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On the basis of 10 patients with chronic cor pulmonale due to chronic obstructive lung disease and secondary polyglobulia in a clinical and experimental study could be made evident that by limited isovolaemic haemodilution (haematocrit value of 0.58 +/- 0.03 reduced to 0.36 +/- 0.01) are to be expected a decrease of the total pulmonary-arterial resistance, a reduction of the mean pulmonary arterial pressure, an increase of the partial O2-pressure as well as an increase of the heart index. Analogically to this as a consequence of the improved rheologic conditions a clear involution of the clinical signs of a heart insufficiency developed. Complications were not observed. The technique of the limited haemodilution should find a broader use in the medical practice, taking into consideration the isovolaemia as adjuvant treatment principle for patients with the indication mentioned.

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In patients with atrial septum defect and mitral stenosis, respectively, the ventilation and blood gas parameters were compared before and after cardiac operation. In general postoperatively no reversibility of preoperatively proved pulmonary functional disturbances could be established. Only in individual cases a discrete improvement of some of the functional indicators could be observed. Therefore, the operative intervention on the heart should be performed possibly before the onset of irreversible pulmonary structural changes.

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On the basis of many years of own experience and evaluating a large number of judgements on exposure to silicogenic dusts-the results of those are reported at a different place-, a scale of function tests for judgement of silicosis is presented and discussed. It consists of largely applicable tests (examination of ventilation and arterial blood gases at rest and with standardized exercise). The results, in a modification of Knipping's method, are proposed in form of a table for scaling of bodily impairment. The importance of a solidly based first judgement is stressed.

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The retrospective evaluation of 472 judgements of professional disease in persons exposed to dusts showed that all observed restrictions of cardio-pulmonary function (obstructive lung disease, increase of residual volume, respiratory failure, pulmonary hypertension) occurred almost independently from the presence and stage of silicosis, but correlated first of all with the duration of exposure. Frequency and degree of functional disorders in exposed persons without radiologically demonstrable silicosis indicate that the fraction of nonspecific dusts, which is by far larger than the SiO2-fraction, produces chronic obstructive lung disease and its sequelae (emphysema, pulmonary hypertension). The term "pneumoconiosis" should therefore be used in a much broader sense than hitherto. This leads to considerations of the present practice of judgement on silicosis which are presented and discussed in detail.

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Lung function measurements in 472 dust-exposed workers have shown, that bronchial obstructions prevail, irrespective of the occurrence and severity of silicosis. Severe obstructions were growing more frequent with increasing duration of exposure. The incidence rate of arterial hypoxia at rest also increased with increasing duration of exposure. Regardless of the duration of exposure to dust there was pulmonary hypertension at rest in about 15 per cent of the patients examined. It is not unlikely that a correlation exists between the duration of exposure and the incidence rate of exercise-induced pulmonary hypertension (in about 40 per cent), in which arterial hypoxia concerning the functional aspect of increasing precapillary resistance (Euler-Liljestrand mechanism) seems to be of paramount significance.

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After retrospective evaluation of numerous expertises of patients exposed to dust with and without silicosis the high value of the arterial partial oxygen pressure and of the ergooxytensiometry in the estimation of the cardiorespiratory functional breadth is explained. On an average in patients with silicosis III and silicotuberculosis, respectively, more frequently a respiratory insufficiency is found than in patients exposed to dust with lower stages of silicosis or without clue to the presence of a silicosis. In the individual case there is no firm relation between the x-ray-morphological findings and the result of the ergooxytensiometry. The roentgenological stage of silicosis does not allow a conclusion to the loss of function, on the contrary, the frequently existing bronchitis in patients exposed to dust plays an important part in the development of the disturbances of the pulmonary function.

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Taking into consideration biological calibration of ergometers the authors suggest load steps to be related to oxygen uptake. A pedalling rate of 45 rev/min should be used. At each stage of load an almost steady state should be reached, at which there is no further increase of the pulse rate. Thus, one load period will extend over 3--6 minutes. Intermittent rest pauses are required only for special reasons of method. The parameters to be measured depend on required data. In evaluating test results it should be considered that poor performance in an exercise test cannot only be caused by heart or lung diseases, but also by functional disturbances.

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After introducing heart catheterization especially the right heart catheterization according to Grandjean the direct measurement of right ventricular as well as pulmonary artery pressure has been made possible in a relatively simple manner. Thereby the diagnosis cor pulmonale chronicum can be secured or omitted respectively with high confidence. In this regard the exercise--induced increase in pulmonary artery pressure has evident importance especially in case of clinical uncertainty. But because the right heart catheterization is not available in each patient suffering from a pulmonary disease distinct parameters (PaO2, FEV1, pulmonary residual volume, ECG, heart rate) can be used for recognition of the not yet decompensated state of the pulmonary heart disease considering the clinical situation as well as the correlation calculations pointed out by us. With increasing number of implicated functional parameters the security of diagnosis raises.

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Pressure measurements in the pulmonary artery were performed on 34 patients by intracardiac floating catheter during rest and under ergometer load of 51 Watt (corresponding to an oxygen consumption of 750 ml/min). 15 of the patients were suffering from myocardial infarction 4--6 weeks after admission, 12 from chronic coronary heart disease respectively angina pectoris and 7 from affection of the aortic valve. The pressure during rest ranged within the norm. Under load the patients suffering from myocardial infarction and coronary heart disease showed two forms of reaction: 1. moderate ascent of pressure up to 40 torr systolic and 15--18 torr diastolic (mean pressure 25--28 torr). 2. distinct ascent of pressure up to 50--60 torr systolic and 25--30 torr diastolic (mean pressure 36--42 torr). Evidence of latent pulmonary hypertension was irrespective of classification as myocardial infarction with or without complications. That demands regarding of central hemodynamics for the further course of rehabilitation more than hitherto.

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The medical and juridicial side of the information duty concerning the basic character of a disease as well as diagnostic and therapeutic interventions are briefly discussed. By means of information paper for cardiological invasive examinations it is possible to deepen and to confirm the references given in the medical information talk. Apart from this the patient confirms by his sign that he was informed about the planned examination and that he agrees with it, which possibly is of importance for expertises.

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1. In patients with chronic cor pulmonale there is a regression dependence between the amount of exercise-induced increase in pulmonary arterial pressure and the level of resting value. 2. Hemodynamics during exercise are influenced by the patient's position in a certain degree. 3. The exercise-induced increase in pulmonary arterial pressure in chronic cor pulmonale is not influenced by the patient's age. 4. The time course of pressure fall during recovery depends on the amount of pressure increase during exercise, it depends less evidently on the level of the resting values. 5. Tachycardia is not a compulsory symptom of chronic cor pulmonale.

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Parameters of pulmonary mechanics were measured at rest and during physical effort in patients with silicosis and normal subjects. Between normal subjects and patients with silicosis of stage I a significant difference could not be found. However, a decrease of dynamic compliance and an increase of elastic work of breathing were found in patients with silicosis III during exercise. The PT/VT-quotient is already high at rest. These results are not in agreement with the subjective symptom "dyspnea". The feeling of dyspnea appears when the PT/VT-quotient is enhanced signifcantly during exercise in comparison with the value at rest. Therefore, only the PT/VT-quotient is a suitable parameter indicating dyspnea.

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The effect of inhalation of Novodrin (beta-receptor-stimulus), Phenylephrine (alpha-receptor-stimulus) and of a mixture of both was tested in patients with chronic nonspecific respiratory syndrome. There was no significant difference of pulmonary arterial mean-pressure. Forced expiratory volume and vital capacity rose both after inhalation of Novdrin and after inhalation of the mixture. Nevertheless inhalation of the mixture can not be recommended because of a significant decrease of arterial oxygen-tension.

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In patients with mitral valvular defects as well as with chronic cor pulmonale there exists an ascertained relation between the pulmonary-arterial pressure in rest and the increase of blood pressure under easy physical load. Patients with high initial value or strong increase of blood pressure reveal a retarded return of the blood pressure of the pulmonary artery to the initial value.

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Mechanics of breathing as studied in patients with different stages of silicosis in rest and during exercise show the following: dynamic compliance and work against elastic and viscous resistances could not be found to be decisive indices of exertion dyspnea. Evidence of exertion dyspnea could only be achieved by means of the ration VT/PT (VT equals tidal volume, PT equals tidal esophageal pressure). Exertion dyspnea was observed at less than 0,081 VT per cm H20 PT. In accordance with Campbell and Howell, dyspnea is seen as an inappropriateness between ventilation and pressure needed.

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