Roentgen Study Research Articles

Lymphography of the normal adult male. Observations and their relation to the diagnosis of metastatic neoplasm.

Recent roentgen study of the lymphatic system began with the investigation of edematous legs. The normal radiographic anatomy of the lymph trunks of the upper and lower extremities has been described by Kinmonth et al. (9), Jacobsson and Johansson (8), and Gergely (6), while abnormalities in their number and structure have been reported by Kinmonth and others (9, 1). Although lymphography of the swollen limb has given valuable information that could be added to and correlated with what was previously known or suspected, we have felt for some time that the most worthwhile use of lymphography would be in the study of lymph node disease. We have directed our efforts to contrast radiography of pelvic and abdominal nodes. This area was selected for study because of the frequency of neoplasms of the uterus, bladder, and prostate and their known propensity to metastasize to these nodes. Also, it is an area where nodes, though not necessarily all nodes, can be visualized by an injection technic without surgical exploration of the pelvis and abdomen. The lack of success in determining the presence of early and minimal involvement of these nodes by conventional means is well known. To evaluate change due to disease, the range of normal must first be understood. Gross lesions may be seen on examination of patients with far advanced disease, but in this group node involvement is most readily apparent clinically, and roentgenography is less important. We sought, therefore, to examine the normal and to obtain information on the limits of normal structure and the possibilities of demonstrating early disease. The worth of lymphography would in our opinion depend upon success in the detection of otherwise unsuspected metastases. Our experience with 72 inguinal and pelvic lymphograms in 38 adult normal males is the basis of the present report. The work was performed on volunteers, inmates of the State Penitentiary, Fort Madison, Iowa. A concurrent portion of our study was devoted to the technic of injection of contrast material into the lymph system. Cannulation and injection of a lymph trunk in the foot is tedious, difficult, and time-consuming. It was believed that a simpler technic would expedite all phases of investigation and permit assessment of its worth. The anatomic terminology to be used in this paper follows that of Rouviere (11). The saphena magna system of subcutaneous lymphatics is defined as comprising those lymph vessels which generally accompany the greater saphenous vein and drain into inguinal nodes. The lymphatics of the saphena parva system accompany the lesser saphenous vein and drain into popliteal nodes and thence by efferent trunks to the inguinal nodes. Inguinal nodes occurring bilaterally, both superficial and deep, are those of the groin inferior to the inguinal ligament. The ilio-pelvic node groups are three, occurring bilaterally: external iliac, hypogastric, and common iliac.

Pyloric stenosis: Postoperative roentgen studies and their clinical significance

<h2>Summary</h2> Twenty infants were studied radiographically following successful pyloromyotomy for hypertrophic pyloric stenosis. Although the gastric emptying time was improved, all showed persistent narrowing of the pyloric canal. Since the postoperative roentgen appearance may not differ appreciably from the preoperative appearance, the decision to perform a second pyloromyotomy should never be based on roentgen findings alone.

Unusual Appearance of the Colon Following Sigmoid Volvulus

The sigmoid colon is the most common site of volvulus of the large bowel. The diagnosis is usually made from the clinical findings and roentgen study of the abdomen; barium-enema examination is not, as a rule, necessary. The characteristic radiologic appearance of this closed-loop variety of colonic obstruction has been well documented (5, 6, 12–15). Its mortality rate has been high, and death is frequently associated with gangrene of the involved segment of the sigmoid. The usual treatment is surgical, but rectal intubation with sigmoidoscopy has been recommended for cases without evidence, proctoscopically, of circulatory embarrassment (1). Although there are numerous reports of the aspect of sigmoid volvulus on barium-enema examination, we have come across none on the appearance soon after detorsion of the volvulus. This is a report of a patient with sigmoid volvulus treated by intubation through a sigmoidoscope. Barium-enema study three days after the detorsion demonstrated striking changes in the sigmoid colon. Case Report B. H., 78-year-old white female, was admitted to the Bronx Municipal Hospital Center on Dec. 1, 1959, with a four-day history of abdominal pain and distention, without vomiting. She had passed no flatus for two days and had only a small bowel movement the day before admission. There was no history of melena or hematemesis. Anorexia had been present for one day. After admission to the hospital, films of the abdomen demonstrated the typical appearance of sigmoid volvulus (Fig. 1). A sigmoidoscope was passed to 20 cm. where a “constricting mass”was encountered in the bowel. As the instrument was passed through the narrowed area, a large amount of gas and watery stool was evacuated, with subsequent subsidence of the abdominal distention and pain. Three days later a barium-enema examination was performed (Figs. 2–4), demonstrating a wide and redundant loop of sigmoid colon with multiple serrations along its borders, having the appearance of numerous small ulcers. The postevacuation film showed pronounced thickening of the sigmoid mucosa. It was believed that these changes represented mucosal edema and ulceration due to circulatory embarrassment at the time of the volvulus. At sigmoidoscopy two days later, however, the sigmoid exhibited only mild injection of the mucosa with no evidence of ulceration. The patient did well and was discharged on a low residue diet. One month after the first admission, a similar episode led to an elective resection of a huge redundant loop of dilated sigmoid colon. Gross and microscopic study of the resected specimen showed only minimal signs of venous stasis. There was mild congestion of the subserosal and submucosal venules. A small amount of proteinaceous hyalinestaining material was present in somewhat dilated lymphatics.

Branchial Arteritis in the Aortic Arch Syndrome: A Roentgen and Differential Diagnostic Study

Branchial Arteritis in the Aortic Arch Syndrome: A Roentgen and Differential Diagnostic Study

Gas in the fetal circulation--reliable antepartum roentgen sign of fetal death.

THE ANTEPARTUM ROENTGEN demonstration of gas in the fetal circulation is the most important pathognomonic sign of fetal death. The phenomenon of visualized gas in the fetal circulation has never been observed in a fetus which was subsequently delivered alive. Wider dissemination of information about this phenomenon is warranted. Gas in the fetal circulation associated with fetal death was first described by Roberts,11of Victoria, B. C., in 1944. He diagnosed fetal death from antepartum roentgenograms in which there was a clear demonstration of gas in the cardiac chambers and blood vessels, and corroborated the finding by postpartum roentgen studies and autopsy. Many confirmatory reports have been published. In the approximately 100 cases reported,2-4, 9, 12-16antepartum roentgenograms revealed gas in the fetal heart and/or larger vessels or umbilical cord. The vessels in the liver were occasionally seen. In rare instances gas was visible about the kidneys. The

The Normal Skull: A Roentgen StudyThe Normal Skull: A Roentgen Study. By ShapiroRobert, M.D., Chairman, Department of Radiology, The Hospital of Saint Raphael, New Haven; Associate Clinical Professor of Radiology, Yale University School of Medicine; and JanzenArnold H., M.D., Assistant Radiologist, The Hartford Hospital, Hartford; Former Chairman, Department of Radiology, The Grace-New Haven Community Hospital and Yale University School of

The Normal Skull: A Roentgen StudyThe Normal Skull: A Roentgen Study. By ShapiroRobert, M.D., Chairman, Department of Radiology, The Hospital of Saint Raphael, New Haven; Associate Clinical Professor of Radiology, Yale University School of Medicine; and JanzenArnold H., M.D., Assistant Radiologist, The Hartford Hospital, Hartford; Former Chairman, Department of Radiology, The Grace-New Haven Community Hospital and Yale University School of

The use of parenteral neostigmine in the roentgen study of the small bowel.

Abnormalities of the small intestine, including tumors, may be clinically unsuspected. Signs and symptoms may be so vague that a small-bowel roentgen examination is not requested by the referring physician (4), and in most institutions this is not carried out routinely following roentgen study of the stomach and duodenum. One reason for this omission is the variability from patient to patient in the time for passage of the barium meal into the cecum, necessitating a large number of films (11). Procedures have been designed by other workers to facilitate roentgen examination of the small intestine. The “small-intestinal enema” of Schatzki, which entails introduction of barium by a catheter into the duodenum or high jejunum, must be done as a separate procedure (12). Weintraub and Williams (15) reported that in 90 per cent of normal cases an orally administered suspension of barium sulfate in saline will, when followed by ice-cold saline, reach the cecum in less than one hour. This method, however, has not ...

Comparison of Three Different Methods of External Irradiation, and Their Results, in the Treatment of Inoperable Carcinoma of the Lunq

The steadily increasing number of patients who are referred for radiotherapy with the diagnosis of advanced inoperable carcinoma of the lung has become a challenge and a problem during the past few years. The solution has not been made easier by the wide range of opinions as to the clinical approach to the disease. Some clinicians have questioned the value of any type of therapeutic interference in such a situation and have felt that no treatment whatever was indicated unless patients were threatened by compression of vital organs, while others have considered aggressive therapy imperative and worthwhile. It has always been the opinion of the writer that supervoltage irradiation offers the most to patients with far advanced inoperable cancer of the lung, and she has accordingly treated such patients with 2-million-volt or cobalt-60 irradiation. Since the results of this treatment approach have been published previously, only those data which are most pertinent to the present discussion will be summarized here. One hundred and fifty-three patients with microscopically proved inoperable carcinoma of the lung have been treated and followed in the Radiotherapy Department of the Francis Delafield Hospital, New York, since 1953. Of these, 138 were treated with a 2-million-volt unit, and 15 with a cobalt-60 unit. It has been our rule to accept every patient for radiotherapy without exception, no matter how far advanced the disease either locally or in lymph nodes, or both. Radiation has been administered through two opposing fields, with a daily tumor dose of 200 r, for a total tumor dose of 5,000 r in the majority of the cases and in a few patients as much as 6,000 r. Neither rotation therapy nor scanning has been used, as we believe that the preservation of the unimpaired function of the healthy opposing lung is essential for survival. The tolerance has been very good, as was to be expected with the use of 2-million-volt or cobalt-60 therapy. Three observations of considerable interest have been made in the course of this study: 1. It has been possible, with the external radiation doses used, to sterilize even large carcinomas of the lung. 2. Malignant lesions of the epithelium have responded far better than those of glandular tissues. 3. There is no correlation between clinical success and roentgenologic findings; the films of most patients will show only little change, as large tumors which have often caused many changes in the surrounding tissues do not melt away under radiotherapy. In addition, radiation pneumonitis, pleurisy, and fibrosis appear quite frequently and, persisting for the duration of the patient's life, make it practically impossible to determine correctly alterations in the original tumor shadow on subsequent roentgen studies.

The roentgenologist as a consultant.

The rendition of a signed report to the referring physician is an important part of the practice of diagnostic roentgenology. This report, based upon examination of the patient, presents the findings of the roentgenologist and expresses his medical judgment or diagnosis. Because definite responsibilities have been assumed in the performance of such an examination, no matter how simple it may be, the report should show that these commitments have been honored. What exactly are these responsibilities? In what manner are they best discharged? Evaluation: In most cases the evaluation of an x-ray examination as to suitability, completeness, and technic requires no direct mention by the roentgenologist. This holds true particularly for the simpler and more standardized procedures. Occasionally, however, it is necessary that a statement be included pertaining to one or another of these three conditions any one of which can be of real significance to the patient and the referring physician. In order to pass on the suitability of any examination that the roentgenologist may be called upon to interpret, a clear statement is required from the referring physician as to the information sought or, in other words the purpose of the roentgen study that has been requested. Unless such information is provided, one is unable to determine whether or not the examination chosen was the one best suited to the purpose. If doubt exists in the mind of the referring physician as to the correct x-ray procedure in a particular situation, then a consultation with the roentgenologist is in order. Usually, however, it is simpler if the patient is turned over to the roentgen diagnostician who, being informed of the problem to be answered, is left free to choose the most efficient way to proceed with his work-up. Should it transpire that an inappropriate examination has been carried out, then the report must define its ill conception and state the correct method of approach to the problem. In this manner the patient's interest will be protected and similar errors may be prevented in the future. The second part of the evaluation concerns the presence of any restrictions on the conduct or execution of the roentgen examination. Restrictions which can lead to an examination that is less than complete, may emanate from the referring physician or from the patient himself. Stipulations imposed by the referring physician, although well intended, are often unwise and founded upon commonly held misconceptions. The failure to permit adequate preparation of a patient, the insistence on the use of certain types of radiopaque material, such as “thin barium,” and the rigid designation of technical matters can seriously undermine the usefulness of the roentgen method. To the extent that an x-ray study is compromised in these ways are the chances for a successful result diminished.

Meckel's diverticula: preoperative roentgen diagnosis in children. Presentation of two cases.

In spite of the finding of Meckel's diverticulum in 1 to 2 per cent of all necropsies (1, 2), its preoperative roentgen diagnosis constitutes a rarity. Stein et al. (2), in a review of the English literature found only 33 instances in which the diagnosis of Meckel's diverticulum had been made preoperatively. They report 5 additional cases in adults, bringing the total to 38 at the time of their publication. Two cases of Meckel's diverticulum in children with preoperative roentgen diagnosis will be reported here. These were consecutive cases studied with this possibility in mind in an interval of three weeks. The presenting complaint in each was periumbilical abdominal pain. This symptomatology and absence of demonstrable disease in the upper gastrointestinal tract prompted distal small bowel study in an attempt to demonstrate a Meckel's diverticulum. Report of Cases Case I: D. C., a 6-year-old white boy, was first seen on May 11, 1959, complaining of intermittent dull aching periumbilical pain during the past year. He frequently had to stop even play activity and lie down until the pain disappeared. During the past three weeks the pain had become more frequent and severe, occurring both day and night. He had vomited on only one occasion, the night prior to the initial visit. The patient was placed on medication and seen four days later, at which time his complaint was the same except that the abdominal pain had become more or less constant. At this time physical examination revealed mild tenderness in the periumbilical area but was otherwise normal. Urinalysis was normal. The white blood count was 7,300, with 27 per cent neutrophils, 50 per cent lymphocytes, 5 per cent monocytes, and 10 per cent eosinophils. Roentgen study was done on May 18. Since the esophagus, stomach, and duodenum appeared normal, it was decided to observe the distal small bowel in an attempt to demonstrate a Meckel's diverticulum. Fluoroscopy was done after an interval of one hour, at which time the barium had advanced to the cecum. At once a diverticulum-like structure was identified, originating from the prepelvic portion of the ileum and directed laterally across the terminal ileum approximately 5 cm. proximal to the ileocecal junction. This appeared as a pouch 2 cm. in diameter, somewhat lobulated in configuration and constricted at the neck at the point of junction with the prepelvic section of the ileum (Fig. 1). On this evidence a roentgenologic diagnosis of Meckel's diverticulum was made. Surgery was undertaken one week after the roentgen demonstration of the diverticulum. At laparotomy, through a right lower quadrant incision, a Meckel's diverticulum was found approximately 35 cm. proximal to the ileocecal valve, measuring approximately 7 cm. in length and 1 cm. in diameter (Fig. 2). A band-like structure tended to draw the diverticulum toward the cecum and probably accounts for the position as observed at fluoroscopy and demonstrated on the spot-film.

Sacral aplasia (agenesis).

Congenital absence of part or all of the sacrum is of infrequent occurrence. Gross aplasia (frequently called agenesis) of the caudal portion of the spine from the mid-thoracic level or higher is probably incompatible with life at an early stage of fetal development and would therefore tend to be unreported. Absence of the terminal part of the coccyx would also be likely to remain undetected unless found during unrelated roentgen studies. An analysis of spinal roentgenograms of 700 children was made by Shands and Bundens (1) in 1956. In a group of 169 anomalies, there were 5 cases of absence of spinal segments, 3 of congenital absence of all or part of the lumbar spine, sacrum, and coccyx, and 1 of solitary coccygeal absence. In 1852, Hohl (2) reported absence of the sacrum for the first time. The first complete review of this subject, however, was presented by Freedman (3) in 1950. By that time, 54 cases had been reported, to which Freedman added a fifty-fifth. An excellent and comprehensive review by Blumel, Evans, and Eggers, recently published (4), presents data on 50 new cases, of which 8 were personally observed and the remaining 42 were collected by correspondence with 300 orthopedic surgeons in the United States. In this series 32 cases showed complete absence of the sacrum and 18 partial absence. Our purpose is to describe and emphasize the clinical and roentgen findings of sacral aplasia. It is important that the clinician and radiologist be made aware of the existence of this conditon and of its relationship to cord bladder, fecal urinary incontinence, infection, and abnormalities of gait. We shall present 3 new personally observed cases of sacral aplasia, of which 2 were complete and 1 partial. Anatomy and Morphogenesis Gray's Anatomy (5) adequately describes the development of the sacrum and coccyx from nine separate segments, and the detailed discussion of the embryology of these spinal segments may best be read in the original. Briefly, after development, the large triangular bone known as the sacrum is situated in the lower part of the vertebral column at the upper and posterior portion of the pelvic cavity. The sacrum is inserted between the two hip bones as a wedge articulating superiorly with the last lumbar vertebra and at its lower margin with the coccyx. Clinical Material Case I: A. W., a 3 1/2-year-old white boy, was admitted to Montefiore Hospital on June 12, 1957, with a history of fecal and urinary incontinence since birth. Motor activity was reported to be unimpaired, and the family had not been aware of any sensory deficits. On examination, the pertinent findings included a protuberant abdomen, a soft-tissue mass over the sacral area, atrophic glutei, absence of natal creases, and thin, atrophic legs. Positive neurologic findings consisted of the inability to stand on either foot, absence of ankle jerks, and bilateral Babinski reflexes. Rectal tone was absent.

Further studies on the accuracy of oral cholecystography.

In a recent communication (1), we discussed the degree of accuracy with which the presence or absence of pathologic changes in the gallbladder could be predicted by means of oral cholecystography. In that study all surgically proved chole-cystographic diagnoses at the Mayo Clinic in 1950 and 1955 were analyzed. These two years were chosen because of the different cholecystographic media employed: iodoalphionic acid (Priodax) in 1950 and iodophenoxic acid (Teridax) in 1955. In 1956, about midyear, we again changed our medium, and by September all patients were receiving iopanoic acid (Telepaque). This study is a summary of results in the first full year (1957) in which this drug was used. Procedure of Oral Cholecystography In this and in our previous study (1), we reviewed some 3,600 cholecystograms obtained in 1950, 1955, and 1957, and were impressed by the fact that the accuracy of the diagnosis seemed to have little relationship to the medium employed for the roentgen study. We are now firmly convinced that correct technical conduct of the examination, and continued vigilance and interest on the part of the radiologist and technician in this phase of the procedure, are indispensable if uniformly accurate results are to be expected. Scant attention has been paid to the actual technic of cholecystography in the literature of the past quarter century. For this reason we wish to recount, in some detail, the procedures which we employ. Preliminary Preparation of the Patient: Each patient is instructed to take four 0.5-gm. tablets of iopanoic acid during or shortly after an evening meal of the usual size, from which eggs and fats have been omitted. He eats nothing from then until after the x-ray examination has been made the next day, although he may drink water, black coffee, or clear tea. He is further advised not to take a laxative. It will be noted that the medium is ingested at a time when the stomach contains food. This, we believe, reduces to a minimum gastric irritation and unpleasant gastrointestinal side-effects attributable to the drug. After some trial of a high-fat meal on the evening preceding examination, we have concluded that more consistent results are obtained if fatty foods are eliminated from this meal. Roentgenographic Technic: The patient reports for examination approximately fourteen to sixteen hours after ingesting the medium; he is placed on the table in an easy posture with the head turned to one side. The arms are brought upward in a comfortable position, and a pillow is put under the ankles so that no weight is borne by the toes. A wide canvas binder is then firmly applied across the back at the level of the lower ribs. All of these procedures are designed to eliminate motion which may obscure roentgen evidence of stones or tumors.

Cyst of the left triangular ligament of the liver.

Cysts of the hepatic ligaments are relatively rare as shown by the fact that only 7 cases could be found in the literature. Four of these were in the falciform ligament (1, 6) and 3 in the ligamentum teres (2, 8, 4). No cases were described in the triangular ligaments. The falciform ligament is a double layer of peritoneum that goes from the upper and anterior surfaces of the liver to the lower surface of the diaphragm and the back of the linea alba. Its line of attachment divides the liver into left and right lobes. The ligamentum teres is a fibrous cord running in the falciform ligament down to the umbilicus; it is the remnant of the umbilical vein. At the posterior portion of the upper surface of the liver, the left layer of the falciform ligament turns to the left and forms the anterior layer of a triangular fold called the left triangular ligament. This passes from the upper surface of the left lobe to the diaphragm (8). Brown (1), in reviewing the reported cases of cysts of the hepatic ligaments in 1948, classified them as primary or secondary. The primary cysts can be of lymphatic origin, a developmental defect, or the result of peritoneal inclusion. Geist (5), discussing solitary nonparasitic cysts of the liver, included some cases in the hepatic ligaments. Various classifications of hepatic cysts have been devised, but that of Jones (7) is probably the most widely accepted. In most of the cases described the cysts were large, some reaching the size of a child's head, and were usually palpable. The diagnosis was not made prior to surgery. In a few cases, roentgen studies of the gastrointestinal and renal systems were done, and in some instances showed extrinsic pressure on the gastrointestinal tract. The symptoms varied somewhat, but a number of the patients had pain in the epigastrium, indigestion, or a full feeling most marked after meals. One patient presented with acute symptoms as result of torsion. Pathologically the cysts were essentially the same except for the case to be reported here, which contained hepatic tissue. There was a thin fibrous connective tissue wall in which muscle fibers were occasionally present. The cysts were in most cases unilocular with a smooth endothelial lining and contained a serous fluid that was clear or slightly cloudy. Case History G. B., a 55-year-old white female, complained of heaviness in the epigastrium and burning epigastric pain. The history and physical examination were otherwise not contributory. Roentgen examination of the upper gastrointestinal tract showed an indentation in the fundus of the stomach. The examination was repeated with air contrast and a defect measuring 2 to 3 cm. was demonstrated, with indentation of the fundus, and also a localized elevation of the diaphragm (Fig. 1).

Diagnosis of esophageal varices by a new radiologic method: a preliminary report.

Until the last few years, the diagnosis of esophageal varices carried a prognosis worse than most other diseases, including coronary occlusion and cancer. The statistics vary but demonstrate similar results. Higgins (1) found that 84 per cent of those entering the hospital complaining of hematemesis died of hemorrhage. Blakemore (2) refers to the experience of Patek, who found that 50 per cent of his patients with Laennec's cirrhosis were dead within one year of the onset of their first hemorrhage. Palmer (3) quotes from Shull's experience: only 37 per cent of 180 cirrhotic patients were alive one year after the diagnosis of esophageal varices was made. The employment of the Sengstaken tube (4) and of relatively new surgical methods, especially the portacaval and splenorenal shunts, in the last few years, have offered hope of improving these statistics considerably, and prophylactic surgery for esophageal varices prior to hemorrhage is being seriously considered as the proper method of management. Therefore, the early diagnosis of esophageal varices has become much more important. Present Diagnostic Methods At the present time, only three acceptable antemortem methods of diagnosis are available: esophagoscopy, splenoportography, and roentgen study of the esophagus. Esophagoscopy offers the most accurate method of diagnosis, although occasionally a roentgen examination of the esophagus with the aid of barium has demonstrated varices which have been overlooked by the esophagoscopist (5). In spite of the fact that there is a morbidity rate (perforation of the esophagus, hemorrhage) of only 2 per cent or less and a mortality rate of 0.5 per cent or less associated with all esophagoscopy (5, 6), many physicians are reluctant to use the procedure in the presence of esophageal varices. In addition, about 8 per cent of patients refuse to undergo this examination (5). Percutaneous splenoportography as yet enjoys only a limited use in the United States, and no large series on the study of esophageal varices by this technic is available. At the present time, it appears to be a less accurate method than esophagoscopy and no more accurate than conventional x-ray examination of the esophagus (7). The advantages of roentgen examination of the esophagus are the absence of associated mortality or morbidity and ease of application. The disadvantage of this method is its low percentage of accuracy, though differences of opinion on this point are found among radiologists, who claim as little as 15 and as much as 50 per cent positive diagnoses in all cases of esophageal varices, both with and without a history of hematemesis (8, 9). A study of this type of examination was made by Brick and Palmer on the basis of a total of 172 patients examined in three separate university radiology departments under the direction of three different radiologists (10).

Unilateral pulmonary "emphysema.

Increased radiolucency of one lung associated with decreased prominence of its hilar and pulmonary vascular markings is observed most commonly in obstructive emphysema due to occlusion of a main or lobar bronchus by a mass or foreign body and in compensatory emphysema following collapse of a pulmonary lobe or segment. Recently, however, there have appeared several reports describing a condition in which the roentgen findings simulate obstructive or compensatory emphysema but which proves on further roentgen examination to be neither. The first comprehensive analysis of a group of such patients was made by Macleod, who reported 9 cases under the title Abnormal Transradiancy of One Lung (2). Later Dornhorst, Heaf, and Semple (1), designating the process as “unilateral emphysema,” described 4 additional examples and reported follow-up studies on 5 of Macleod's original cases. Neither of these reports identifies the disease as one of the recognized forms of pulmonary emphysema. Actually the first case, in a boy of six years, was reported by Swyer and James, who entitled their paper A Case of Unilateral Pulmonary Emphysema but were careful to point out the clinical and roentgen features distinguishing the process from both compensatory and obstructive emphysema (6). Even though it may eventually prove to be incorrect, it seems preferable to designate the lesion as “emphysema” rather than as “abnormal transradiancy,” which is a purely roentgenographic description. The cardinal point of differentiation of unilateral “emphysema” from other forms of airway obstruction is the absence of major bronchial occlusion demonstrable by bronchography. In most of the patients movement of the mediastinum is toward the abnormal lung on inspiration, the opposite of what takes place in obstructive emphysema. The present paper describes a case which is representative of those previously reported. Case Report A 38-year-old male, a machinist, was referred for study in July 1955 because of an abnormal chest roentgenogram. He was asymptomatic except for occasional dry cough and mild exertional dyspnea. He gave a history of a severe respiratory illness in childhood which was diagnosed as “pneumonia” and treated at home, with no apparent sequelae. There were infrequent “colds” which cleared readily. The left hemithorax was hyperresonant and the breath sounds were decreased. Cardiovascular examination was normal. Roentgen study showed the left hemithorax to be slightly smaller and much more radiolucent than the right. There was a striking decrease in the vascular markings, with a corresponding decrease in the size of the hilar shadow on the left side. The right lung showed a marked increase in prominence of the vascular markings. There was minimal displacement of the mediastinal structures to the left side.

Yield of Gastric Carcinoma from Radiologic Screening

Summary Results of an experiment in the radiologic detection of gastric cancer have been presented, Patients were selected for roentgen study when they were over 45 years of age and exhibited hypochlorhydria. A yield of one cancer for every 447 years of patient observation was found. The yield was seen to diminish after the first year of observation, whereas the percentage of early cases of gastric cancer detected was seen to increase after the first year of observation. No doubt, the application of this method for mass surveys is presently impractical. It is questionable whether the yield would be sufficient to justify the extensive use of personnel which would be involved. As a prophylactic procedure for individual patients, in whom these indications are present, it may be of considerable value. Widely practiced in this way, some increase in the salvage from gastric carcinoma would result.

Arteriovenous fistula of the lung.

Pulmonary arteriovenous fistulas are anomalous connections between the arteries and veins of a portion of the pulmonary vascular bed. Since the first clinical diagnosis of pulmonary arteriovenous fistula by Smith and Horton in 1939 (13), 200 cases have been reported. The detection by routine chest roentgenograms and photofluorograms of clinically silent spheroid pulmonary lesions has been largely responsible for an increasing frequency of diagnosis. It is now mandatory that a radiologist, confronted with a density in the lung parenchyma, include arteriovenous fistula in the differential diagnosis. This is of prime importance, since the surgical approach may differ from that for the usual “coin lesion.” Case Reports Case I: On Feb. 15, 1958, a 27-year-old Caucasian sailor was admitted to the St. Albans Naval Hospital. A routine chest roentgenogram for discharge from the service revealed a density in the right lower lobe. History and physical examination were unremarkable. A murmur within the right chest could not be detected and examination of the mucous membranes and skin failed to reveal telangiectasia. There was no history of familial disease. Oxygen saturation and pulmonary function studies were normal. The roentgenograms are shown in Figures 1–4. A segmental resection of the fistula in the right lower lobe was performed with an uneventful postoperative course. Case II: A 24-year-old Caucasian sailor was admitted to the U. S. Naval Hospital in December 1955 because of a mass in the left lung, detected on an annual chest roentgenogram. He was asymptomatic and had never had any operation or serious illnesses. System review and familial history were unremarkable. Physical examination failed to reveal telangiectasia or other abnormalities except for a soft, sharply localized systolic murmur in the left posterior axillary line over the eighth rib. This did not change with respiration. Results of laboratory studies were within normal limits. Oxygen saturation of the arterial blood was normal. Roentgen studies are shown in Figures 5–7. At surgery, a wedge resection removed the fistula intact and no murmurs or thrills were detectable in the remaining lung. The postoperative course was uneventful. Case III: A 33-year-old Caucasian female was admitted to the St. Albans Naval Hospital in September 1945. During a bout of acute tonsillitis a chest roentgenogram revealed a mass in the left lung, adjacent to the hilus. History and physical examination were otherwise unremarkable and there were no familial diseases. Angiocardiography confirmed the diagnosis of a pulmonary arteriovenous fistula but surgery was refused by the patient.

Prognosis in osteitis condensans ilii.

The entity of osteitis condensans ilii is first mentioned in the English literature in 1936 (1). Since that time there have been several good reviews of the subject (2, 3). It has been impossible however, to settle upon a definite etiology or constant clinical picture. The few aspects which seem to be relatively established are the radiological picture, the age and sex incidence, and the pathological picture. The purpose of this paper is to contribute some clarifying information regarding the prognosis. Nineteen cases of osteitis condensans ilii seen at Duke University Medical Center, in the years 1940 to 1958, were obtained from the x-ray museum file. These did not represent all of the cases seen during the period but only those cases placed in the teaching collection because of their roentgen appearance. The radiological criteria for diagnosis were: (a) the presence of a homogeneous triangular area of increased density involving the ilium adjacent to the sacroiliac joint and located at the lower border of the articulating surface of the ilium; (b) normal appearing sacroiliac articulating surfaces and joint space; (c) little or no radiologic evidence of involvement of the sacrum; (d) minimal or no spurring at the lower margin of the sacroiliac joint. Nine of this series of 19 patients whose last admission dated back twelve months or more have been followed up. These patients were interviewed and examined, and repeat roentgen studies were obtained. An attempt was made in each case to duplicate the technic of the previous x-ray examination. Caution must be used in distinguishing osteitis condensans ilii from several other diseases. Probably the condition most resembling it is hypertrophic arthritis of the sacroiliac joint. Here, however, the area of condensation is usually much smaller and is located at the most caudad portion of the sacroiliac joint. The joint space may be narrowed and the typical finding of eburnation with spurring is present. The process also involves the sacrum and it does not improve with time. One should look for a history of injury or other skeletal abnormalities to support this diagnosis. Marie-Strümpell arthritis may also offer somewhat of a problem both clinically and radiologically. In Marie-Strümpell arthritis the joint space should show signs of involvement, with irregularities and loss of definition. There should be evidence of sacral involvement and the area of increased density should parallel the articulating surfaces of the sacrum and ilium rather than being of a triangular pattern. The area of increased density is irregular and splotchy with poorly defined limitations, not the clearly defined homogeneous density of osteitis. Other conditions which might be mistaken for osteitis condensans are metastatic tumors, Paget's disease, osteomyelitis, and syphilis. Results The findings for the total series of 19 cases are presented in Table I. The results of follow-up are listed in Table II.

Radiographic examination of surgically removed specimens with a radiologic-pathologic correlation.

Roentgen study of gross surgical specimens has been found to offer certain advantages under a variety of circumstances. Some of the information that can be obtained in this way will be considered here. After the superfluous blood and fluid are drained off, the specimen may be placed upon absorbent paper and carried to the department of roentgenology for immediate radiography. The hemostats may be left in place, especially for studies of the intestinal tract. A lead arrow will serve readily to indicate either the oral or caudal end of the specimen. Suitable identification similar to that used in routine roentgen examinations should be incorporated in the radiograph—the date, case number, and indication as to the side, left or right. The specimen, with clean absorbent paper, is placed upon a cassette of suitable size and the exposure is made. A brief résumé of the technical factors is given in Table I. All examinations should be made on the table top of the radiographic unit, with par-speed intensifying screens in the cassette. The cassette size depends on the size of the specimen; the usual dimensions are 6 1/2 × 8 1/2, 8 × 10, or 10 × 12 inches. All exposures are made at 30 inches, with a cone to cover the cassette. The films are developed like any other film, usually for three and a half to four minutes. The selection of kilovoltage is based upon the usual thickness of the part, on the assumption that moderate collapse and flattening of the specimen will occur. For every additional 1.0 cm. thickness of part 2.0 kv may be added. The only exception to this is Category 4, where an occlusal film may be used. A small calculus or chicken bone does not measure 1 cm. in thickness, but with the reduced milliampere-second ratio, increased kilovoltage is needed to obtain a satisfactory image. Since screens are not used in the small film holders employed for this type of exposure, a longer developing time may be needed. With practice, a skilled technician will readily become adept in this procedure. Cardiac and Vascular Lesions Frequently on acute fluoroscopic scrutiny a calcified plaque may be identified in the pericardium, a vascular orifice, or in one of the cardiac valvular cusps. The aortic and mitral valves are more commonly the site of such deposits, but accurate localization by radiographic or fluoroscopic study is difficult. A black and white photograph will not show to advantage the location of these plaques, but on a radiograph of the specimen they are readily localized as to chamber or vascular stem. Similarly, the identity of a cardiac or aortic aneurysm with or without calcification can definitely be determined. Coronary artery sclerosis is also easily demonstrated. Pulmonary Lesions Verification of partial pulmonary sequestration incident to a broncholith is readily accomplished by a radiograph of a segment of resected lung. The same is true for an hemangiomatous vascular anomaly.

Benign duodenocolic fistula; report of autopsy case due to peptic ulcer and review of literature.

Introduction Fistulous tracts are of unusual interest when they occur between the duodenum and the colon. Benign lesions are less common as an etiologic factor than malignant neoplasms. Rees, 1 in 1933, reported the first nonmalignant duodenocolic fistula and considered a ruptured typhoid ulcer to be the cause. Up to date a total of 21 examples have been recorded. 2-19 Other implied causations for this condition have been peptic ulcer, tuberculous lymphadenitis, ulcerative colitis, acute gallbladder disease, and even appendicitis. However, it appears that the same case has been cited by Krock 9 and Olson. 10 The patient presented by Blondeau 2 has been rejected because the death occurred without surgical proof of the diagnosis. Likewise, Case 2 of Garland and Wyatt 15 is open to question, since the sinus tract was not seen at operation, and was diagnosed later by roentgen studies. Thus it would appear that there are