Roentgen Study Research Articles

The Roentgenologic Diagnosis of Appendiceal Calculi

The occurrence of calculi in the appendix has been familiar to surgeons and pathologists for many years, but there is no record of a correct preoperative diagnosis of this condition prior to the use of x-rays. The importance of early diagnosis at once becomes apparent when it is realized that appendiceal calculi usually result in acute appendicitis and that the incidence of perforation in these cases is about 50 per cent. Weisflog (63), in 1906, contributed the first case report with a correct preoperative diagnosis, demonstrating two calculi in the region of the appendix on a roentgenogram. In a study of 100 cases reported since that time, we have been able to find only 11 more in which the diagnosis was made preoperatively and proved surgically. In an additional 11 instances surgical confirmation was lacking. In 19 patients an incorrect interpretation of the x-ray films was made, and in 13 others the preoperative diagnosis was not clearly stated. In the remainder roentgen studies were not made. In spite...

Roentgen Diagnostic Aspects of Chronic Arthritis and Bursitis

The purpose of the present communication is to evaluate the place of roentgen examination in the study of chronic joint disease, to correlate the clinical and roentgen aspects, and to demonstrate the pathologic alterations as they are revealed by roentgen study. The entire subject of chronic joint affections is one of such wide scope that it would be impossible to cover it fully in a single paper. Clinically the chronic arthropathies fall into three main groups: (1) chronic joint disease of more or less generalized nature, or at least affecting multiple joints, exemplified by rheumatoid arthritis and degenerative joint disease; (2) chronic arthritis limited to a single or, at the most, a few joints, represented by tuberculous arthritis, neurotrophic arthropathy, traumatic arthritis, gouty arthritis, and the secondary form of degenerative joint disease; (3) chronic disease limited to the periarticular tissues, the most common representative being the so-called subacromial bursitis and the related “frozen s...

Appendiceal Coproliths: Their Surgical Importance

The clinical diagnosis of appendicitis is still a major medical problem, not only because of its frequency but because of the morbidity which is associated with the condition, not to mention a mortality of over 17,000 deaths per year in the United States. The literature has been saturated with data on the cause, diagnosis, and treatment of the disease; in 1931 McClure (1) reported that over 9,000 articles had been written on appendicitis, and to that number over 3,000 have since been added, making a total of 12,000 articles. Even though great strides have been made in the technic of appendectomy, and despite the use of the more recent antibiotics (sulfa drugs and penicillin), the morbidity is still considerable and complications remain a serious hazard. In one large clinic (2) the complication rate is unchanged over a period of 19 years. The common origin of the complications in some mechanical factor must therefore be considered. Roux (3) in 1913 was the first to write on the use of roentgen rays in the diagnosis of appendicitis. The early radiologic diagnosis of uncomplicated appendicitis is difficult and seldom essayed. However, when perforation has occurred with periappendiceal abscess formation, free peritoneal gas, peritonitis, subphrenic or subhepatic abscess, or even fistula formation. roentgen studies can give prima facie evidence not only localizing the disease but often exhibiting its extent. The early clinical diagnosis is recognized as all-important in appendicitis, but often the clinical signs are few and the history unconvincing, or possibly all signs and symptoms may be subsiding when the patient is first seen. It is in this group of cases—or at least a percentage of them—that the radiologist might be useful, especially where the appendix is found to contain a coprolith with enough calcium to cast a shadow on the roentgenogram.2 Because of the morbidity in 4 of the cases in our small series, it was thought wise to emphasize the importance of a roentgenographic diagnosis of appendiceal coprolith. The significance of this diagnosis is obvious when one reviews the literature on appendicitis and finds that the most frequently mentioned cause is appendiceal obstruction. There are two types of appendiceal obstruction: (a) that due to external causes—a kink and or adhesions; (b) that due to internal causes, namely, foreign bodies, including fecaliths (4). It is in the latter group that we are especially interested because the more severe complications occur following rupture of the appendix due to obstruction by a fecalith; that is, an internal obstruction. The actual blocking of the lumen is considered only the precursor of the obstruction of the lymphatic and blood supply which produces gangrene of the appendiceal wall (4, 5). The demonstration of appendiceal coproliths which contain enough calcium to be visible radiographically is important not per se, but for the implications inherent in their presence.

Calcification of Pleura and Lung

Calcification of the pleura or of the lung is not uncommon, but the massive involvement of an entire lung is so rare that the following case may be of interest. A few such lesions have been reported in the American and foreign literature, but none of these has been studied by body-section (planigraphic) roentgenography. Case Report A white female of 74 years gave a history of diphtheria and scarlet fever in youth, pneumonia at 40 years, influenza at 42 years, and pulmonary tuberculosis with pleuritis (hospitalization for one year) also at 42 years. The diagnosis of tuberculosis was confirmed by two sputum samples of separate date positive for acid-fast bacilli. Symptoms at that time (1912) included cough, fever, and left thoracic pain. No thoracentesis or roentgen study was done. There were two admissions to the Hospital of the University of Pennsylvania, in 1915 and 1924, because of pain in the left shoulder, thorax, and lumbar area, loss of weight, hoarseness, dyspnea, palpitation, and vertigo. At these times expansion was almost entirely right thoracic; tactile fremitus and vocal resonance were increased on the left above the 7th rib posteriorly. There were bronchial breath sounds, whispered pectoriloquy, depression of the supraclavicular fossa, and dullness to percussion on the left. The heart and trachea were constantly retracted to the left. On the second admission, the sputum was negative for acid-fast bacilli and roentgen study of the chest revealed no expansion on the left, the heart retracted to the left lateral chest wall, and left deviation of the trachea. Other findings were probable thickening of the pleura and pulmonary fibrosis, and a suggestion of encroachment by emphysematous right lung upon the left hemithorax. (The plates were not available for review.) No mention was made of calcification. From 1934 to 1945 the patient has been seen by Dr. O. H. Perry Pepper (to whom we are indebted for this report), as an outpatient. She has been in rather good health, suffering occasionally and moderately from cough, weakness, dyspnea, vertigo, sore chest or shoulder, and “heart attacks.” However, these do not prevent her doing all her housework and driving a car. Discussion High-speed Potter-Bucky roentgenograms in the postero-anterior and lateral projections reveal an extensive calcification in the left thorax and obscuration of the heart (Fig. 2, A and B). The contour of the upper and lower lobes can be seen well, and apparently both have undergone contraction with upward displacement. The right lung has expanded across the mid-line. The distance between the left rib cage and the calcium might be due to an uncalcified parietal pleura, but may be attributable simply to the fact that the shrunken lung lies posteriorly in the thorax and does not reach the lateral wall at its greatest diameter. This is analogous to a plan view of a spherical jar partly occupied by an opaque material (as in the accompanying sketch, Fig. 3).

Cholangiography and Biliary Regurgitation

Cholangiography, the roentgen study of the biliary tract by means of the direct introduction of a contrast medium, may be accomplished in a number of ways and with a number of contrast substances. The material may be injected directly into the gallbladder or the common duct—immediate cholangiography—at the time of a surgical exploration of the biliary tract. Roentgenograms are then made on the operating table (Fig. 1). More commonly the injection is made postoperatively through a drainage tube previously inserted into the gallbladder or the common duct—delayed cholangiography. Recently some efforts have been made to inject a radiopaque substance into the gallbladder before operation. This can be accomplished by either of two procedures. A catheter can be placed in the gallbladder through a simple abdominal incision. Cholangiography is then done and the situation of the biliary tract determined (Fig. 2). The information obtained will govern the exact type of surgery to be undertaken. Another method is that suggested by Horan (1) and Marcel Royer (2). Under the guidance of a peritoneoscope introduced into the peritoneal cavity, a needle is thrust into the gallbladder and the biliary tract is thus injected with the contrast medium. Roentgenograms may then be obtained and the presence or absence of calculi, strictures, tumors or other abnormalities may be determined. In the first attempts at cholangiography, Carnot and Blamoutier (3) used a barium suspension as a contrast medium but the medium was unsatisfactory, so the effort was unsuccessful. The first satisfactory result was accomplished by Lanari and Squirru (4), using lipiodol. A clear delineation of the major biliary ducts was obtained. This medium is still used by many radiologists, notably in South America. In this clinic, iodized oil as a contrast medium for cholangiography was abandoned many years ago because of its viscosity, its tendency to form globules, and the uneven distribution which resulted (Fig. 3). Following this we used thorotrast (thorium dioxide sol), finding it a most satisfactory substance because of its great opacity to x-rays and its ready miscibility with aqueous solutions. An unfortunate experience led us to discontinue its use. A patient, in whom a tube had been placed in the common duct during the course of a cholecystectomy, was given an injection of thorotrast through this opening. The tube, however, had been diverted from the duct and the inner end was lying in the peritoneal cavity. The contrast medium was therefore introduced into the peritoneal space. The result was a violent reaction, high fever, and evidences of peritoneal irritation. Recovery eventually occurred, but the thorium dioxide remained in the sinusoids of the peritoneum and in the lymph nodes for many years.

Gastrocolic Fistula Complicating Carcinoma of the Colon

Gastrocolic fistula has long been established as a distinct clinical entity. Although it is rare in occurrence, many isolated cases have been reported in the literature. The condition exists only as a complication to other primary gastrointestinal or intra-abdominal lesions. The characteristic symptoms of gastrocolic fistula are fecal vomiting in the absence of symptoms of intestinal obstruction, eructation of foul gas, a fecal odor to the breath, general weakness, extreme loss of weight, and persistent diarrhea with undigested food particles in the stools. The diagnosis can safely be made when fecal vomiting occurs in the absence of intestinal obstruction. However, because of the variable symptomatology resulting from the different primary lesions, clinical diagnosis sometimes becomes difficult and roentgen study may be required. By means of the barium meal, barium enema, and double contrast enema the diagnosis of gastrocolic fistula can be established easily and definitely. Case Report A 37-year-old whi...

Principles in Roentgen Study of the ChestPrinciples in Roentgen Study of the Chest. By SnowWilliam, M.D., Director of Radiology, Bronx Hospital; Roentgenologist-in-Charge, Harlem Hospital, New York City. A volume of 414 pages, with 508 illustrations. Published by Charles C Thomas, Springfield, Ill., 1946. Price $10.00.

Principles in Roentgen Study of the Chest<scp>Principles in Roentgen Study of the Chest</scp>. By SnowWilliam, M.D., Director of Radiology, Bronx Hospital; Roentgenologist-in-Charge, Harlem Hospital, New York City. A volume of 414 pages, with 508 illustrations. Published by Charles C Thomas, Springfield, Ill., 1946. Price $10.00.

Diffuse Calcification of the Pancreas

The literature contains only seventeen cases of pancreatic calcification other than stones. The infrequent mention of this condition in radiologic journals would indicate the desirability of individual case reports. In our first case the condition was proved by surgery. The second case is included because of the typical roentgen findings. Case 1: A white male, 23 years of age, a sprayer in a lemon orchard, had been in good health until three years earlier. At that time he was in bed for seven days, complaining of epigastric pain, diarrhea, and some fever. After recovery from this acute onset, there was a recurrence of the epigastric pain every four to six weeks, with nausea and vomiting, usually lasting for five to seven days. In the past year the attacks had been more frequent. In 1942 a roentgen examination at a veterans' hospital showed a duodenal ulcer. A later roentgen study elsewhere was negative. During the two weeks preceding admission, cramping epigastric pain had been present. Some pain was refe...

Cephalopelvimetry

Although childbirth is a normal physiological function, one is impressed with the many difficulties of the obstetrical patient, and also of the obstetrician, despite the fact that nature has apparently provided a considerable margin of safety. Statistically, in only a very small percentage of all pregnancies is a true cephalopelvic disproportion encountered. It is of interest, however, to the obstetrician, should his patient be in this classification. Since 1897 (1) attempts have been made to measure the maternal pelvis roentgenologically. The various methods of pelvimetry—external, internal, and radiologic—give information relative to the linear measurements and conformation of the pelvis, but the fetus for the most part has been assumed to be normal. Any method of measurement that does not consider the fetus to be delivered with an accuracy comparable to that with which the linear measurements of the maternal pelvis are determined must be considered incomplete. From a practical standpoint, it seems illogical to calculate the linear measurements to one-tenth of 1 per cent when, in the natural course of events, the physiological process allows for a 20 to 30 per cent margin of safety. This margin is further influenced by factors of morphology, dynamics, moldability, resistance, position, and presentation, some of which cannot be evaluated by roentgen methods. Obviously, somewhere between the meticulous measurement of radiology and the utter disregard of any roentgen study there must be a common meeting ground between the obstetrician and the radiologist. The obstetrician who is entrusted with the responsibility of the mother and child should be the judge of the necessity for cephalopelvimetry, but there are indications other than personal judgment, as when the clinical examination and the history suggest abnormality of size or type of pelvis, or size of fetus; when there is a history of previous dystocia or fetal death; when vaginal examination is contraindicated or such examination gives insufficient information, and, lastly, during labor, if dystocia is present, to localize the site of the arrest. For the most part, however, labor is an emergency which does not readily lend itself to diagnostic procedures, except those of maximum simplicity, and, as a general rule, accuracy and simplicity do not go hand in hand. With few exceptions, a patient in active labor is primarily an obstetrical and not a radiological problem. Hence, only by proper preliminary teamwork between the obstetrician and the radiologist can warning be given and possible disaster be circumvented. As Hirsch (2) pointed out in 1922, all methods of roentgen pelvimetry represent modifications of the following: (1) comparative method; (2) teleroentgen or orthodiagraphic method; (3) position frame method; (4) stereoscopic method; (5) triangulation method.

Principles in Roentgen Study of the Chest.

Principles in Roentgen Study of the Chest.

Subacromial Bursitis: Clinical and Roentgen Observations

In the average clinic and hospital, painful shoulders constitute an appreciable percentage of ailments treated. In the past five years this percentage has been increasing, and the condition is now encountered almost daily by the general clinician. A source of wonder to the author is the high incidence of cases of long standing, some of which are not only distressing but incapacitating, preventing the patient almost completely from performing his daily work. Whether the patient has failed to visit his doctor in the early days of distress or the physician has failed to take advantage of a complete study need not enter into consideration. The average case is readily recognizable and, with competent procedure, the diagnosis may be made with little or no difficulty. To refrain from a roentgen study of the shoulder joint in this condition is comparable to the omission of a blood sugar test in the care of a diabetic. Injuries of the shoulder joint are relatively frequent. Our attention is drawn chiefly to fractures and dislocations because of their more common occurrence. Subacromial or subdeltoid bursitis is a traumatic lesion having a lower incidence, but, while its clinical manifestations are at times less dramatic, the condition is crippling and may result in a major disability. The writer has been frequently impressed with these injuries in and about the shoulder joint and has attempted to record the variations in anatomy and surface structures in subacromial bursitis. While such variations occur, certain salient points have been observed in clinical cases which can be considered as an average pattern. On the roentgenogram are recorded changes in contour of the greater tuberosity of the humerus and variations in outline of the trabeculae. These, with a clinical picture of painful abduction and outward rotation, suggest a lesion of the subacromial bursa. Formerly attention was paid only to the bursa in which calcium deposits were visualized in the soft tissues, either beneath the acromion process or adjacent to the greater tuberosity of the humerus. It is now believed that roughening, excavation, and localized thickening of the periosteum or cortex on the greater tuberosity, indicate, in the greater number of instances, underlying involvement of the subacromial bursal sac (Fig. 3). That portion of the bursal sac lying between the deep surface of the deltoid muscle and the outer surface of the capsule of the shoulder joint is called the subdeltoid bursa. A delicate membrane may divide this from the subacromial bursa, interposed between the tendon of the supraspinatus, which forms its floor, and the acromion and the deltoid muscle which form its roof. Because of the frequent communication between these bursae, they may be considered as one; together they form a flat, translucent sac, almost invisible when the normal joint is opened, about the size of the palm of the hand (1).

Roentgen Diagnosis of Duodenal Ulcer in the Right Lateral Decubitus Position

Since the introduction of the roentgen method in the diagnosis of gastroduodenal lesions, various echnical procedures have been devised from time to time in order to increase the percentage of accurate diagnoses. The one which has been and is still being extensively used con sists of filling the stomach wit barium suspension and observing it fluoroscopically, after which one or more roentgenograms are made in the postero-anterior position. In the great majority of cases this technic has been found quite satisfactory for demonstrating the presence of a gastroduodenal lesion. The newer methods include serial films, the compression technic, the spot-film technic, and the use of the filming fluoroscope. There is no doubt that all of these more or less complicated procedures do help in recognizing abnormal changes in the stomach and duodenum, but if the same end can be achieved in a simpler way, as we believe that it can, there is no special advantage in resorting to them. The method which has been used in our laboratory for many years with satisfactory results in the case of the stomach and duodenum is based upon one of the most fundamental principles underlying roentgenography, that is, the making of two projections at right angles of any part of the body to be examined. Such a procedure gives one a three-dimensional study of the part under investigation. The value of this technic is fully recognized in general roentgenology; it is equally valuable in examination of the stomach and duodenum. The three-dimensional study of the stomach and duodenum is obtained by making two views, postero-anterior and right lateral in the horizontal position. These views are illustrated by Figure 1, A and B, respectively. The anterior view shows the normal outline of the average stomach and duodenum with their lesser and greater curvatures. It fails, however, to show the contour of the anterior and posterior walls, and does not demonstrate the true relationships of the several parts in the abdominal cavity. On the other hand, the right lateral view does these very things. Special attention is called to the anteroposterior direction of the superior segment of the duodenum; this is naturally foreshortened in the ventral position and thus a good deal of the contour, with any possible abnormality, is completely obliterated from sight. Furthermore, in hypersthenic subjects and under certain abnormal conditions, the duodenal bulb is often completely obscured by the overlapping pylorus, as shown by Figure 2, A and B. The roentgen study of lesions of the duodenum is concerned with three types of bulbs. In the first type the bulb is completely obscured by the pylorus and, in order to visualize it, the right lateral projection is essential. Several representative cases (Figs. 3–6) have been chosen in order to emphasize the value of the lateral projection in this type of duodenum.

A Radiographic Chest Survey of Patients from the Dachau Concentration Camp

In view of the tremendous publicity given the “horror” concentration camps of Germany, it was felt worth while to present an account of routine radiographic chest examinations made of patients admitted to one of two evacuation hospitals functioning as station hospitals in the Dachau Camp. A brief explanation of the conditions, difficulties, and problems which were encountered by the medical unit to which the writer was attached seems warranted. The first echelon entered the concentration camp approximately ninety hours after the infantry units had taken over the area. A typhus epidemic was prevalent at the time of arrival. The interiors of buildings were shambles, with liberated displaced persons roaming around, looting, searching for food and for any of their Nazi captors. Approximately thirty-five thousand individuals were crowded into quarters designed to accommodate eight thousand. Small-arms fire could still be heard in certain areas of the camp. The filth and abominable conditions within the area of concentration have been amply described by others. The task of cleaning out vermin-infested barracks outside the central compound for hospital purposes was an enormous one, while the obtaining of sufficient beds, sundry equipment, and material was a serious problem. Patients were admitted, however, the day after the arrival of the unit in Dachau. In the meantime, the tempers of the prisoners in the central compound were on “trigger edge” because of the delay in their release and the curtailment of dietary allowances due to their lowered tolerance to food. The hospital within the compound was congested beyond description, and tribute must be paid to the prisoner physicians who, under overwhelming odds, accomplished miracles in the face of inadequate facilities. Patients were taken to the Receiving and Evacuation Section of the hospital and were admitted and deloused. They were then taken to the adjoining X-ray Department, and a routine chest film was made. The patients were then moved to their respective wards. Most of the initial patients were in extremely poor physical condition and some were moribund. Those seen later were considerably better. Following is a statistical compilation of the x-ray findings in the initial roentgenograms of 2,267 patients. Language difficulties and lack of any reliable diagnosis, history, or physical examination made interpretation hazardous, and account for the large number of undiagnosed pathological processes. The obvious cases were reported as such. Of the 626 definite cases of active tuberculosis, 324, or 51.7 per cent, showed bilateral involvement. Of the 365 cases of undiagnosed pneumonic densities and peribronchial infiltrations (pneumonitis), bilateral involvement was found in 61, or 17.0 per cent of the two groups. Comment Nearly all the nationalities of Europe are represented in this series of roentgen studies, with a predominance of Poles, Russians, French, Yugoslavs, and Czechs.

Gas Formation in Abdominal Abscesses: A Roentgen Study

The early diagnosis of abdominal abscesses is of considerable clinical importance. Roentgenologic examination is not only valuable in their diagnosis and localization but also in the differentiation from tumors and hematomas. The roentgenologic features of abdominal abscesses have been described in a small number of excellent studies and will not be the subject of this discussion (1, 2, 3). Generally, the roentgenologic signs depend to a great extent upon the localization of the abscess. Thus, an intraperitoneal abscess may be demonstrable as a space-occupying process displacing the intestinal loops, which usually reveal some degree of ileus in the neighborhood of such an infection. A roentgenologic sign of prime importance is the obliteration of the intermuscular and subperitoneal fat layers of the adjacent abdominal wall, which may be attributed to edema associated with the inflammatory condition. Abscesses invading or originating in the retroperitoneal space may cause blurring or obliteration of the psoas shadows and frequently lead to swelling of the soft tissues of the flank, which may be demonstrated to advantage on roentgen examination. The changes in the position and motility of the diaphragm associated with subphrenic, intraperitoneal, and retroperitoneal abscesses are generally known. These signs, in conjunction with clinical findings, will in many instances be sufficient to establish a diagnosis. Not infrequently, however, the roentgenologic evidence mentioned above may be equivocal or difficult to demonstrate. In children and old people, the subperitoneal and intermuscular fat layers of the abdominal wall may be poorly defined, and marked intestinal distention may obscure the detail of the psoas shadows. On the other hand, large retroperitoneal tumors and hematomas may distort the structures of the abdominal wall and make their fat layers indistinct. Thus, there remain cases in which the differential diagnosis between an inflammatory mass and tumor or hematoma is difficult. Any additional roentgenologic sign, therefore, will be of definite value. It has been shown by Laurell (1, 2) that abscesses may occasionally contain gas vesicles visible roentgenologically. The roentgen demonstration of gas production in infections caused by Cl. welchii and related organisms is now generally recognized as a valuable diagnostic procedure (4). It is surprising, therefore, that in the roentgenologic literature little attention is given to gas formation in infections which are caused by other organisms, such as colon bacilli and anaerobic streptococci. Subphrenic abscess is the only condition in which gas formation, due to the colon bacillus, is commonly known to occur (5). There is no doubt, however, that in many subphrenic abscesses the observed gas represents air which has penetrated into the abscess cavity by way of a fistula from the lungs or gastro-intestinal tract.

Congenital Cystic Disease of the Lung

The characteristic features of congenital cystic disease of the lung are sufficiently known today so that the diagnosis may be surmised from the clinical history, the physical findings, and especially the roentgenographic picture. The multifarious aspects of the malady may, however, be a source of misinterpretation to the roentgenologist not familiar with them. Congenital cystic disease of the lung is defined as consisting in intrapulmonary heterotopic spaces (or a single space) whose walls are composed of bronchial lining epithelium and whose fluid content is a product of the bronchial epithelium. The cysts may be single or multiple, with or without communication with a bronchus. Congenital cystic disease of the lung presents itself in two forms: cystic disease proper and the “fluid cyst.” The former is characterized by numerous cystic cavities, which may involve a part of a lobe, a whole lobe, an entire lung, or both lungs. The cysts communicate freely with their respective bronchial branches. Examination of a large series of cases would reveal various stages of transition, from the normal to frankly multiple cystic involvement. Many names have been applied to this form of the disease, as congenital bronchiectasis, honeycomb lung, etc. The following case is illustrative of this type: Case I (Figs. 1 3). Preoperative Diagnosis: Bronchiectasis of right middle lobe. Postoperative and Pathological Diagnosis: Congenital cystic disease of right middle lobe. S. D., a 39-year-old female, entered the hospital on Dec. 13, 1943, complaining of pain in the right side of the chest, which had appeared for the first time in 1936. The past history revealed the usual childhood diseases and a right-sided pleurisy in February 1943. The pain was said to be periodic and of constrictive nature, accompanied by a hacking and moderately productive cough. There had been an episode of hemoptysis in 1936. The blood pressure was 90 mm. Hg systolic and 60 diastolic; hemoglobin 12.5 gm. Examination of the sputum was negative for tubercle bacilli. Routine fluoroscopic examination of the chest disclosed no evidence of a parenchymatous lesion. The heart and aorta presented no abnormalities; the trachea was in the mid-line. Roentgen studies with iodized oil (Fig. 1) showed a saccular dilatation of one of the larger bronchi in the right middle lobe, with definite cupping at the bronchial end. The cystic cavities were fairly well outlined. Lobectomy of the right middle lobe was performed on Dec. 21, 1943, by Dr. William Adams and Dr. J. E. Bryant. The pleural surface of the specimen was smooth. The parenchyma was crepitant. The cut surface showed four cavities, varying from 0.5 to 1.0 cm. in diameter. The lining epithelium was an even yellowish-gray. No fluid was seen. Microscopic sections showed large cystic cavities lined with high columnar pseudostratified to low cuboidal epithelium (Figs. 2 and 3).

Congenital Duodenal Obstruction

Congenital obstruction of the duodenum, first described by Calder (7) in 1733, was long considered a fatal malformation of the newborn and a subject merely of academic interest. In view of the rapid downhill course within a week or two after birth, the diagnosis was formerly made by the pathologist at the necropsy table. More recently, however, the condition has been recognized clinically and roentgenologically, and during the past decade surgical procedures have been carried out successfully (2, 5, 11,12, 13, 18, 19, 24, 25, 31, 38, 40, 43, 46, 48, 49). So far about three hundred cases have been recorded in the literature (32). Approximately fifty patients have been operated upon, one-half of whom survived. Due to improved methods, introduced by Ladd (29), Donovan (10), and their coworkers, the mortality rate has been still further reduced. In spite of these advances, however, the disorder has received but little attention in the roentgen literature (20, 26, 35, 44, 45). In this communication we shall report six cases of congenital duodenal obstruction and summarize the salient features from the literature. Report Of Cases Case 1: Atresia of First Portion of the Duodenum (French Hospital, Service of Dr. F. C. Holden). A newborn white male vomited persistently after each feeding, at first food, later blood-tinged and finally coffee-ground material. The stools contained only meconium. The patient died on the third day of life, having had no roentgen examination. At autopsy, the stomach and first portion of the duodenum were found to be greatly dilated, the latter forming a blind pouch. There were numerous submucosal hemorrhages. The second portion of the duodenum was completely separated and contained at its funnel-shaped apex the orifice of the common bile duct. The head of the pancreas was closely attached to this region. There was no abnormality of the gallbladder or extrahepatic bile ducts. The pathological diagnosis was congenital atresia of the first portion of the duodenum. Case 2: Duodenal Atresia at Ampulla with Anomalies of Pancreatic and Common Bile Ducts. Non-Rotation of Intestine (French Hospital, Service of Dr. F. C. Holden). A newborn white male vomited shortly after the first feeding and continuously thereafter. The stools contained only meconium. A roentgen study revealed a moderate dilatation of the stomach and proximal portion of the duodenum; no barium passed into the jejunum. The intestine contained no gas (Fig. 1). A diagnosis of congenital duodenal atresia was made, but when a laparotomy was performed, on the ninth day, only a non-rotation of the intestine was found. Death occurred five days later. At autopsy, the stomach appeared moderately dilated. The first portion of the duodenum formed a blind pouch with a small bulge through which the duct of Santorini emptied.

The Lateral Projection of the Chest

The routine chest screening of hospital admissions by the fluororoentgen method is practicable in most general hospitals where the x-ray department is directed by a certified roentgenologist. Such procedures yield results of at least equal, if not greater, magnitude than other routine hospital laboratory procedures.Abnormal and pathologic conditions of the chest of clinical importance are discovered in approximately 10 per cent of chests examined in hospital screening programs. About 10 per cent of these pathologic findings are probably due to pulmonary tuberculosis. Although pulmonary tuberculosis represents a relatively small percentage of the clinically important findings such case detection in hospitals is extremely important for several reasons: (1) It minimizes exposure of other hospital patients to tuberculosis by providing reason for segregation or transfer. (2) It permits of early diagnosis and institution of proper therapy. (3) It minimizes exposure of hospital personnel to tuberculosis. (4) It provides valuable data in compensation matters and disputes.Nontuberculous diseases of the chest in hospital surveys are of much greater frequency and probably of equal importance. Cardiac abnormalities, mediastinal tumors or widening, enlarged hilar nodes, metastatic lesions, etc., account for approximately 90 per cent of the pathologic conditions uncovered by this method.Admission chest fluororoentgenograms provide at least one more advantage. The availability of so-called “control” films of the chest is of great value in those instances where chest complications develop during the hospital stay or even at a later date after discharge from the hospital. Comparison of the “control” films with subsequent roentgen studies affords criteria which often permit of unequivocal diagnostic statements. With such comparative roentgen studies of the chest diagnostic uncertainty is often reduced to a minimum.The viewpoint of the roentgenologists as regards chest surveys or screening is no different from the viewpoint of the medical profession in general; that is, to provide feasible, well planned and supervised programs. Such planning is mandatory if the procedure is not to be discredited and the reputation of the medical profession is to be sustained. It is imperative that the medical profession undertake and supervise such programs if leadership in public health matters is to be regained and retained.

Roentgen Study of the Ankle in Severe Sprains and Dislocations

There has more recently been an increasing tendency toward the use of the x-rays in clinical medicine to demonstrate not only the anatomical structure and pathological lesions of a part but also its physiology and any disturbances thereof. This is well illustrated in roentgen studies of the urinary and digestive tracts. The study of the skeletal system has not kept pace with that of other systems in this respect and, even today, is for the most part on a purely anatomical basis. In examination of the ankle, roentgenograms are obtained, as a rule, in the anteroposterior and lateral positions. If no bony injury or abnormality is demonstrable, the report usually reads: “Nothing abnormal is seen, but this examination does not exclude injury to the soft parts.” In other words, our examination fails to record the presence of a soft-tissue injury. This was brought forcibly to our attention by the following case: Case Report R. M. U., a white male, 53 years of age, was admitted to the service of Dr. Paul C. Colon...

Roentgen Observations on Primary Atypical Pneumonia

Approximately ten years ago scattered reports began to appear in the foreign literature concerning certain lobular pneumonias of atypical character and distribution associated with unusual clinical findings. Later reports appearing in the American literature (Bowen, Allen, Reimann, Goodpasture and others) established the disease as a new clinical entity of characteristic symptomatology, course, and laboratory findings. Excellent discussions of the clinical and roentgen findings in this disease are to be found in the recent medical literature, but certain features, it is believed, have either escaped notice or have not received the attention they deserve. The observations which are the subject of this paper are derived from a study of approximately 1,500 pneumonia patients admitted to the AAF Regional Station Hospital of the Santa Ana Army Air Base over a period of two years. Of these, approximately 1,200, or 80 per cent, have been clinically classified as suffering from “primary atypical pneumonia.” All have had interval roentgen studies. For the purpose of accurate analysis, the roentgen findings in 300 of these cases have been carefully tabulated. Clinical Aspects One of the most striking features of primary atypical pneumonia, at least to the radiologist, is the relatively mild clinical course of the disease as compared with the amount of infiltration shown on corresponding chest films. In one series of 26,448 routine 4 × 10-inch photoroentgen examinations of the chest on supposedly healthy young adults applying for air crew training, 153, or 0.58 per cent, showed varying degrees of infiltration, usually small in amount, but occasionally occupying as much as one-fourth of a lung field. The findings were confirmed by recheck 14 × 17-inch films, and the subsequent clinical classification was almost invariably primary atypical pneumonia. When questioned, many of these men reported no symptoms of any kind. Others complained only of a recent “cold” or “cough” or of feeling weak, easily fatigued, or “under par.” Patients admitted to the hospital because of a more acute or severe illness complained primarily of fever and chills, cough, general malaise, weakness, and various aches and pains. The onset was usually moderately acute over a period of one to three days. Cough, either dry or productive of slight mucoid sputum, was present in most cases, and was often the outstanding symptom, complained of bitterly because of its persistent, irritating character. A sensation of extreme weakness, fatigue, or exhaustion was one of the most pronounced and also one of the commonest findings. In mild cases, it was sometimes the only symptom. There was often accompanying moderately severe and persistent headache, general aching, or both. Sore throat was frequently present but was seldom severe or the presenting symptom. Chills or chilly sensations and profuse perspiration were encountered commonly, especially in the early stages of the disease.

Roentgen studies of the heart in asthmatic children: Derbes, V. J., and Engelhardt, H.T.: J. Pediat. 25: 394, 1944

Roentgen studies of the heart in asthmatic children: Derbes, V. J., and Engelhardt, H.T.: J. Pediat. 25: 394, 1944