small-angle light scattering studies on xylose cataract formation in bovine lenses. Using polarized light scattered in the I'' and I+ modes, we determined the relative contributions of density and orientation fluctuation to the opacity of bovine lenses. In both the cortex and the nucleus of bovine lenses cultured in xylose column, we found that the increase in hydration effects the optical anisotropy (birefringence) first, before the lake formation will contribute heavily to the density fluctuation.


Different loci suggested to mediate tilt and spiral motion aftereffects. Interocular transfer of two figural aftereffects was examined in orthotropes and strabismic subjects. Within both groups there were persons with an appreciable degree of stereoacuity and others who had little or none. Experimental evidence from a variety of sources has suggested that stereopsis depends upon binocularity of units in the geniculostriate system. For the tilt aftereffect, interocular transfer correlated with stereoacuity among both orthotropes and strabismics. For the spiral motion aftereffect, interocular transfer did not correlate with stereoacuity; it was present among orthotropes and absent among strabismic individuals. The correlation of stereoacuity with interocular transfer of the tilt aftereffect agrees with previous observations and is consistent with the interpreation that this effect is mediated at a cortical level. The lack of a correlation between stereoacuity and interocular transfer of the spiral motion aftereffect suggests that this effect is mediated by units other than those responsible for stereopsis. Richards and Smith, on the basis of certain phenomenal differences between the spiral motion aftereffect and other figural aftereffects, have suggested that the former is mediated at a midbrain level. If strabismic persons lack binocular units in midbrain, the present results are consistent with their hypothesis.


Binocular vision tested with visual evoked potentials in children and infants. Evoked potentials (EP's) in response to phase-alternating gratings were recorded from normal and stereoblind or stereodefective subjects (adults and children) under monocular and binocular viewing conditions. The amplitude of the binocular EP was found to exceed the larger monocular EP in normal but not in stereodefective subjects, no matter whether the amplitudes of the two monocular EP's were the same or not. This finding provides an objective method for screening out defects of binocular vision. EP's recorded from a group of infants 2 to 18 months old suggest that a larger amplitude of the binocular EP, as compared with the monocular EP's, is the norm even in the earliest period of life.


Missing evidence for HLA antigen association with Eales' disease, chorioretinitis, central serous retinopathy, and malignant choroidal melanoma. Patients with Eales' disease, chorioretinitis, central serous retinopathy, or malignant choroidal melanoma were tested for HLA antigen deviation. When corrected p values (pc) are used, the first three disorders did not show any significant deviation, whereas a significant increase of HLA-Aw32 (pc = 0.026) was found in the malignant melanoma group. For conclusive evidence the latter finding needs confirmation by analysis of a greater number of patients with this disorder.


Absence of an effect of timolol on the pupil. Timolol, a relatively new beta-adrenergic blocker which has been found to lower the intraocular pressure in man, has not been observed to have any side effects upon the visual system. This study utilized pupillography to determine the effect of conjunctival instillation of 0.5% timolol ophthalmic solution upon pupillary size and reaction. No clinically significant effect was observed, but a statistically significant decrease in the amplitude of redilation of the pupil was found in the eye that received timolol.


Instrumented measurement of human joint motion. Accurate measurement of human joint motion is essential to the design and evaluation of internal joint prostheses and artificial limb replacements. A triaxial electrogoniometer instrumented by three miniature precision potentiometers was developed to fulfill this task. A special linkage was used to attach this apparatus externally to the joint. Three-dimensional angular motion following the classical Eulerian angle definition was measured in real time. The error due to exoskeletal attachment was corrected by the method of 4 x 4 matrix. This technique is now being routinely used for objective functional evaluation on the patients with abnormal hip, knee and ankle joints as well as lower extremity amputees fitted with artificial limbs.


Impact characteristics of articular cartilage. A rigid l m high stainless steel drop tower employing linear bearings has been used to study the impact characteristics of human articular cartilage. Instrumentation included a specially designed optoelctronic position transducer, piezoelectric force transducer, and high speed storage oscilloscope. Forty-eight 9 mm diameter samples of living articular cartilage and subchondral bone from the tibial plateaus of 4 human donors have been impacted at strains from 10 to 50%, and strain rates of 500s-1 and 1000 s-1. The integral bone/cartilage samples were mounted in polymethyl methacrylate for testing. Bone and cement impact characteristics have been studied separately. Stress, strain, and energy absorption data have been assembled for all the samples. Chondrocyte viability subsequent to impact has been investigated with the use of tritum labeled proline and autoradiography. Viability has been studied in relation to both the mechanical data and structural damage.


Endocarditis and ventricular septal defect: surgical vs. conservative treatment. Three patients with ventricular septal defect and bacterial endocarditis are reported. Because of the very frequent spontaneous closure of the defect, especially in children, and the rarity and benign nature of bacterial endocarditis superimposed on ventricular septal defect, it is suggested that the condition be treated conservatively. An exception to this is the rare case with recurrent endocarditis, mainly in older individuals, in whom surgery may be contemplated.


Congenital QT interval prolongation. A review with a survey of three families. The prolonged QT interval syndrome without hearing loss (Romano-Ward syndrome) is described in three families with 48 affected members. Syncope or dizziness caused by different ventricular tachyarrhythmias were the presenting symptoms in the symptomatic patients. Four of the subjects died suddenly. Right stellate ganglionectomy was performed in one patient in order to abolish the ventricular dysrhythmia. beta-blockers are considered the drug of choice in patients with hereditary prolonged QT interval; if the beta-blockers fail to abolish the syncopal attacks of severe bradycardia complicates the clinical course, a pharmacological blockade of the stellate ganglia should be performed and its results carefully evaluated in order to establish whether a stellate ganglionectomy is justified.


Echocardiographic left ventricular function in mitral stenosis. Left ventricular function was measured by echocardiography in 22 patients with pure mitral stenosis. Thirteen patients underwent closed transventricular mitral valvulotomy and nine underwent open mitral valvulotomy using cardiopulmonary bypass. Preoperative left ventricular function was normal in most patients but was depressed in older subjects (P less than 0.05) and in those undergoing a second operation on the mitral valve (P less than 0.001). The decrease in left ventricular function was probably related to the duration of mitral valve disease, with fibrosis and rigidity of the subvalvar apparatus and posterobasal left ventricular wall. There was no change in ventricular dimensions or in left ventricular function as measured by percentage shortening of the left ventricular diameter and ejection fraction 7 to 12 days after open or closed mitral valvulotomy.


Lymphoproliferative disorders in four patients receiving chronic diphenylhydantoin therapy: etiologic correlation or chance association? The occurrence of angioimmunoblastic lymphadenopathy, Hodgkin's disease or IgG-lambda multiple myeloma is described in four patients receiving chronic diphenylhydantoin (DILANTIN) therapy. Although the association between diphenylhydantoin therapy and the development of immunosuppression and lymphoma is well documented, the role of the drug in the etiology of these disorders is still controversial. It is suggested that periodic examination of patients receiving diphenylhydantoin for lymphadenopathy and repeated serum electrophoresis may be useful in detecting early aberrations of the immune system in these individuals.


Lead-erythrocyte protoporphyrin correlation in blood of exposed workers. A systematic survey of blood samples from 174 industrial workers occupationally exposed to lead fumes and lead dust, revealed some poor correlations between the lead (Pb) level and the free erythrocyte protoporphyrin (FEP) level. In addition to those workers who had an expected correlation (normal Pb-normal FEP or elevated Pb-elevated FEP) there were two groups with atypical correlations. In one group a normal Pb level was associated with an elevated FEP level and in the other group an elevated Pb level was associated with a normal FEP level. This shows that neither the Pb nor the FEP test can substitute for the other. Since the individual FEP response to Pb absorption is unpredictable, both tests should be carried out routinely. This would make it possible to determine simultaneously the degree of absorption (Pb level) and the degree of intoxication (FEP level) and would improve significantly the assessment of undue lead absorption of occupationally exposed workers. If, however, only one of these tests is used for screening the other test should always be carried out as a confirmatory test when the screening detects an elevated Pb or FEP level.


Demand for medical care in a rural setting: racial comparisons. Household data from a southern rural community are used to examine racial differences in the utilization of medical care services, and both monetary and nonmonetary determinants of demand are considered. Regression analysis results indicate that office waiting time (for black households) and travel time to the provider (for both black and white households) have a greater impact on demand than price. Racial differences exist in the effects of health insurance coverage and household income on household medical visit expenditures, and both need and household size are found to be consequential determinants of demand.


Parameters affecting hospital occupancy and implications for facility sizing. Simulation is used to investigate the effects on hospital occupancy of the number of beds in the facility, the percentage of patients who are emergencies, the percentage of elective patients who are scheduled, and the average lengths of stay of emergency and elective patients. A practical method is presented for estimating the optimum size of a short-term hospital on the basis of expected demand, and use of the results in planning is discussed.


Estimating the need for additional primary care physicians. A systems approach is used to assess the primary health care delivery system in Indiana. The output (office visits) of primary care physicians is estimated and compared with the demand for their services. Indexes of demand, supply, cost, and need are derived and used to determine the additional number of primary care physicians needed in each area. The results of this study are being used to encourage graduating medical students to practice in areas in need of additional primary medical care.


[New antibiotics in the treatment of urinary tract infections]. Based on the frequency of the isolated bacteria the antibiotics and chemotherapeutics commonly used in infections of the urinary tract are discussed. It turns out that ampicillin and sulphamethoxazole-trimethoprim are still the drugs of choice in the treatment of these bacterial diseases. A true advance is achieved by the introduction of carbenicillin and the new aminoglycoside amikacin. Carbenicillin can be used in Pseudomonas infections and is characterized by its low toxicity. Amikacin is the drug of choice against aminoglycoside-resistant gramnegative bacteria.


[Factors which influence the size of calcium oxalat crystals during their formation from saturated solutions]. The nucleation and growth of Ca-oxalate crystals from metastable and instable solutions was studied in some detail to find out the dependence of the crystal size on the absolute calcium resp. oxalate concentration, further on their molar ratio, on the presence resp. absence of crystal seeds, on the agitation resp. stagnation of the Ca-oxalate solution, on the duration of crystallization and on the renewing of the Ca-oxalate containing supernatant, thus simulating a prolonged (dietary) oxalate load in vivo. The most important findings are the clear inhibition of crystal growth at higher and very high calcium concentrations (in contrary to the unhindered crystal enlargement at high oxalate concentrations), further the eminent role of the oxalate in the formation of big crystals and crystal aggregates, as well as the substantial crystal enlargement at the persistent oxalate load.


[Prevention of urinary calculi with covalitin and by general measures]. The prophylaxis of the urinary lithiasis by means of drugs (alkalinisants, Eisemberg's syrup, allopurinol, etc.) obtains a very good result against uric acid and urate stones. The prevention of stones of oxalates, phosphates, carbonates, etc. is possible by trichlormethiazide (if hypercalciuria is present) and especially by a new drug, the Covalitin. Naturally diet and hydrotherapy. Decalogue for the stone's prophylaxis is done.


[Normocalcemic nephrolithiasis and primary hyperparathyroidism]. In normocalciuric and in hypercalciuric renal stone formers tubular calcium reabsorption (TRCa) was studied before and during an intravenous calcium infusion. In addition two patients with proven primary hyperparathyroidism (pHPT) were studied. TRCa was decreased in hypercalciuric stone formers whereas an increase was noted both in pHPT and in normocalciuric subjects. It is concluded that normocalciuric nephrolithiasis may be a manifestation of mild and/or early pHPT.


[Use of a human fibrin adhesive in nephrotomies]. Report on the use of a physiologic adhesive, a human fibrin product, in surgery of nephrotomies; the new technique allows the performance of nephrotomies for the removal of complicated and extensive lithiasis with minimal trauma to the renal parenchyma.


[Testosterone, FSH and LH level in the serum of patients with prostatic neoplasms, treated with female hormones]. Testosterone, FSH and LH were measured in serum of patients suffering from prostatic carcinoma. The efficacy of treatment with 1 mg diethylstilbestrol/d (Cyren A) was shown by suppressed serum levels of testosterone, FSH and LH comparable to castration in a follow-up until 560 weeks after beginning of therapy. Prolactin was raised in all patients under treatment.


[Histologic change of a prostatic leiomyosarcoma. Case report]. Case report on a leiomyoma of the prostate, becoming a leiomyosarcoma within 15 months. The patient was cured by radical surgery. The difficulties of histological diagnosis and proper surgical treatment are discussed.


[Immunologic studies for the diagnosis of chronic prostatitis]. A prospective study comparing the results of Antibody-Coating-Test (ABC) in semen and aspiration biopsy of the prostate with immunodiffusion of the former was carried out. In 143 patients with clinical signs of prostatitis only 98 showed a positive ABC in their ejaculates. IGA-specific ABC was positive in 75%, IGG-specific ABC in 48%, and IGM-specific ABC in 9.6% respectively. Specimens gained by aspiration biopsy of the prostate were also demonstrating positive ABC. Consistently negative was the ABC in 15 healthy male who served as a control. In 30 patients the ABC-Test of ejaculate speciments was compared with complement (C3) and coeruloplasmin content of the ejaculates using immunodiffusion technique. Contrary to the reports in the literature, however, elevated levels of complement (C3) and coeruloplasmin were not correlated with local infection of the prostate proven by ABC.


[HL-A antigenicity in bladder tumors].

[HL-A antigenicity in bladder tumors]. 30 patients with papillary transitional bladder tumours were treated by TUR. The stage O and A tumour specimens obtained were examined for presence or loss of antigenicity by the specific red cell adherence test (SRCA). The patients were followed up between 4 and 17 years. A correlation between loss of antigenicity and secondary occurrence of tumours with more aggressive biological behaviour was apparent. Possible therapeutic consequences are discussed.


[Positive demonstration of bladder tumors by means of double contrast cystography]. Using a contrast medium mixture adhering to the mucosa of the bladder, tumors with a diameter of only a few millimeters are to be seen positive in the double contrast cystogram. Evaluation of dimension and location is possible. The method is simple and the radiation dose is lower than in other cystographic procedures.


[Genital mycoplasma strains as a cause of male infertility]. Mycoplasma hominis, M. fermentans, M. orale, M. gallisepticum and Ureaplasma urealyticum are able to reduce the motility of spermatozoa. Electron microscopical investigation confirmed an affinity of these mycoplasmas to the structures of the cell-membranes of the spermatozoa. Simultaneously there could be observed extensive destructions in spermatozoa.


[Treatment of the neurogenic detrusor-sphincter dyssynergy with lioresal]. A double-blind placebo trial was taken with Lioresal, and antispasticity drug acting on the spinal cord level. The drug produced improvement of voiding function in 13 paraplegics with upper motor neuron lesions and detrusor external sphincter dyssynergia. As a main result, the opening time was reduced.


[Conservative-surgical therapy of the neurogenic bladder]. If physical therapy and drugs remain unsuccessful in the treatment of the neurogenic bladder, conservative-operative interventions should be performed prior to urinary diversion. Bladder neck incision, supraselective neurectomy and implantation of a bladder pacemaker in highly selected patients offer a good chance of avoiding diversion. In 64 cases of bladder neck incision, 80% improved or were cured. Experience with the neurectomy in patients with hyperactive detrusor is still limited. The preliminary results, however, proved that this technique should be included in the treatment of neurogenic bladder. 8 of 11 patients in whom a bladder pacemaker was implanted showed voiding following implantation. 7 patients displayed reflex evacuation.


[The continent colon-conduit stoma].

[The continent colon-conduit stoma]. A conduit occlusor is presented consisting of a tube surrounded by foam rubber and covered by a latex membrane, with a polyurethane cap attached to the other end. A valve imbedded in the cap allows voluntary urine drainage. This atraumatic, pneumatic, non-invasive occlusor device was used quite succesfully in 3 volunteers who had had a colon conduit urinary diversion. The device was well-tolerated, leakage was effectively prevented. Further experience, however, will be necessary for final evaluation.


[Animal experimental and clinical experiences with carbon polymer stomas]. Biocarbon implants consist of 99.9% pure carbon and are characterized by chemical inactivity and good tissue compatibility. Biocarbon was used for subfascial implantations, as well as coecostomies, ileostomies and cystostomie on mongrel dogs. The most important clinical results was the good healing over of the material without adverse reaction. The cystostomies showed only a very slight tendency to form incrustations. Drainage was watertight without signs of leakage. The satisfying results with two patients who were provided with a cystostoma are reported and further uses of the procedure, such as ureterocutaneostomy, iliac and colonic conduit, are discussed.


[Case report on acute scrotum].

[Case report on acute scrotum]. Torsion of the vestigial appendix testis may cause acute intermittent pain in the scrotum, which can arrise difficulties in diagnosis.


[Selective catheterization of peripheral arteries for the monitoring of patients in intensive care units]. In critical ill patients, determination of blood gases is a crucial part of patient evaluation and management. In intensive care situations many blood-gas determinations are required in a single day. The introduction of an arterial catheter into a small peripheral artery is an invaluable technique that allows continuous blood-sampling. During the past three years we had catheterized either the radial, ulnar or the pedal artery in 450 instances. The arterial catheter was left in place from 1 to 15 days. There were no serious complication. Haemorrhage due to accidental opening of the catheter occurred in three occasions. No case of ischaemia was encountered after a single artery catheterization. Temporary ischaemia of the upper limb appeared in three patients after simultaneous catheterization of both ulnar and radial arteries. The infection rate was nil. Arterial catheterization and maintenance of indwelling catheter for repeated blood-samples is a simple and safe procedure with minimal complications, invaluable in the management of critical ill patients.


[Indications and late results in the treatment of femur neck fractures with femur head arthroplasty]. On the basis of the case histories of 45 subcapital fractures of the femoral neck treated by hip arthroplasty (endoprothesis) indication and long-term results are demonstrated (average period after operation 54 months, longest period 16 years). Late complications (acetabular erosion, loosening) and possibilities to prevent them are discussed.


Hemoglobins Lepore and anti-Lepore.

Hemoglobins Lepore and anti-Lepore. The structure, properties, genetics, and clinical and biochemical expression of hemoglobins Lepore (deltabeta) and anti-Lepore (betadelta) are described. In addition to the three Lepore variants (Lepore Hollandia, Lepore Baltimore and Lepore Washington) at least four anti-Lepore variants (Miyada, P Nilotic (P Congo), Coventry and Lincoln Park) are known at the present time. All known hemoglobins Lepore and anti-Lepore are products of non-homologous crossing-over between the delta and the beta genes. Although the Hb Lepore condition is expressed phenotypically and clinically as beta thalassemia, the presence of about 10% of Hb Lepore distinguishes the condition hematologically from beta thalassemia. Data on the hematological and biochemical expression of this hemoglobinopathy are presented. In contrast to the anemia in the Lepore condition, there is no phenotypic evidence of thalassemia in persons with hemoglobin anti-Lepore, because no beta chain deficiency accompanies the latter condition. Although no adequate explanation has been advanced concerning the factors which maintain a low synthesis of the Lepore and anti-Lepore chains, it has been suggested that multiple rare codons may introduce rate-limiting steps or that the deltabeta and betadelta mRNAs may be unstable. Data on the geographical distribution and structural identification of Hb Lepore are presented.


Hemoglobin Hoshida (beta43 (cd-2) Glu leads to Gln), a new hemoglobin variant discovered in Japan. An electrophoretically G-like hemoglobin variant, Hb Hoshida, was detected from a ten year old girl and her mother. No clinical and hematological abnormalities were seen in the individuals heterozygous for this mutant gene. Structural studies of this abnormal hemoglobin demonstrated a previously undescribed substitution of beta43 (CD-2) Glu leads to Gln. The proportion of the abnormal hemoglobin in hemolysate was 42.1 per cent. The hemoglobin revealed neither instabilities nor functional abnormalities.


Hemoglobin Legnano (alpha2 141 (HC3) Arg replaced by Leu beta2): a new abnormal human hemoglobin with high oxygen affinity. An abnormal, fast moving hemoglobin was noted in a 34-yr-old male patient living in Legnano (northern Italy) affected with renal failure and iron deficiency anemia, not related to the presence of the Hb variant. Structural studies have demonstrated a previously undescribed amino acid substitution, alpha 141 Arg replaced by Leu. This new variant has been named Hb Legnano, and is characterized by an increased oxygen affinity and a low cooperativity, at least as far as preliminary functional studies carried out on whole blood have indicated. Family studies are reported: three other heterozygous carriers were observed among the relatives of the propositus, all showing a mild polycythemia which, however, does not seem to produce appreciable clinical consequences.


Allosteric effect of o-iodobenzoate on hemoglobin. O-Iodobenzoate interacts non-covalently with hemoglobin and lowers the oxygen affinity of the protein. In contrast to 2,3-diphosphoglycerate or inositol hexaphosphate, its interaction does not depend upon the presence of free amino groups at the beta-chain amino terminals. Lysine beta82 is one of its oxygenation linked binding sites. As with the organic phosphates, the halogenated benzoate reacts preferentially with deoxy-hemoglobin to shift the allosteric equilibrium from R to T.


Semiquantitative computerized image analysis of fetal hemoglobin distribution patterns in sickle cell anemia and its variants. Computerized, semiquantitative image analysis of 2913 erythrocytes from 29 young patients with sickle cell anemia and its variants was conducted utilizing a modified method for determination of fetal hemoglobin distribution by an acid elution procedure. Histograms of eight arbitrary levels of staining intensity, proportional to fetal hemoglobin levels, were analyzed in relationship to both computer-generated, mathematical parameters of erythrocytic shape abnormalities and clinical parameters of disease severity. Shifts in fetal hemoglobin distribution were observed in analysis of sequential specimens. An inverse correlation was observed between angularity of erythrocytes and their individual fetal hemoglobin content (p less than or equal to 0.05). A positive correlation was noted between growth percentiles and percentage erythrocyte ghosts by acid elution (p less than or equal to 0.01).


Hb Nottingham (alpha2beta2 (FG5) 98 val leads to gly) in a Caucasian male: clinical and biosynthetic studies. A second instance of the unstable mutant Hb Nottingham (alpha2beta2 (FG5) 98 Val leads to Gly) is reported in a 7-year-old boy. Because of splenomegaly, cholelithiasis, and frequent episodes of abdominal pain, he underwent a splenectomy and cholecystectomy at age 6. The surgery resulted in both an amelioration of his RBC destruction and an acceleration of his rate of growth.


Hemoglobin H disease in Sardinia: phenotypic and genetic observations. In this study the clinical and hematological characteristics, the transmission pattern and the relative rates of globin chain synthesis were determined in the members of four Sardinian families with 14 patients affected by hemoglobin H disease. The severity of hemoglobin H disease in Sardinian subjects shows a high degree of variability. Clinically it usually appears intermediate between the hemoglobin H disease found in Oriental and Negro populations. The alpha/beta specific activity ratio was 0.42 +/- 0.10 indicating an analogous biochemical defect like that described in the Chinese. On the basis of hematological data and alpha/beta ratio, the genetics of hemoglobin H disease in Sardinians seem to follow a pattern similar to that observed in Orientals: one parent showing alpha-thalassemia-1 trait and the other alpha-thalassemia-2 trait. Parent offspring transmission of hemoglobin H disease did occur in 2 out of 6 hemoglobin H matings with spouses carrying the alpha-thalassemia-1 gene. This observation indicates either a high frequency of alpha-thalassemia trait in Sardinians or a high incidence of inbreeding. In one family the mating of a patient with hemoglobin H disease and a normal person produces 6/6 offspring with alpha-thalassemia-1. The genetic implications of this transmission pattern are discussed.


Amino acid sequence of the hemoglobin of raccoon (Procyon lotor). The amino acid sequences of the hemoglobin alpha- and beta-chains of raccoon have been determined by a combination of manual and automatic sequencing procedures. The raccoon beta-chain shows 16 amino acid differences from that of dog. The alpha chain shows 10 differences. These values are identical with those predicted by analogy from their tryptic peptide compositions.


Hemoglobin A and B of the cat: occurrence in the same cell. The two major hemoglobins found in domestic cat blood occur within the same erythrocyte. A putative asymmetrical hybrid, alpha2betaAbetaB, is shown to be present in the cell by isoelectric focusing.


[The indications for revision radical maxillary sinus surgery (author's transl)]. Surgery of the maxillary sinus is one of the commonest in otorhinolaryngology. The classical Caldwell-Luc procedure however is not infrequently followed by infraorbital or some other facial neuralgia or discomfort. In 1976,246 patients were assessed for revision maxillary sinus surgery, and the symptomatology, clinical, transnasal endoscopic and radiological (polytomography) findings were documented. 59 revision operations were performed and a critical analysis of the preoperative, operative and postoperative findings are presented. Polytomography together with sinus endoscopy is a very valuable assessment of the need for revision surgery. Careful sublabial periosteal wound closure is emphasized, and as an alternative to the Caldwell-Luc procedure the intranasal antrostomy under endoscopic control is recommended.


[Surgical or conservative treatment in orbital complications of sinus inflammations (author's transl)]. 47 patients with orbital complications resulting from acute sinusitis have been treated at the Freiburg ENT Department during the last seven years. Acute ethmoiditis predominated in children, while pansinusitis was more common in adults. Previous sinus surgery did not prevent orbital complications arising from the same sinus. Orbital involvement was classified into periostitis, subperiosteal abscess and orbital cellulitis. According to clinical findings, 44.7% of the patients were managed conservatively. Prognosis was best in periostitis, whereas consersative treatment was unsafe in orbital cellulits. Children usually respond well to appropriate antibiotic coverage but the occurrence of common upper respiratory or anaerobic pathogens should be kept in mind.


[How good is the inferior meatal antrostomy in chronic maxillary sinusitis? (author's transl)]. 44 inferior meatal antrostomies in 32 patients with chronic maxillary sinusitis were followed at two month intervals over a period of two years. Closure of the antrostomy occurred in 29.4% of the cases reported. Allergy was unimportant for the operative result, nor was an increased frequency of infections demonstrated following surgery. Subsequently, improvement of sinusitis was noticable, even after closure of the fenestration. In contrast to other reports in the literature, mucociliary drainage from the maxillary sinus to the nose occurs through the operatively placed fenestra.


[A contribution to the operative treatment of diplopia in patients with long-standing orbital floor fractures. A combined operative technique by an ophthalmologist and an otorhinolaryngologist is described (author's transl)]. A patient with an 8-month old orbital floor fracture presented with inferior displacement of the globe, enophthalpmus and diplopia on upward gaze due to an entrapped inferior rectus muscle. In a combined approach, the orbital floor was first repaired by an otorhinolaryngologist. The ophthalmologist then severed the adhesions of the inferior rectus muscle, and a piece of silicone sheeting was sutured to periorbital tissue under the muscle to prevent the formation of new adhesions as well as to provide a smooth surface for the muscle to slide on. This approach restored the muscle function which has remained intact 13 months postoperatively. The simplicity of the procedure is stressed.


[A method for management of midfacial fractures (author's transl)]. In the treatment of severe "dish-face" deformities which result from Le Fort II and III middle face fractures, reposition and fixation of the maxilla can be achieved by an extraoral cranial fixation apparatus. We describe a modification of the Georgiade head frame which achieves higher stability in fixing the maxilla and arch wires. The joints applied to the rigid wire connecting the arch bar to the head frame make an adaptation to the upper lip possible; traction of the maxilla to maintain its fixation can be applied extra-orally so that closure of the lips with correction of occlusion is possible, making easier the uptake of nourishment.


[Head and neck manifestations of lymphogranulomatosis X (author's transl)]. Immunoblastic lymphadenopathy was first described in the german literature in 1975 by Lennert as "Lymphogranulomatosis X." The disease is characterized by generalized lymphadenopathy, hepatosplenomegaly, dysproteinemia, fever and hyperergic reactions such as pruritus, skin rush and eosinophilia. The first ORL occurrence of the disease in Waldeyer's ring and cervical lymph nodes is reported. The histologic picture is characterized by a vascular proliferation with immunoblasts, plasma cells and interstitial amorphous acidophilic material but without Sternberg cells. The origin of the disease from primary malignant neoplasia or hyperergic reactions has not yet been defined. Although prognosis is uncertain and therapy limited, the best management involves small doses of corticoids, supplemented by antibiotics.


[High tone audiometry I. Dominant sidedness of hearing (author's transl)]. Tests for determining the dominant hearing ear by use of high tone audiometry (18 to 16 KHz) on 100 male and female "normal hearing" patients aged between 5 and 71 years of age demonstrated a relationship with whole body laterality (eye dominance, preferred tongue side, vocal cord asymmetry and hand and foot dominance). Right ear dominance was found in 62 of 85 right-handed individuals, whereas left ear dominance was found in only 3 of 10 left-handed individuals. In 5 with ambidexterity high tone audiometry failed to show any significant preference. High tone audiometry clearly clarifies cerebral hemisphere dominance and this auditory dominance can be utilized therapeutically as well as prognostically.


[High tone audiometry. II. Clinical application (author's transl)]. High tone audiometry, which is the testing of the auditory threshold between 8 and 16 KHz, increases the clinical usefulness of pure tone audiometry. Specific patterns of audiograph were obtained from 100 children and adults with auditory dysfunction of varied cause. The clinical application of high tone audiometry as an audiological aid to specific diagnosis should be pursued.


[Bronchoscopies under etomidat general anesthesis (author's transl)]. 64 bronhcoscopies performed in 1977 under general anesthesia are reported from the ENT Department of the Protestant Hospital, Oldenburg, West Germany. Indications for bronchoscopy were primarily for the diagnosis of bronchial tumors, but also included treatment of foreign body aspirations as well as the definition of tracheal stenoses and injuries from intubation anesthesias. The hypnotic agent "Etomidat" was used as anesthesia, during which the parameters of heart and peripheral circulation were carefully monitored. These remained stable; patients needed only a short time to waken, and were quickly able to again cooperate with the doctor.


Lack of effect of vagal afferent input on central neural respiratory afterdischarge. The effect of respiratory inhibition caused by vagal stimulation or lung inflation on the central neural mechanism that maintains respiration after cessation of a facilitatory stimulus was studied in anesthetized cats. Phrenic activity was increased by carotid sinus nerve stimulation or by squeezing or stretching calf muscle. On cessation of stimulation there was an immediate decrease in respiratory output followed by a slow decrease (afterdischarge) over a period of 5 min. Vagal stimulation or lung inflation,  which caused marked inhibition of inspiration, had no effect on the development of the afterdischarge or on the course of the subsequent recovery process. The mechanism causing afterdischarge is probably a buildup of activity in a neural network in the medulla and pons. Since its activity is unaffected by vagal inhibition of respiration, it can be concluded that the network is separate from inspiratory output neurons and those involved in phase switching and that it is not dependent on increased central inspiratory neuron activity.


Effect of altitude on dietary-induced thermogenesis at rest and during light exercise in man. Measurements of metabolic rate and the thermic response (specific dynamic action) of a 400-kcal liquid meal were made in six subjects at rest and during light exercise. The tests were conducted before (LA1) and after (LA2) a 3-wk sojourn (HA1, HA2, HA3) at 3,650 m on the Monte Rosa. Fasting metabolic rate at rest increased inittally and then fell, as did fasting and fed exercising metabolic rates. The fall in metabolic rates, but not the initial increases, can be ascribed to the change in body weight. Resting thermic responses at altitude were only slightly lower than normal, although peak values were significantly depressed at HA2 (P less than 0.05). The mean exercising thermic response was also significantly lower at HA2 (P less than 0.05) but recovered in HA3 and LA2. In the time taken for thermic responses to decrease and recover there were interindividual differences that were best explained by the previous altitude experience of the subjects. The possibility of a cardiovascular shift during hypoxic exercise causing depression of postprandial metabolism is discussed.


Effects of exercise, altitude, and food on blood hormone and metabolite levels. Measurements of blood glucose and plasma free fatty acids (FFA), thyroxine (T4), free thyroxine (FT4), triiodothyronine (T3), and thyroid-stimulating hormone (TSH) were made on samples taken from fed and fasted human subjects while at rest and immediately after 20 min moderate exercise. Six subjects were studied on successive weeks before (LA1), during (HA1, HA2, HA3), and after (LA2) a 3-wk sojourn at high altitude (3,650 m). The subjects and location were the same as those used for the energy expenditure measurements described in the preceding paper (J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 45:345--349, 1978). The most marked effect of altitude was to potentiate the rise in FFA due to exercise. This effect was most noticeable in fed subjects during HA1 and HA2. Changes in the plasma levels of the thyroid hormones correlated with the FFA changes and, once again, exercise at altitude caused the greatest increase in circulating levels. Possible causes of the parallel changes in FFA and thyroid hormone levels and their relationship to changes in energy metabolism are discussed.


Regional lung expansion at total lung capacity in intact vs. excised canine lungs. A computer-based biplane videoroentgenographic recording technique that determines the spatial coordinates of radiopaque lung parenchymal markers was used to compare regional lung expansion at total lung capacity (TLC) in the intact dog (prone and supine) and after removal from the chest. The reproducibility of the technique was examined by repeated determinations of intermarker distances at various static lung volumes during stepwise inflation and deflation of the lungs. Most of the variability in repeated determinations of intermarker distances at any lung volume was due to cardiogenic motion. When marker positions were determined repeatedly at the same phase of the cardiac cycle, the maximum coefficient of variation was less than 3% for a marker pair separated by 16.5 mm. At TLC, distances between all intralobar marker pairs in the intact thorax (prone and supine) and excised were highly linearly related (r = 0.96-0.99), whereas distances between interlobar marker pairs did not correlate as well (r = 0.77-0.86). We conclude that at TLC 1) the intact thorax does not distort the shape of the individual lobes from the state of isotropic expansion, and 2) in different body positions, overall lung shape may be different due to displacementof lobes relative to each other, but individual lobes remain uniformly expanded.


Time course of sympathoadrenal adaptation to endurance exercise training in man. One possible reason for the lower exercise heart rate after endurance exercise training is that the sympathetic drive to the heart is reduced. We have studied the relationship between plasma catecholamines and heart rate during exercise in the course of a 7-wk training program. Six untrained subjects exercised vigorously (on bicycle ergometers and by running) 30--50 min/day for 7 wk. Prior to the beginning of training and at weekly intervals thereafter, participants were subjected to a 5-min strenuous bicycle ergometer test. In the test prior to training, plasma epinephrine increased to 0.5 ng/ml and norepinephrine increased to 3.0 ng/ml. The major proportion of the training-induced decrement in catecholamine response was reached at the end of the 3rd wk when epinephrine increased to 0.17 ng/ml and norepinephrine increased to 1.5 ng/ml in response to the same test. Heart rate during exercise continued to decrease even after the catecholamine response had plateaued, implying that the reduced sympathetic response is not solely responsible for the reduced exercise heart rate.


Estimating central and peripheral respiratory resistance. An analytic approach for fractionating total respiratory resistance into central (Rc) and peripheral (Rp) components is presented. In the analysis, linear regression equations relating the logarithm of the measured total resistance to the logarithm of frequency are derived for data spanning the frequency range 1-16 Hz. The computed slope and intercept are used to obtain estimates of the fraction of the resistance in the periphery (Fp) and of Rp and Rc. Data from anesthetized, closed-chested dogs in a control state and with an external resistor (1.37 cmH2O.1-1.s) were used to test the approach. Mean values +/- SE's for control data were: Fp = 0.400 +/- 0.039, Rp = 1.37 +/- 0.16 cm H2O.1-1.s, and Rc = 1.98 +/- 0.10 cmH2O.1-1.s. Mean values of Rp obtained with and without added resistance were not significantly different (P less than 0.1). The increase in the mean values of Rc represented 85% of the value of the added resistance but was significantly different from the known value of the external resistance (P less than 0.05). These data suggest that it may be possible to fractionate total respiratory resistance into central and peripheral components using the frequency dependence of forced oscillatory resistance.


Oxygen consumption during constant-load exercise. Previous investigators have reported that oxygen consumption (VO2) continues to rise after the initial 2- to 3-min transient period of exercise when work exceeds approximately 60% of VO2 max. The purpose of this investigation was to examine the possible causes of this slow rise in VO2. Eighteen subjects exercised for 20 min at 65% and at 80% of VO2 max on the bicycle ergometer. VO2, ventilation (VE), and respiratory exchange ratio were monitored by a continuous computer-based system. Blood lactate concentration and rectal temperatures were measured at 2- to 3-min intervals during the exercise. VO2 increased significantly from the 5th to 20th min of exercise in 81% of the tests at both levels of work intensity. The magnitude of the rise was not different for the two work loads. No evidence was found to support the lactacid explanation proposed for this rise. Increased temperature could account for 30% of the rise; the estimated cost of increased VE could account for 30 and 81% of the rise at the two work loads. The sum of these factors could account for 60 and 111% of the rise in VO2 at the 65 and 80% of VO2 max work loads.


Effects of lung volume and electrode position on the esophageal diaphragmatic EMG. In anesthetized dogs studied both supine and prone, the electromyogram (EMG) of the diaphragm recorded directly from three portions of the diaphragm (crural, anterior, and costal) was compared with simultaneous recordings of the diaphragmatic EMG recorded from 10 sites in the esophagus and stomach. Effects upon the EMG of lung volume change and esophageal electrode position change were determined during bilateral supramaximal tetanic phrenic stimulation with airway occluded. Lung volume change had little effect upon the directly recorded EMG. The effect of lung volume change upon the EMG recorded from the esophagus was somewhat greater and marked change was noted as the esophageal recording site was varied. In supine dogs two sites of maximal signal were observed, one 1 cm above the cardia and the other 4--6 cm below the cardia. In prone dogs a single site for maximal signal was observed 3 cm above the cardia. An electrode site as close to the cardia as possible appears to be optimal from the point of view of variation in signal due to lung volume change and due to body position change. Gastric balloon stabilization is recommended. Proximity of the electrode and posterior gastric wall to the diaphragmatic crura may explain the maximal EMG signal recorded below the cardia.


Effects of angiotensin antagonism at rest and during exercise in sodium-deplete man. Mean intra-arterial pressure (P-), heart rate (HR), cardiac index (CI), total peripheral resistance index (TPRI), and plasma renin activity (PRA), norepinephrine (PNE), and epinephrine (PE) were estimated in five normal male subjects placed on a low-sodium diet for the previous 7 days. Subjects were studied during rest in recumbency and during intravenous infusion of either glucose or saralasin in a) recumbent position, b) sitting position on the bicycle ergometer, and c) during submaximal graded exercise. At rest recumbent saralasin induced pressure changes that were closely related to logPRA. During exercise the increase in P- was significantly lower during saralasin as compared to glucose from 110 W on, related to a greater reduction in TPRI. The increase of PRA during exercise was about three times greater with saralasin as compared to glucose, but the rises in PNE and PE were similar in both series of tests. Angiotensin II may thus have a role in the maintenance of P- in the supine sodium-deplete normal subjects, and stimulation of the renin angiotensin system during physical exercise contributes to a minor extent to the increase in P- in these conditions.


Plasma volume changes with movement to supine and standing positions. The chronology of hemoconcentration and hemodilution associated with changes in posture, and the reliability of venous hematocrit (Hct), hemoglobin (Hb), and plasma proteins (PP) as indicators in evaluating changes in plasma volume were determined in seven male subjects. Red cell mass was also measured by the CO method at the termination of the erect and supine positions. Movement to and from supine and erect positions produced consistent, rapid, and progressive changes in Hct, Hb, and PP. Thirty-five minutes in a supine position resulted in a 440-ml expansion of plasma volume. Resumption of the standing position resulted in an increase of 10.3 and 10.8% for Hct and Hb, respectively, and an increase in PP of 20.8%. A fluid efflux of 593 ml reduced blood and plasma volume by 9.5 and 16.2%, respectively. Red cell mass was unaffected by changes in posture. The significance of these postures on the reported alterations in plasma volumes consequent to the imposition of stresses on man are discussed.


Blood flow and relative tissue PO2 of brain and muscle: role of carotid chemoreceptors. The effects of inspiration of low O2 and/or high CO2 gas mixtures on relative tissue PO2 and perfusion of brain and muscle were studied in 60 pentobarbital-anesthetized spontaneously respiring rats. These animals were studied in intact condition, after administration of phenoxybenzamine hydrochloride, 2 mg/kg, or after bilateral denervation of their carotid bodies. In the intact rats, the relative tissue PO2 ratio of biceps brachii to cerebral white matter always decreased after exposure to the above gas mixtures. This indicated a better maintenance of O2 supply to demand in the brain than in muscle. After either carotid denervation or alpha adrenergic blockade, this change in the ratio was no longer significant. Further, cerebral blood flow responses to these gas mixtures were attenuated (avg + 5.3%) compared to previous work in intact rats. It is concluded that the brain is best protected against hypoxia and/or hypercapnia when the carotid chemoreflex is intact.


Glycogen depletion in exercising rats infused with glucose, lactate, or pyruvate. The influence of an intravenous infusion of glucose, lactate, or pyruvate on the work capacity and rates of glycogen depletion in the liver and hindlimb skeletal muscles of rats has been studied. Running time to exhaustion at a speed of 21 m/min on a treadmill at a +10 degrees incline was prolonged by glucose infusion but shortened by lactate or pyruvate infusions. Blood glucose concentrations were only lowered in the terminal stages of the exercise, whereas at this point lactate was elevated. Declines in liver and muscle glycogen concentrations were retarded by glucose infusion but accelerated by either lactate or pyruvate infusions. In all cases a marked depletion of both muscle and liver glycogen existed at the point of exhaustion. It is concluded from the lack of any major elevation of glucose, lactate, or pyruvate in the blood of the rats during running that these materials were taken up and oxidized, presumably by the working muscles. These observations suggest that skeletal muscle can take up large amounts of glucose and when it is supplied from an external source this can exert a glycogen sparing effect on the liver and working skeletal muscles.


Evaporative water loss in man in a gravity-free environment. Daily evaporative water losses (EWL) during the three Skylab missions were measured indirectly using mass and water-balance techniques. The mean daily values of EWL for the nine crew members who averaged 1 h of daily exercise were: preflight 1,750 +/- 37 (SE) ml or 970 +/- 20 ml/m2 and inflight 1,560 +/- 26 ml or 860 +/- 14 ml/m2. Although it was expected the EWL would increase in the hypobaric environment of Skylab (one-third atmosphere). an average decrease from preflight sealevel conditions of 11% was measured. The results suggest that weightlessness decreased sweat losses during exercise and possibly reduced insensible skin losses as well. The weightlessness environment apparently promotes the formation of an observed sweat film on the skin surface during exercise by reducing convective flow and sweat drippage, resulting in high levels of skin wettedness that favor sweat suppression.


Pressure outside the extrapulmonary airway in dogs. We have measured the static and dynamic transmural pressures of extrapulmonary airways during positive pressure lung inflation in anesthetized dogs suspended in the standing position. Thin, fluid-filled catheters measured pressures within and on the anterior surface of the airways in the mediastinum and neck. The change from mediastinal to cervical static extra-airway pressures (Pea) was not abrupt but occurred through the thoracic outlet and the root of the neck. The static Pea in the mediastinum was more positive than pleural pressure when lung volume was increased with positive pressures. During forced deflation equal pressure points (EPP) were in labor bronchi from which airway narrowing extended towards the mouth. Under these conditions, the dynamic mediastinal Pea mouthward of the EPP remained close to pleural pressures even at high volumes. This suggested that forces of restitution generated in the surrounding tissues by the narrowing of the airways did have a small effect in reducing the pressure affecting their anterior surface.


Effects of lung inflation on pulmonary arterial pressure in dogs with pulmonary edema. The effects of lung inflation from positive airway pressure (Paw) on pulmonary arterial pressure (Ppa) and the slope deltaPpa/deltaPaw were studied in normal dogs and dogs with pulmonary edema. Under base-line zone 2 conditions with the lungs perfused at constant flow (100 ml/kg per min) and vascular pressures measured relative to pleural (atmospheric) pressure, the slope deltaPpa/deltaPaw was nearly one (at Paw greater than or equal to 5 cmH2O). Pulmonary edema from high capillary pressure and oleic acid caused deltaPpa/deltaPaw and Ppa to decrease at high lung volumes and Ppa to increase at low lung volumes. These changes were not simulated by vasoactive drugs (adenosine and norepinephrine) but were reproduced by instilling dextran into the lungs and, in part, by occluding the right intermediate bronchus. In pulmonary edema the increased Ppa at low lung volumes is caused by the effects of decreases in the caliber of extra-alveolar vessels, by trapped air or liquid raising alveolar pressure, or by both; the decreased deltaPpa/deltaPaw and Ppa at high volumes is caused mainly by nonuniform distribution of driving pressures and blood flow.


Impedance cardiography for estimating cardiac output during submaximal and maximal work. Impedance cardiography was used to estimate cardiac output in 10 men during rest and within 5 s after exercise on a bicycle ergometer, including work up to and including maximal aerobic capacity. An indwelling venous catheter permitted simultaneous sampling of venous blood for observing changes in hematocrit associated with each exercise level. Cardiac output, calculated from a standard equation which assumes a constant value of 150 omega.cm for the electrical resistivity of blood, was compared with corresponding calculations in which blood resistivity was individually determined as a function of hematocrit. It is concluded that many of the discrepancies in the literature related to values for cardiac output obtained during exercise by the impedance method may be inherent in calculations that do not consider the changing electrical resistivity of the blood with a changing hematocrit.


Role of physical effort in the etiology of rat heatstroke injury and mortality. A total of 171 untrained, unacclimatized, and unanesthetized rats were used to evaluate the effects of sedentary and work-induced hyperthermia on the incidence of mortality and cellular injury, 24 h postexposure. Cellular injury was defined as serum transaminase activity (SGPT and SGOT) exceeding 1,000 IU/l (heatstroke levels). Both the percent mortality and the percentage of 24-h survivors with transaminase levels above 1,000 IU/l were plotted against maximum core temperatures. Exertion-induced hyperthermia produced a significantly higher incidence of cellular injury and heatstroke death at lower core temperatures than hyperthermia alone. With hyperthermia only, the SGPT and SGOT dose-response curves were identical. When work was combined with hyperthermia, there was a greater incidence of elevated SGOT at lower core temperatures. These curves bore a striking resemblance to curves reflecting heat- and/or work-induced mortality in humans. The results suggest a direct role of physical effort in causing heatstroke injury and mortality.


Cold-induced pulmonary hypertension in cattle. The frequency with which cattle develop right-heart failure during the winter at high altitude suggested that cold might contribute to hypoxic pulmonary hypertension. Indeed in a preliminary study conducted out-of-doors during early Spring, two calves with known hyperreactive pulmonary vessels showed elevated pulmonary arterial pressures attributed to their prior exposure to nighttime cold (-5 degrees C). In a second study five hyperreactive calves had increases in mean pulmonary arterial pressure from 29 to 45 Torr (+ 55%) during 48 h of exposure to cold (0 to -5 degrees C) in a climatic chamber. Three calves with less reactive lung vessels increased their pressures from 25 to 36 Torr (+ 44%). In a more complete study, six calves selected as potential hyperresponders showed increases in pulmonary arterial pressure (+ 60%), blood flow (+ 18%), and vascular resistance (+ 38%) during 48 h of cold exposure. Arterial PO2 decreased (-10 Torr) and PCO2 rose (+6 Torr) suggesting hypoventilation. Oxygen breathing returned pulmonary pressures and resistance to near control values, suggesting that cold had induced a hypoxic pulmonary vasoconstriction and an increased blood flow. Thus, a cold produced pulmonary hypertension in cattle at the modest altitude of 1,524 m and the pressor responses were greater in calves with more reactive lung vessels.


An electromagnetic valve for inspiratory occlusion pressures. An electromagnetically powered respiratory valve to occlude a respiratory circuit for short (30--300ms) periods of the respiratory cycle may be inexpensively constructed from available laboratory instruments and controlled by an electronic circuit. Occlusion of the inspiratory breathing circuit may be repeated at different levels of ventilation without altering slopes or intercepts of CO2 rebreathing curves. The early phases of airway occlusion (P0.1) may therefore be studied in conscious unanesthetized human subjects.


A cell membrane theory of endothelial repair and vertical cell loss after cataract surgery. Endothelial cell counts were taken of the superior, central and inferior corneas of controls, immediate post-operative cases and a four year post-operative case. A vertical mean cell density was found to correlate well with central densities, and mean vertical cell loss (42%) compared well with central cell loss (44%). There was no trend for vertical cell disparity (VCD) in control eye, but a definite disparity was seen in all post-operative eyes, including the one four years after surgery. A cell membrane stimulus theory is proposed for endothelial cell reparation after endothelial damage describing cessation of cell migration once the defect is covered.


Experience with the Russian made Fyodorov intraocular lens. One hundred cases have been operated using the Fyodorov Russian made lens. The installation and the postoperative course have been no more difficult that that experienced with other lens styles.


Management of some complications of the medallion circular loop lens. Iris damage in the area with loop contact can be prevented by lowering the dosage of steroids. An already damaged iris can be saved with phospholine iodide followed by phospholine iodide combined with atropine to immobilize the iris. On a low dose keratic precipitate-like spots will be formed on the pseudophakos, but they will disappear spontaneously. This lens does not tolerate pilocarpine in the first month after surgery. A small pupil needs mydriatics. Retinoscopy is always possible because of the large optic part. On intracapsular cataract extraction this lens seems to be the most safe, stable and convenient lens.


Biometric analysis of intraocular lens power required to produce emmetropia: results of 450 implants. We analyzed 450 consecutive cases of intraocular lens implantation (omitting only two inadvertent implantations in patients with high myopia) to determine the dioptric lens power in each case required to produce emmetropia. The mean was 18.3 D with a standard deviation of 2.6 D. The data did not conform to a normal or Gaussian distribution because of an abnormally high number of cases that required greater than 25 D to achieve emmetropia and clustering between 17 to 19 D. The deviation from a normal distribution may be explained by our considering patients with high hyperopia and high myopia (which are for the most part excluded from intraocular lens data) to be separate populations. The data are valuable to the intraocular lens surgeons, in that they demonstrate the range and frequency of intraocular lens powers needed to achieve emmetropia in a large population sample.


Save the endothelium.

Save the endothelium. The health of the corneal endothelium is a critical factor in the final outcome of intraocular surgery . With the advent of intraocular lens implantation, the hazard of inadvertent endothelial trauma is greatly increased. A rigorous technique has been presented which will minimize the risk of such trauma in extracapsular cataract surgery with implantation of Binkhorst type intraocular lenses.


Kelman anterior chamber lens: a preliminary report. The Kelman anterior chamber lens is thin and lightweight. Its design is unique for introduction through a small limbal incision following phacoemulsification or as a secondary implant. It can be used easily in conjunction with intracapsular or extra-capsular surgery. The postoperative course is quiet and short, and the patient has rapid visual rehabilitation with a comfortable eye.


Ciliochoroidal detachment and pseudophakos implantation. Ciliochoroidal detachment perhaps occurs more frequently than is actually recognized and/or looked for. The majority of cases spontaneously resolve without sequelae. A pre-operatively soft eye and a well-closed, clean wound are the best prophylactic measures; even then, detachment may not be prevented. Perhaps something could be said for the lower incidence of wound separation when the limbal incision is small. Extreme caution and care must be exercised when the plastic lens approaches corneal endothelium. The possiblity of ciliochoroidal detachment must be contemplated. Depending upon the type of impant and its relationship to the corneal endothelium, early surgical intervention may be indicated.


Extracapsular surgery in lens implantation (Binkhorst lecture). Part iv. Some anatomical and pathophysiological implications. Extracapsular surgery is an ideal type of cataract surgery in combination with lens implantation in that stability and fixation of the lens is greatly enhanced. However, a number of complications can be expected. The main problem of extracapsular surgery is posterior capsule opacification. This is due to regeneration of germinal lens fibres. To prevent this a complete removal of cortical lens matter is advisable, even in lens implantation. This however requires special lenses which have additional iris fixation. The author's technique for extracapsular surgery is described. The clinically protective effect of extracapsular surgery for the macula has led to the discovery of a new antomical structure in front of the macula, the bursa premacularis. The bursa premacularis is a well-defined fluid-filled space inside the vitreous body in front of the macula. It is postulated to have a protective function for the macula in a hydrodynamic and biochemical sense. A number of pathological conditions could be explained as primarily determined by toxic substances in the premacular bursa or defective detachment of the premacular bursa in the course of posterior vitreous detachment. If this latter condition exists, intracapsular surgery will cause cystoid macular edema, as aqueous can enter the perimacular retina. Cystoid macular edema therefore is postulated to be anatomically predetermined.


Intraocular pressures and visual fields following pseudophakos implantation. 9 of 636 pseudophakos patients developed post-operative intraocular pressure elevations. All were treated successfully, 5 medically and 4 surgically. No permanent glaucomas resulted. Goldmann perimetry on 210 representative patients showed no glaucomatous or peripheral defects.


Endothelial cell loss in intraocular lens placement. Endothelial cell counts were done on eyes selected to fall into four categories: unoperated, intracapsular cataract extraction without implantation, and intracapsular cataract extraction with easy or difficult insertion of an intraocular implant. Uncomplicated cataract extraction resulted in less than 9% cell loss. Implantation in "easy" eyes resulted in 12% cell loss (p greater than 0.3). Eyes in which implantation was difficult suffered an average loss of 65% of the endothelial cells (p less than .001). The reasons for cell loss are discussed and some improvements in techniques are mentioned with examples of the value of analysis of motion picture records of the surgery. The obvious lesson to be learned is that everything possible must be done to optimize routinely the conditions for lens implantation. The surgeon who finds conditions unfavorable for lens implantation must consider that persistence will mean sacrificing, on the average, two-thirds of the corneal endothelial cells.


Lens injury in children treated with irido-capsular supported intra-ocular lenses. The treatment of lens injury in children with irido-capsular supported intraocular lenses is described. A consecutive series of 73 children is analyzed as to the functional results and complications. Surgery and anesthesia are discussed in detail. Guidelines are given for future straight-forward management of eye injury in children, using this promising possibility of visual rehabilitation.


The uveitis-glaucoma-hyphema syndrome associated with the Mark VIII anterior chamber lens implant. An update on the percentage of my patients showing the UGH syndrome associated with the Mark VIII anterior chamber lens implant as manufactured by Surgidev is given. Of seven patients having the syndrome sufficiently severe to warrant removal of the offending lens, six have now been reimplanted, two each with Rayner, IOLAB, and PC lenses. Whereas, other physicians have observed a similar UGH syndrome associated with iris chafing and erosions, this process was not particularly apparent in my cases involving the Surgidev lens. As for the chafing phenomenon, one could logically assume that it could be in large part eliminated by significantly increasing the curvature of the lens and simply vault the iris to a greater degree than is obtainable with lenses currently on the market. Perhaps too much emphasis has been placed on avoiding the endothelium and not enough emphasis on avoiding the iris.


Retinal detachment with intraocular lenses. Of 740 patients undergoing intracapsular cataract extraction with intraocular lens implantation by the same surgeon, 18 (2.43) experienced retinal detachment. Analysis of the data of these 18 patients reveals:--the series covered 6.25 years (75 months).--there were 13 males and 5 females (72% males).--their average age at the time of cataract surgery was 63.--the median duration between cataract surgery and retinal detachment was 11 months. The shortest interval was 5 weeks, the longest was 39 months.--a predisposing fall was documented in 17%.--33% suffered vitreous loss at the time of cataract extraction.--of the 18 patients, 15 (83%) underwent retinopexy; of the remaining 3, one eye (6%) was not repairable and 2 patients (11%) refused detachment surgery.--only 6 (33%) of the 18 achieved useful post-detachment vision.


Comparison of titanium loop and supramid loop lens implants: 100 patients. One-hundred patients having intracapsular cataract extraction with intraocular lens implantation are compared with 139 patients having routine intracapsular cataract extraction. All patients were operated on by one surgeon, utilizing one technique, and, where implantation was performed, utilizing one style of lens from one manufacturer. Follow-up period was 6 to 28 months. Seventy-four percent of the implant patients achieved VA greater than or equal to 20/40, compared to 84.2% of the routine cataract patients. Of patients receiving Supramid/Prolene-supported lenses, 84.7% had VA greater than or equal to 20/40. Those patients with titanium-supported loops have a much higher incidence of CME resulting in decreased VA, indicating that this type of lens should not be used. Dislocation of intraocular lenses was the same, whether or not the loops were sutured.


Endothelial cell loss and trauma during intraocular lens implantation: a specular microscopic study. We analyzed the results of a retrospective specular microscopic study of 80 cases with unilateral medallion suture implants and contralateral unoperated eyes. In all cases a clinical estimation of operative endothelial trauma (ET), graded from 0 to 3+, was made at the time of surgery. The mean decrease in endothelial cell density (compared to the unoperated eye) for those 33 patients with ET 0 was 19%. There was a direct correlation between ET and decrease in endothelial cell density up to a mean of 59% for those 18 patients graded ET 2.5 to 3.0. The role of sample bias and small case sampling is significant in explaining the large discrepancy in endothelial cell loss after intraocular lens implantation reported in the literature.


Choyce lens warp testing: effect of temperature and pressure changes. Choyce-style lenses made from sheer PMMA (ICI Perspex CQ) have a different thermal response than lenses made of Rohm & Haas injection molded PMMA: Perspex lenses are more resistant to high temperature deformation. However, under simulated physiologic temperatures and pressures, there is no apparent lens deformation, nor is there a difference in response between lens types. In general, the susceptibility of all thermoplastics to heat, and the ease with which high temperatures may be achieved in transportation, require improved packaging; great care must be taken to protect and inspect intraocular lenses before implantation. Demonstrated variation in thermal response from lens to lens, and even from foot to foot, further mandates such care and also cautions against the acceptance of claims based on inadequate or incomplete data. All lenses should be checked, with the best clinical test for flatness being that in which each foot is depressed to check for rocking or lift.


Anticoagulation, intraocular bleeding and pupillary paralysis following Choyce intraocular lens implantation. Four cases of pupillary paralysis are presented which followed implantation of the Surgidev version of the Choyce Mark VIII implant. In three of these cases the lenses were removed. Of the four cases, two had been anticoagulated and showed massive vitreous or anterior chamber hemorrhages, the appearance of which was related by time, or in severity, to the anticoagulation with coumadin.


Solar retinitis, photic maculopathy and the pseudophakic eye. The pseudophakic retina is shown to be at greater risk than the normal retina to photochemical damage from solar observation because current polymethylmethacrylate intraocular lenses allow greater ultraviolet retinal irradiances and higher retinal temperature increases than crystalline lenses. The implications of this finding are presented in terms of mechanisms for photic retinal damage, and relationships between photic maculopathy and degenerative retinal diseases are discussed.