should be given to pentazocine and similar drugs; it could be as useful to study the effect of such drugs on gas exchange in the lungs as on hemodynamics.
S. Lal, M.B., M.R.C.P., M.R.C.P.E. R. S. Savidge, M.D., F.R.C.P.
D. M. Davies, M.D., M.R.C.P. Pulmonary Function Laboratory
and Coronary Care Lkit Fairfield General Hospital
Bury, Lancashire, England
West, J. B.: Blood-flow, ventilation and gas exchange in the lune. Lancet 2:1055. 1963. Riley, -R. L., Per&t, S., Said, S:, Godfrey, M., Cheng, T. O., Howell, J. B. L., and Shepard, R. H.: Effect of posture on pulmonary dead space in man, J. Appl. Physiol. 14:339, 1959. Pain, M. C. F., Stannard, M., and Sloman, G.: Disturbances of pulmonary function after acute myocardial infarction, Brit. Med. J. 2591, 1967. McNicol, M. W., Kirby, B. J., Bhoola, K. D., Everest, M. E., Price, H. V., and Freedman, S.: Pulmonary function in acute myocardial infarc- tion, Brit. Med. J. 2:1270, 1965. Lal, S., Savidge, R. S., and Chhabra, G. P.: Cardiovascular and respiratory effects of mor-
phine ;md peutazocine in patients with myocar- dial iufarction, Lancet 1:379, 1969. Rees, H. A., Muir, A. L., MacDonald, H. Ii., Lawrie, I>. M., Burtou, J. L., and Donald, K. W.: Circulatory effects of pethidine in patients with acute myocardial infarction, Lancet 2:863, 1967. MacDonald, H. R., Rees, H. A., Muir, A. L., Lawrie, D. M., Burton, J. L., and Donald, K. W.: Circulatory effects of heroin in patients with myocardial infarction, Lancet 1:1070, 1967. Thomas, M., Malmcrona, Ii., Fillmore, S., and Shillingford, J.: Haemodynamic effects of morphine fn patients with acute myocardial infarction. Brit. Heart 1. 27:863, 1965. Keats, A.S., and Telford, J.: Studies of anal- gesic drugs. VIII. A narcotic antagonist anal- gesic without psychotomimetic effects, J. Pharmacol. Exp. Ther. 143:157, 1964. Lal, S., Savidge, Ii. S., and Chhabra, G. P.: Oxygen administration after myocardial in- farction, Lancet 1:381, 1969. Leading article: Brit. Med. J. 2:3, 1966. Hershberg, P. I.: Does morphine deserve a primary role in coronary care therapy? AMER. HEART J. 77:289, 1969.
Cornea1 arcus in the Ugandan African
Cornea1 arcus (arcus senilis, arcus lipoides cor- neae)b,* has been variously associated with athero- sclerosis 1Q,11,13,15 hypercholesterolemia,l~~~* aging,2T5*s diabetes mellitus,8 endocrine disease, and vitamin deficiencies. The association between cornea1 arcus and arterial disease, and especially coronary athero- sclerosis, has been found by many1~4~6~~~6 but not all investigators.7*8B12 Cornea1 arcus has also been shown to be common in the Zambian,s the American Negro,Q and the Aleut of southwest Alaskae; in none of these groups has an association with arterial disease been noted.
The present investigation was undertaken to establish the incidence of cornea1 arcus in a group of Ugandan African patients and to attempt to associate its occurrence with cardiac disease and serum cholesterol, and also with age, sex, tribe, and serum protein levels. Atherosclerosis and coronary artery disease are extremely rare in the Ugandan African.17
-One hundred consecutive patients admitted to one medical ward at the Mulago Hospital, Kampala, were studied. Detailed questioning was used to obtain a history with particular reference to the cardiovascular system. A full clinical examination, including a blood pressure recording and retinal examination, was made. Assessment of the presence of arcus was made by naked eye in good daylight
and also by torch light, and was graded 0, 1, 2, and 3 (0 = absence of any evidence of arcus; 1 = definite incomplete ring of translucence at the periphery of the cornea, with a clear ring separating it from the limbus; 2 = moderate sized ring with a clear ring separating it from the limbus; 3 = very marked dense ring with no clear cornea between the ring and the limbus). Chest x-rays and electrocardio- grams were performed on all patients. Serum cholesterol was measured in 98 patients.* Serum total proteins and electrophoresis, bilirubin, alkaline phosphatase, glutamic oxaloacetic transaminase, and hemoglobin were estimated in most of the patients by standard techniques.
The study included 60 male and 40 female sub- jects. The mean ages were 37 (range 10 to 70) and 36 (range 10 to 70) years, respectively. The corre- lation between the presence and grade of arcus and stated age is significant (r = $0.550; p < 0.001; n = 100). Five patients with arcus were below 20 years and 2 of those were 10 years old. There is no significant difference in the sex incidence of arcus (Table I). Sixty-nine of the patients were from the local Baganda tribe, 19 were immigrants from Rwanda, and 12 were from Nilotic or Hamitic tribes; there is no significant difference in the inci- dence of arcus between these tribal groups.
There was a wide range of diagnoses. Eight of
Volume 79 Number 5 Annotations 719
Table I. Incidence of cornea1 arcus in the diferent sexes and age groups
Grade of cornea1 arcus (see text) Sex, ~---
* 1 I ) 2 ) 3 1 Total (absent)
Male 10-30 31-50 51-70
14 (23.3%) 7 (11.7%) 3 (5.0%) 0 (0%) 24 (40.0%) 8 (13.3%) 10 (16.7%) 7 (11.7%) 2 (3.3%) 27 (45.0%) 1(1.7%) 1(1.7%) 7 (11.7%) 0 (0%) 9 (15.0%)
All ages Female
10-30 31-50 51-70
23 (38.3%) 18 (30.1%) 17 (28.4%) 2 (3.3%) 60
8 (20.0%) 9 (22.5%) 2 (5.0%) 0 (0%) 19 (47.5%) 4 (10.0%) 4 (10.0%) 5 (12.5%) 0 (0%) 13 (32.5%) 0 (0%) 0 (0%) 5 (12.5%) 3 (7.5%) 8 UO.O%,)
12 (30.0%) 13 (32.5%) 12 (30.0%) 3 (7.5%) 40
3.5 31 29 5 100
31 (25.8 per cent), 9 of 29 (31.0 per cent), and 3 of 5 (60.0 per cent) of the patients with Grade 1, 2, and 3
corneal arcus, respectively, and 6 of 35 (17.1 per cent) without arcus had evidence of cardiovascular disease; in only one patient, with Grade 3 arcus, did this have an ischemic origin. This difference between patients with and without cardiac disease is not significant (x2 = 2.95; p < 0.30). One 40-year- old patient with Grade 3 arcus had evidence of ischemic myocardial disease on the electrocardio- gram. Three patients had conduction defects. Two of these (aged 70 and 54 years) had left, and one (aged 70 years) right bundle branch block. Two of them had Grade 3 arcus. Cardiomegaly was shown on the chest x-ray in 16 patients; in no case was aortic calcification present. There was no relation to the presence or degree of hypertension. Other diseases were also evenly distributed between pa- tients with the various grades of arcus. Four of 3.5 (11.4 per cent) patients without arcus, and 3 of 31 (9.7 per cent), 21 of 29 (72.4 per cent), and 4 of 5 (80.0 per cent) of the patients with Grade 1, 2, and 3 arcus, respectively, had gray hair.
11.3 (2.2 to 17.6) Gm. per 100 ml., serum albumin 2.6 (0.6 to 4.2) Gm. per 100 ml., total globulin 4.1 (2.2 to 6.3) Gtn. per 100 ml., and r-globulin 2.1 (0.3 to 4.3) Gm. per 100 ml. There is no significant relationship between cornea1 arcus and serum bilirubin, alkaline phosphatase, or glutamic oxalo- acetic transaminase.
A very high incidence of cornea1 arcus (65 per cent) has thus been shown in these 100 Ugandan African patients. This proportion is the highest so far reported in any population group. Although there was a significant relation to increasing age, the condition was present in 5 patients of less than 20 years, of whom 2 were only 10 years of age.
No significant difference in the sex incidence has been shown in this study and this differs from other reports, which have shown a male predominance.1~8J3 Our numbers were small, however. In the Aleut, in whom arcus occurs at an early age and is not associ- ated with cardiac disease or raised serum cholesterol levels, which is similar to the situation in our pa- tients, a higher male incidence of the condition also exists6
The relationship between the presence and grade The cause of the cornea1 arcus in our patients is of arcus, and the serum cholesterol level is not sig- unknown. The composition of the deposit has not nificant (r = - 0.186; p < 0.10; n = 98). The mean been analyzed and may be different from that of serum cholesterol was 142 (72-275) mg. per 100 ml. European patients in whom an association with in the male patients, and 152 (77-360) mg. per 100 ischemic cardiac disease has been shown. There ml. in the female. The mean cholesterol level in the was no association in our patients with cardiac 51 to 70 year group was 141 mg. per 100 ml., and disease or high serum cholesterol levels. A significant in the 10 to 30 year group, 146 mg. per 100 ml. There correlation of the presence and degree of arcus has is not a significant correlation between the presence been shown to occur with the height of the serum and grade of cornea1 arcus and the individual -r-globulin. This could indicate that an infective hemoglobin levels (r = + 0.122; p > 0.10; n = 95) process, e.g., malaria, is relevant in its etiology. or between cornea1 arcus and serum albumin (r = There was no evidence in our patients of local -I- 0.073; n = 99), or total globulin (r = - 0.122; trauma or of trachoma. A dietary factor has not n = 97). The correlation between serum y-globulin been eliminated. It seems likely, in view of the and cornea1 arcus is, however, significant (r = + recently reported high incidence in the American 0.217; p < 0.05; n = 97). The mean hemoglobin was Negro9 and the Zambian African,3 that the Ugandan
720 Annotations Amer. Heart .I. May, 1970
African population is genetically predisposed to this condition.
Although cornea1 arcus may suggest hyper- cholesterolemia and ischemic cardiac disease in young European and American men,rO,rl racial and geographic factors clearly must be carefully taken into account.
G. C. Cook, M.D., B.Sc.(Lond.), M.R.C.P. Defiartment of Medicine
Makercre University College P. 0. Box 7072
Kampala, Uganda B. R. Kanyerezi, M.B.(East Africa), M.R.C.P.
Department of Medicine The University of Zambia
P.O. Box 2379 Lusaka, Zambia
Boas, E. P.: Arcus senilis and arteriosclerosis, J. Mount Sinai Hosp. N. Y. 12:79, 1945. Canton, E.: Observations on the arcus senilis, or fatty degeneration of the cornea, Lancet 1560, 18.50. Davidson, J. C., and Kolbe, R. J.: Arcus senilis and ischaemic heart disease, Lancet 1:707, 1965. Finley, J. K., Berkowitz, D., and Croll, M. N.: The physiological significance of gerontoxon, Arch. Ophthal. 66:211, 1961. Forsius, H.: Arcus senilis corneae: its clinical development and relationship to serum lipids, proteins and lipoproteins, Acta Ophthal. (Suppl.) 42:1, 1954. Garn, S. M., and Gertler, M. M.: Arcus senilis and serum cholesterol levels in the Aleut, New Eng. J. Med. X2:283, 1950. Gessler, A.: Bestehen Beziehungen zwischen dem frtihzeitigen Auftreten eines arcus lipoides
pooped intra-atrial lead: A knofty problem*
Knotting of flexible wires being used to record in- tracavitary electrocardiograms from the right atrium has been reported.-a Four instances of knotting of a flexible wire electrode around a permanent pace- maker catheter have also been reported.*,6 These four episodes occurred at the time of placement of the permanent catheter after temporary pacing had been effected by the flexible wire electrode. The passage of a large lumen catheter over the wire up to the knot has not been reported as a technique to aid in removal of the knotted wire. The catheter may be used to push the knot back to the tip of the wire or to dilate the venous valves adequately so that the knot will not catch on the valves.
*Written while Dr. McGawey was supported by Postgraduate TrainLnp Grant HE 5776.
corneae und Zirkulationsstijrungen des Herzens insbesondere dem Herzinfarkt, Ophthalmologica l&118, 1959. Lindholm, H.: Arcus lipoides corneae and arteriosclerosis, Acta Med. Stand. 168:45, 1960. Macaraeg, P. V. J., Lasagna, L., and Snyder, B.: Arcus not so senilis, Ann. Intern. Med. 68:345, 1968. McAndrew, G. M., and Ogston, D.: Arcus senilis and coronary artery disease, AMER. HEART J. 70:838, 1965. Rifkind, B. M.: The incidence of arcus senilis in ischaemic heart disease. Its relation to serum- huid levels, Lancet 1:312. 1965. Rintelen, P.: Uber die .klimische Bedeutung des Arcus lipoides corneae, Schweitz. Med. Wschr. 72:515, 1942. Rodstein, M., and Zeman, F. D.: Arcus senilis and arteriosclerosis in the aged, Amer. J. Med. Sci. 245:70, 1963. Sackett, G. E.: Modification of Bloors method for the determination of cholesterol in whole blood or blood serum, J. Biol. Chem. 64:203, 1925. Schettler, G.: 1st der sogenannte Greisenbogen der Hornhaut ein Hinweis auf Atherosclerose, Deutsch. Med. Wschr. 79:915, 1954. Shanoff, H. M., and Little, J. A.: Arcus senilis and ischaemic heart-disease, Lancet 1:1076, 1965. Shaper, A. G., and Williams, A. W.: Cardio- vascular disorders at an African hospital in Uganda, Trans. Roy. Sot. Trop. Med. Hyg. 54:12, 1960. Verse, M.: Ueber die Blut und Augenveran- derungen bei experimenteller Cholesterinamie, Munchen. Med. Wschr. 63(2):1074, 1916.
This technique was used in a patient in whom the flexible wire* became knotted while attempting to re- cord an intra-atria1 lead. This knot could bewithdrawn to the supraclavicular area, but in spite of firm traction and maneuvering could not be withdrawn beyond this point. A No. 8 Cournand catheter was threaded over the wire into the vein in an attempt to slip the catheter over the knot or to push the knot back to the tip of the wire. Although the catheter would not go over the knot, it came to rest firmly against it, and it was possible to with- draw the catheter and the wire by direct traction.
*Sterile electrode $4 inch platinum probe with atahdasa multi- strand Flexon steel. Tetlon insulated. 60 inches, 12569-60. Davis & Geck. American Cyamid Company, Danbury. COllXl.