Routine Chest Films Research Articles

Roentgenologic aspects of Hodgkin's disease. II. Role of routine radiographs in detecting initial relapse.

The role of routine follow-up diagnostic radiographs in detecting initial relapse in Hodgkin's disease was assessed. Of 442 patients treated for cure between 1955-1970, 130 suffered relapse. Significantly, the diagnosis of relapse was initiated by radiographic findings alone (patients who were symptomatically and clinically without evidence of disease) in 35% of all relapses. These findings were equally divided between changes in retroperitoneal lymph nodes and in the mediastinum/lungs, and emphasize the value of routine surveillance abdominal and chest films, as well as repeat lymphangiography in selected cases. In 30% of all relapses, detection was based upon combined radiographic and clinical findings, while the remaining 35% were initiated primarily on the basis of clinical findings. There were 77 radiographically detected anatomic sites of relapse: 44 were seen on the abdominal film (34 abnormal retroperitoneal lymph nodes, 6 bone lesions, 4 enlarged spleens) and 31 on the chest radiographs (12 parenchymal lesions, 11 mediastinal and/or hilar adenopathies, 5 pleural effusions, and 3 bone lesions). Two sites were in the skull.

Plasma cell granulomas of the lung.

Plasma cell granuloma of the lung, a designation that we consider preferable to “inflammatory pseudotumor,” represents localized proliferations predominantly of mature plasma cells, with Russell bodies, reticuloendothelial cells, and intermediate forms, supported by a stroma of granulation tissue. Other cellular elements, including lymphocytes and large mononuclear cells, may coexist with the plasma cells. The latter may have a large content of cytoplasmic fat, hence the term “xanthoma” or “fibroxanthoma” applied by some. The stroma may contain interlacing or whorled masses of fibroblasts, and may be focally ossified or calcified. It is often hyalinized with an appearance similar to that of paramyloid. These lesions are usually asymptomatic, and are most commonly detected in routine chest films as circumscribed “coin” lesions, or large masses. They may be static or increase slowly in size. In a minority, they are sessile or polypoid intrabronchial masses. More than two thirds of the patients are less than 30 years of age; indeed plasma cell granulomas are prominent among the large solitary intrapulmonary lesions in children. Bacterial cultures and skin tests for mycobacteria and fungi have been negative. The prognosis is good even after lobectomy, and probably even after segmental resection. Plasma cell granulomas have structural features and a natural history quite distinct from those of sclerosing hemangioma and myeloma.

A mortality study of shipyard workers with pleural plaques.

<b>Fletcher, D. E. (1972).</b><i>Brit. J. industr. Med.,</i><b>29,</b> 142-145. <b>A mortality study of shipyard workers with pleural plaques.</b> Mild asbestos effects are seen frequently in shipyard workers. It is known that exposure of this type may be associated with mesothelioma, but it is not generally thought that an increased bronchial carcinoma risk exists unless there is pulmonary fibrosis. A number of cases of both types of malignant disease were seen in the Barrow hospitals, associated with pleural plaques. In view of this a retrospective survey was carried out. All routine administrative chest films taken in the works clinic between 1960 and 1970 were reviewed, together with the films of the 1962 mass radiography session, and 408 men were found to have evidence of pleural plaques. The men were followed up from the year of diagnosis until 1970 and 65 men died in this period. A similar control group of 404 men was chosen and 56 of them died. Both groups were compared with the expected mortality of Barrow men of the same age groups. There were 16 bronchial carcinomas in the plaque series compared with an expected figure of 6·74 (P = 0·0047), while in the control series there were 7 bronchial carcinomas compared with 5·61 expected (P = 0·516). Three mesotheliomas occurred in the plaque series (P = 0·0002).

RADIOLOGIC EVALUATION OF MYOCARDIAL INFARCTION

Plain films, fluoroscopy, and angiography are all useful in the evaluation of myocardial infarction and its sequelae, though none are precise; nor are the demonstrated abnormalities specific in many instances. Routine chest films of the patient with acute infarction serve primarily to exclude other diagnoses which might account for the presenting clinical picture. Abnormal findings are usually those of left heart failure. The radiologist has a particular responsibility for recognizing the postinfarction syndrome---a diagnosis which calls for significantly different therapy than do the other diagnostic possibilities with which it is commonly confused. Observation of calcification within coronaries, infarcted myocardium, or thrombus is helpful. Abnormal ventricular wall motion (asynergy) is seen in the majority of patients following myocardial infarction and should be sought at fluoroscopy. Asynergy is an expression of functional derangement and results in impaired myocardial performance. More accurate evaluation of asynergy requires left ventricular cineangiography, which should be performed when surgery---resection, revascularization, or both---is contemplated or when the nature of the myocardial abnormality is not clear from noninvasive studies. Angiography is essential for the diagnosis and management of such complications as rupture of the interventricular septum or severe papillary muscle dysfunction.

The scapular sign in rickets.

Rachitic changes in the inferior scapular angle are presented and discussed. These changes, whicli have not been described previously, are divided into three stages according to the severity of the disease. The importance of detecting rickets by observing scapular involvement on routine chest films made for other purposes is stressed. Cases showing regression of the changes after vitamin D therapy are presented.

Radiologic notes in cardiology: obscuration of the aortic knob in coarctation of the aorta.

Obscuration of the superior margin of the aortic knob together with a widening of the mediastinal shadow to the left is a common sign of coarctation of the aorta. It is easily seen on the routine frontal chest film and may be the first detected evidence of the lesion. Although the appearance is not pathognomonic of a coarctation, it certainly indicates the need for further studies.

Calcified mediastinal bronchogenic cysts.

THE DIFFERENTIAL diagnosis of mediastinal lesions is difficult because of the large number of anatomic structures contained within this small space and the homogeneity of tissue densities. Although numerous diagnostic technics may be employed, the location of the tumor still remains the most critical factor in arriving at the correct diagnosis. One of the few additional helpful features is the presence of calcification. Although numerous reports in the literature have been concerned with bronchogenic cysts, it was not until recently that Cornell (1) described milk of calcium layering within the lumen of two such cysts. This communication is the first report of the demonstration of radiographically detectable calcium within the walls of two bronchogenic cysts. Case Reports Case I: In this 43-year-old man a mediastinal mass was found on a routine chest film. Aside from episodic asthma of many years duration, the patient was asymptomatic. The findings on physical examination, laboratory investigation, bronchoscopy, and mediastinoscopy were normal. Radiographic studies (Fig. 1) showed a middle mediastinal mass, 8.5 cm in diameter, in the subcarinal region to the right of the midline, indenting the anterior portion of the esophagus. A thin, curvilinear calcification 5 cm in length was visible in the outer and inferior aspect of the mass. This calcification did not change shape or position with change in position of the patient, indicating that it was not milk of calcium. At exploratory thoracotomy the lesion was removed. Histologic examination revealed a bronchogenic cyst with a fibrous tissue wall lined by ciliated columnar epithelium. No cartilage was present. Calcium was noted within the wall of the cyst. CASE II: During a work-up for migratory joint pain, a mediastinal lesion was discovered on a routine chest film in this 23-year-old male. There were no respiratory symptoms except for a mild dry cough. Radiographic studies (Fig. 2) showed a middle mediastinal mass, 5 cm in diameter, in the subcarinal region, projecting to the right and indenting the right side of the esophagus. A thin, curvilinear calcification 3 cm in length was best seen in the posterosuperior portion of the mass on the ovcrpenetrated oblique film. At exploratory thoracotomy the lesion was removed. Histologic examination showed the wall of the cyst to be lined by ciliated columnar epithelium. It contained mucous glands and smooth muscle, but no cartilage was demonstrated on the available sections. Calcification was noted in the fibromuscular tissue of the cyst wall, beneath the epithelium. Discussion Mediastinal bronchogenic cysts are congenital in origin and result from abnormal budding or branching of the tracheobronchial tree (2). The majority of them are located in the vicinity of the trachea or main bronchi, although some may be far removed from this area (3, 5).

Epicardial fat: Lateral plain film analysis in normals and in pericardial effusion.

Before the advent of cinefluoroscopy, the diagnosis of pericardial effusions depended upon the demonstration of enlargement of the cardiac shadow, characteristic water-bottle configuration of the cardiac silhouette, and diminished pulsations of the left cardiac border at fluoroscopy. None of these findings is consistently reliable. Diagnostic pericardiocentesis, C02 cardiograms, and angiography are all definitive but involve certain risks. In 1955 the epicardial fat line in its relationship to pericardial effusions was described both by Torrance (1) and by Kremens (2). Their method of demonstrating the fat stripe by laminagraphy is unreliable, however, due to the long exposure time and motion of the heart. In 1962, Jorgens, Kundel, and Lieber (3) described the cinefluorographic approach using image intensification in cinefluoroscopy, which was considerably more reliable in diagnosing effusions; and since the time of their paper the emphasis in such a diagnosis has been placed upon cinefluoroscopy. It is evident from our experience that, with a good knowledge of the anatomy and relationships of the subepicardial fat, in conjunction with good quality lateral chest radiographs, the diagnosis and exclusion of pericardial effusions can often be made with consistent reliability. In addition, totally unsuspected effusions are often detected. Cross-sectional preparations of the anterior mediastinum near the diaphragm reveal the essential anatomic relationships observable on lateral chest radiographs (Fig. 1). Immediately posterior to the body of the sternum and somewhat laterally placed are the internal mammary vessels with an abundant amount of fat accompanying them. Immediately posterior to this fat lies anterior mediastinal fat, and beneath this lie the parietal and visceral layers of the pericardium, usually separated by a thin film of serous fluid normally present in the pericardial sac. Beneath the visceral pericardium (or epicardium) and slightly to the left of the midline lies the anterior descending branch of the left coronary artery. This vessel also has considerable perivascular fat, as does the right coronary artery, and so the anterior part of the heart is covered with subepicardial fat, often in great abundance. It would appear, therefore, that in a lateral radiograph of the chest these fat plains would be visible and distinguishable from the soft-tissue density of the heart and the bony structure, of the sternum. In addition, the two layers of pericardium will be depicted as a thin line of soft-tissue density interposed between the anterior mediastinal fat in front and the subepicardial fat behind (Fig. 2). In our experience we have noted precisely that relationship in approximately 40 per cent of the routine lateral chest films of patients without pericardial disease.

Survival in Males with Bronchogenic Carcinomas Resected as Asymptomatic Solitary Pulmonary Nodules

hen the diagnosis of lung cancer follows the development of symptoms, a large portion of patients already have inopW erable disease and many who may still have resectable pulmonary lesions have metastatic disease. The diagnosis of lung cancer by x-ray examination before the disease has progressed to the point of producing symptoms is an obvious approach in attempting to increase the operability rate and decrease the proportion of lung cancers which spread beyond the lung. The study reported here was designed to examine the value of this approach. A large-scale cooperative study was initiated in 1959 in a number of Veterans Administration and Armed Forces hospitals for the study of resected asymptomatic solitary pulmonary nodules 6 cm. or less in diameter in males, the nature of these nodules having been undiagnosed preoperatively. Cases were collected largely through routine chest films taken on admission to hospitals for diseases other than pulmonary or for pulmonary diseases unrelated to the nodule. The collection of cases of pulmonary nodules of various etiologies was discontinued in the spring of 1962, but patients with nodules which proved malignant were added to the study up to October 31, 1963. The first phase of the study has been reported previously [8, 91. The present report is concerned with 392 males with primary bronchogenic carcinomas appearing as asymptomatic solitary pulmonary nodules 6 cm. or less in diameter first diagnosed at thoracotomy.t Of the total of 392 patients, 22, or 5.6%, had unresectable lesions, giving a total resectability rate of 94.4%. The cancer was confined to the lung in 308 (78.6%); in 62 (15.8%) there was gross or microscopic evidence that not all tumor had been resected. The operative mortality

The internal thoracic muscle and the lateral chest roentgenogram.

To a large extent, the current rapid progress of thoracic surgery has both depended upon and stimulated sophisticated radiological diagnosis. As a corollary, there has been decreasing reluctance to perform exploratory thoracotomy when routine chest films disclose an abnormality of indeterminate nature. It is the purpose of this paper to emphasize the radiographic characteristics of the internal thoracic muscle (m. transversus thoracis), a structure frequently projected on lateral films of the chest and one that may engender needless concern or confusion. Awareness of the anatomic features of this muscle will generally permit its accurate identification on routine chest films without resort to complicated radiological procedures or surgery. Material and Method One hundred and twenty unselected lateral chest films were examined and evaluated with respect to the presence and characteristics of the density cast by the internal thoracic muscle. In addition, slips of accessible muscle were marked unilaterally with radiopaque clips in 24 patients undergoing thoracotomy (Figs. 2 and 3). The distribution of these clips in the lateral postoperative chest film was noted. As a further means of identification, breast plates obtained at necropsy were studied roentgenographically after the internal thoracic muscle had been superficially outlined by metal staples, subfascial instillation of barium sulfate, or intramuscular puncture with Dionosil Oily (Fig. 4). Discussion The internal thoracic muscle (M. transversus thoracis) may be briefly described in general terms as arising from the inner lower sternum, including the xiphoid, as well as from the sternal ends of adjacent costal cartilages. The slips course upward and laterally to insert on the inner surfaces of the second through the sixth costal cartilages and adjacent ribs. The muscle acts to draw the anterior portions of the ribs downward during respiration (2). Anatomically the muscle is quite variable, not only from individual to individual but usually between the sides in the same thorax as well (1) (Fig. 1). On 37 of 120 consecutive lateral chest roentgenograms, there were demonstrated identifiable shadows attributable to the internal thoracic muscle. Twenty-six were seen in men, and 11 in women. The heaviest shadows were cast on chest films of muscular males.

Carcinoma of the lung, including systemic manifestations

In summary, the incidence of lung cancer has greatly increased in the past 50 years. Long-term survival data is poor. Evidence now suggests that bronchogenic carcinoma may be a long time evolving and that significant extension or wide-spread metastases may be present by the time the patient develops the first symptom. The routine chest film is an unsatis-factory method of uncovering truly early lung cancer, and we may have to await the development of a better diagnostic test if real inroads are to be made into this calamity. On the other hand, at least in part, the epidemic nature of this disorder may be prevented by elimination of atmospheric pollution, especially the personal one represented in the present-day cigarette. Many systemic signs occur in relation to lung cancer that appear to be mediated or influenced by something that the tumor makes or possesses. These systemic manifestations may sometimes precede symptoms relative to the tumor and divert the clinician's attention from the thorax or other primary sites. Once recognized for what they are, these manifestations may prompt a search for the silent underlying malignancy. Furthermore, it is possible that these manifestations may act to hasten demise, and the patient may be significantly benefited if these abnormalities can be eliminated or improved.

CONGENITAL KINKING OF THE AORTA (PSEUDOCOARCTATION).

KINKING of the descending arch of the aorta is a condition that may cause serious difficulty in the interpretation of the routine posteroanterior chest film and lead to unnecessary exploratory thor...

AN UNUSUAL CASE OF HODGKIN'S DISEASE PRESENTING THE X-RAY APPEARANCE OF LUNG ABSCESS.

PREVIOUS publications have presented the incidence of pulmonary involvement as a feature of generalized Hodgkin disease, ranging from 30 to 40 per cent of autopsy cases. Hodgkin's disease limited initially to the lungs has been the subject of more recent publications. In 4 of these x-ray features of pulmonary cavitation were described, and the case reported below is the fifth of the pulmonary form of Hodgkin's disease brought to medical attention by a routine chest film that disclosed a lesion characteristic of lung abscess.Case ReportA 27-year-old Army specialist was admitted to Madigan General Hospital on July 10, 1962, . . .

VISUALIZATION OF THYROID TISSUE BY CONTRAST ANGIOGRAPHY.

The incidence and significance of thyroid gland opacification during angiography have been largely ignored in the literature. Ecoiffier, Baudey, and Picard demonstrated a thyroid tumor in the neck by retrograde aortography, but we have encountered no reports specifically dealing with opacification of thyroid tissue outside its normal site. It is the purpose of this paper to present 3 cases of thyroid tumor defined by intravenous angiography and to discuss opacification of the normal thyroid gland. Case Reports Case I: E. W., a 67-year-old female admitted for an unrelated disorder, was found roentgen-ologically to have a widened superior mediastinum. A goiter had been present for several years but had “disappeared” from the neck some months previously. There were no symptoms except for slight fullness in the chest during swallowing. The patient was aware of relative prominence of the veins of the chest and neck on the right side. The venous pressure in the right arm was higher than that in the left. Bilateral manual injections of contrast material into the antecubital veins with the patient in the sitting position resulted in the angiogram reproduced in Figure 1. At surgery, the right lobe of the thyroid, which projected into the superior mediastinum, was removed. It weighed 151 gm. Histologic diagnosis: Thyroid with follicular and microfollicular hyperplasia. Case II: R. C., a 29-year-old female, had an anterior mediastinal mass discovered on a routine chest film. The history, physical examination, and laboratory studies were normal. At fluoroscopy, the mass was noted to pulsate, and it appeared to decrease in size during performance of the Valsalva maneuver. Figure 2 illustrates the findings on angiocardiography. At thoracotomy, the mass was localized in the superior-anterior mediastinum, projecting into the left chest. It was invested by a thin layer of parietal pleura. Its vascular supply arose from communications with the internal mammary artery. The tumor was removed in toto and weighed 33 gm. Histologie diagnosis: Maturing microfollicular (fetal) thyroid adenoma. Case III: S. M., a 71-year-old female, had a well differentiated follicular adenocarcinoma of the thyroid gland diagnosed at the time of partial thyroidectomy, Oct. 19, 1961. On Dec. 14, she was admitted with a tender pulsating mass in the pelvis, palpated on rectal examination and thought to be an aneurysm of the right hypogastric artery. A film of the pelvis (Fig. 3,A) revealed a lytic destructive lesion in the sacrum on the right. Therapy up to this time had consisted of 5,000 r external radiation to the neck and 75 millicuries of I131. Intravenous angiography (Fig. 3,B) outlined a large round “tumor stain” in the pelvis adjacent to the right hypogastric artery and superimposed upon the lytic area in the sacrum.

A correlative study between the radiologic and pathologic diagnoses of atherosclerosis of the aorta

1. 1. The pathologic and radiologic findings of atherosclerosis of the aorta have been compared in 190 subjects who were over the age of 30 years. 2. 2. The reliability of the radiologic signs of atherosclerosis has been discussed and attention drawn to the positive diagnostic value of elongation and calcification, and the unreliability of dilatation of the thoracic aorta. The presence of calcification alone does not indicate the presence of severe aortic atherosclerosis. 3. 3. Routine posteroanterior chest films constitute a useful and easily applicable procedure in the detection of aortic atherosclerosis.

Calcification of the Aortic Knob: Its Relationship to the Fifth and Sixth Embryonic Aortic Arches

Calcium deposits in the wall of the thoracic aorta constitute a frequent radiological observation in older persons and are considered to be a manifestation of arteriosclerosis (8, 13, 14). They may be widely distributed or concentrated in a small area (8). Very often the calcifications are seen in the aortic arch (8, 14). In the postero-anterior chest film they are visualized in the aortic knob as a comma-like (13), sickle-shaped (8, 14), or circular (14) opacity of calcific density. In the oblique position, more extensive calcifications of the thoracic aorta may be demonstrated as linear shadows or scattered clumps (14). Semicircular calcifications in the aortic knob have also been observed in patients with patent ductus arteriosus (4, 5, 7, 10). It has even been suggested that they may constitute a confirmatory sign of patent ductus in young persons, in whom the presence of calcification from arteriosclerosis would be unlikely (10). Our own experience, confirming the frequency of calcifications in the aortic arch in older persons, as well as its occurrence in patients with patent ductus arteriosus (Fig. 1), provided the incentive for this study. It was our purpose (a) to identify the site of preference of calcium deposition, (b) to investigate the nature of this finding, and (c) to explain its radiological appearance. Material And Methods Tomographic examinations in the anteroposterior and latero-oblique projections were made in 27 patients in whom a calcium-dense opacity at the aortic knob was demonstrated on a routine chest film. In addition, 100 aortic arch specimens were obtained from consecutive autopsies, fixed in formalin, and studied radiologically in three projections: “lateral” with the specimen lying on the film-holder; “anteroposterior,” with the aortic arch held fast by a clamp in a position similar to that in the thorax; “open”—after a lengthwise incision through the brachiocephalic vessels— with the specimen fixed on a cork plate by needles. Every specimen was subjected to gross macroscopic examination and was transilluminated and photographed. Thereafter, tissue was excised for histologic examination. Tomographic Features in the Patient Group Tomograms of patients taken in the anteroposterior projection demonstrated that the calcium-dense opacities were practically always situated in the wall of the aorta. The extent of calcification varied greatly. Small calcific densities are situated in the ventral part only; larger deposits extend from the ventral part to the left lateral wall, while still larger ones include the dorsal wall and may involve the entire circumference of the aorta (Fig. 2, A-D). The deposits were spot-like, comma-like, sickle-shaped, or circular.

Subpleural lipoma.

Lipomas, which are relatively common in the subcutaneous tissues, occur only rarely in the thoracic cavity. In this position, they are usually related to the mediastinum (6, 7, 8, 12). Even rarer is the occurrence of subpleural or parietal tumors unconnected with the mediastinum. Three such cases were treated in The New York Hospital during the past five years. Case Reports Case I (Fig. 1): A 14-year-old white boy was admitted to the hospital because of an abnormal routine chest film, which had been taken two weeks previously. It demonstrated a 4 × 7 × 8-cm. density in the right posterior chest wall, opposite the sixth rib interspace. There was localized widening of the rib interspace with attenuation of the adjacent sixth and seventh ribs. On physical examination, a firm, nontender, 4 × 4-cm. mass was found to the right of the spine at the midscapular level, corresponding in position to the density on the chest film. At operation a large, yellow, fatty, dumbbell-shaped mass was found, extending from outside the chest wall through the sixth interspace into the posterior thoracic cavity. The entire mass was excised, and the pathological report was lipoma. Case II (Fig. 2): A 72-year-old white woman was admitted to the hospital without complaints. Two weeks prior to admission she fell, and roentgenograms were taken of the right shoulder for possible fracture. There was no evidence of bone injury, but a density was fortuitously discovered in the right chest. It measured 2 × 3.5 cm. and was adjacent to the lateral chest wall. Exploratory thoracotomy was undertaken and revealed a yellow, encapsulated, subpleural mass. Its base was in the intercostal space but did not penetrate it. The mass was resected and the pathological report was lipoma. Case III (Fig. 3): A 69-year-old white woman was admitted to the hospital for a retinal detachment. A routine chest film revealed a 3.5 × 4-cm., sharply circumscribed density in the left upper lung field adjacent to the lateral chest wall. A left thoracotomy was performed and a soft subpleural mass was found bulging into the pleural cavity. The mass, which did not penetrate the rib interspace, was completely removed. The pathological report was lipoma. Discussion Heuer (6, 7) divided intrathoracic lipomas into three groups: (a) hourglass tumors consisting of an intrathoracic and extrathoracic mass connected by a thin isthmus perforating the thoracic wall between the ribs; (b) anterior superior mediastinal masses which extend up into the root of the neck, presenting as visible and palpable tumors; (c) wholly intrathoracic masses, which are most commonly related to the mediastinum. Those masses separated from the mediastinum have been designated as subpleural lipomas and may be located beneath the costal or diaphragmatic pleura (2, 13). They are rare in the latter location.

Recognition of infrapulmonary pleural effusion.

Pleural effusion of the infrapulmonary type, though common, may not be recognized by conventional radiographic studies of the chest until the fluid has increased to considerable proportions. In its subpulmonary, basal, or diaphragmatic position the fluid forms as a layer in the pleural space between the concavity of the undersurface of the lung and the convexity of the dome of the diaphragm. In this position it is often overlooked because it masquerades as an elevated diaphragmatic leaf. The films are frequently interpreted as indicating elevation of the diaphragm with a small amount of fluid in the costophrenic gutter, whereas in fact the diaphragm lies at a normal or lower than normal level, and the quantity of fluid present is large. An observer who is suspicious of every apparent elevation of the diaphragm and cognizant of the appearance and diagnostic meaning of minimal amounts of fluid will discover that infrapulmonary effusion, although generally considered rare, is rather unrecognized than unusual. The cases presented in this paper were drawn from a larger group representing the general practice of radiology. Twenty-five2 were selected for study because of excellence of film quality or because particular features were demonstrated or special diagnostic procedures had been performed. Ten cases were associated with heart disease, 7 with malignant neoplasm, 4 with hypoproteinemia (nephrosis, cirrhosis), and 4 with inflammatory pulmonary or pleural disease. In 5 patients the process was bilateral; of the 20 with unilateral involvement, the effusion was on the right side in 14 and on the left in 6. Only 1 of the group was followed to autopsy. In this instance, films taken before death showed bilateral infrapulmonary effusions. At autopsy, although the costal pleura was studded with tumor nodules, the visceral pleura was normal and there were no interpleural adhesions (Fig. 7). Roentgen Manifestations of Infrapulmonary Effusions Although the true nature of the infrapulmonary effusion will declare itself when studied by particular technics, its prompt recognition from routine chest films is of value. A number of characteristic signs may establish the diagnosis. From this selected group of cases the roentgen manifestations of the disease processes both on conventional examinations and by special technics have been determined, and the findings are presented. Typically an infrapulmonary effusion presents itself in the postero-anterior upright projection as an apparently elevated leaf of the diaphragm, with a contour similar to a diaphragmatic shadow and just as sharply outlined. Hessén (11) described a characteristic form of this pseudo-diaphragmatic shadow (not always present) which suggests effusion. There is a gradual inclination upward and laterally from the cardiac shadow, with a rather abrupt drop near the costal margin to form a sharp gutter similar to a normal costophrenic angle (Fig. 1, A).

Radiologic aspects of stab wounds of the chest.

The purpose of this paper is to describe the significance of initial roentgenograms following stab wounds of the thorax and to emphasize the importance of follow-up examinations in certain circumstances. The material is dealt with under three topographical areas: supraclavicular and mediastinal; pericardial; lower thoracic. Supraclavicular and Mediastinal Wounds Stab wounds of the supraclavicular region may be quite deceptive to the clinician on cursory examination; yet a roentgenogram of the chest, usually ordered to determine whether or not pneumothorax is present, may demonstrate widening of the superior mediastinal shadow resulting from hemorrhage into the mediastinum. Hemomediastinum leads rapidly to compression of the great veins and the atria of the heart, having the same effect as acute cardiac tamponade. Usually, as pressure in the mediastinum mounts, the mediastinal pleura ruptures and associated hemothorax develops. Case I: A 34-year-old colored male sustained a stab wound of the left supraclavicular region. There was no evidence of shock and he was in good general condition. A chest film taken for assessment of possible pneumothorax (Fig. 1, A), showed widening of the superior mediastinal shadow, particularly on the left side, and separation of the fundus of the stomach from the base of the left lung. These changes were interpreted as indicating hemomediastinum and hemothorax at the left base. Surgical exploration of the supraclavicular area showed that the subclavian artery had been damaged, and a branch just distal to the thyrocervical trunk had been severed completely. Profuse bleeding occurred, requiring thoracotomy for control. Twelve hundred cubic centimeters of blood was removed from the pleural cavity and the mediastinum. Figure 1, B shows the appearance of the chest one week later; the mediastinum was now normal in appearance, with residual pneumohemothorax. Comment: It should be noted that the changes at the left base represent blood collected beneath the base of the left lung, rather than an elevation of the left leaf of the diaphragm, which could be postulated on the basis of proximity of the wound to the phrenic nerve. The diagnosis of hemothorax is based on the finding of significant separation of the fundus of the stomach (as outlined by gas in the stomach) from the air-filled base of the lung. This is not an uncommon finding in hemothorax and can be confirmed in cases of doubt by an anteroposterior supine film of the chest. In this projection the blood will be seen to have become dispersed over the surface of the lung if the shadow indeed represents blood beneath the pulmonary base. This same appearance may occasionally be seen in routine chest films of normal children and, in rare instances, in normal adults, due to interposition of the left lobe of the liver, spleen, or splenic flexure of the colon between the fundus of the stomach and the left leaf of the diaphragm (Fig. 1, C and D).

Early Diagnosis and Treatment of Tuberculosis in Children

Este trabajo pretende describir el consumo de tabaco, de alcohol y de drogas no institucionalizadas entre la población escolarizada española pre-adolescente y adolescente a mitad de los años noventa (en 1994).La información ha sido recogida en el marco de un estudio transversal periódico sobre los estilos de vida de los escolares europeos, con énfasis particular en los hábitos relacionados con la salud. En el presente trabajo se presentan resultados de la última encuesta realizada en España dentro de este estudio (1994), con una muestra representativa del alumnado español de 11, 13, 15, 17 y 18 años de edad (n = 6.711). Se utilizó un cuestionario anónimo que los propios alumnos cumplimentaron en sus aulas. El sistema de muestreo ha sido aleatorio, estratificado, proporcional, polietápico y por conglomerados.En 1994, el 49% del alumnado español de las edades citadas ha probado el tabaco. El 24% lo fuma esporádica o regularmente. La proporción de chicas fumadoras es mayor que la de los chicos (27% frente a 20%). La proporción de fumadores pasa de un 3% a los 11 años a un 47% a los 18 años. Un tercio (33%) del alumnado de 18 años fuma diariamente.El 84% del alumnado de las edades estudiadas manifiesta haber probado uno o varios tipos de bebidas alcohólicas. El 21% las consume regularmente (al menos una vez a la semana). Este tipo de consumo regular es algo más frecuente entre los chicos (24%) que en las chicas (19%). El 46% del alumnado de 18 años consume bebidas alcohólicas regularmente y el 66% se ha embriagado una o más veces.Casi la quinta parte (18%) del alumnado de 13 a 18 años manifiesta haber probado algún tipo de droga no institucionalizada, mientras que el consumo actual se reduce al 8%. La cannabis es la droga que más alumnos han probado (18%) y la más consumida actualmente (8%), seguida por la cocaína y la heroína. Los chicos han probado drogas no institucionalizadas en mayor proporción que las chicas.El análisis de los datos muestra que el tabaquismo adolescente afecta cada vez más a las chicas. El consumo de alcohol sigue ampliamente generalizado entre los pre-adolescentes y adolescentes españoles. Se inicia en la infancia y se arraiga y consolida en la adolescencia. Los resultados sugieren, en relación a las diferencias de género en el consumo de tabaco, de alcohol y de drogas no institucionalizadas, que hay una fuerte tendencia a la homogeneización entre ambos sexos a este respecto. Es necesario enfatizar las medidas preventivas de las drogodependencias entre los pre-adolescentes y adolescentes españoles.This study was undertaken in the mid-1990s (1994) to describe the use of tobacco, alcohol, and non-institutionalized drugs among pre-adolescent and adolescent spanish students.Information was collected within the framework of a periodic transversal study of life styles among European students, with particular emphasis on health-related habits. In the current study we present the results of the last survey carried out in Spain within the context of this study (1994), which involved a representative sample of Spanish students 11, 13, 15, 17 and 18 years-old (n = 6,711). An anonymous questionnaire was completed by the students in class. The survey sampling uses proportionate stratification and multistage sampling.In 1994, 49% of the Spanish students in this age group had tried tobacco. Twenty-four percent were sporadic or regular smokers. There was a large proportion of female smokers than male smokers (27% vs 20%). The overall proportion of smokers increased from 3% at 11 years to 47% at 18 years. One third (33%) of the 18-year-old students smoked daily.Eighty-four percent of the students of this age indicated that they had tried one or more types of alcoholic beverage. Twentyone percent consumed alcohol regularly (at least once a week). Regular alcohol use was somewhat more common among males (24%) than among females (19%). Forty-six percent of the 18-year-old students consumed alcoholic beverages regularly and 66% had been intoxicated one or more times.Almonst one fifth (18%) of the 13-to-18 year-old students indicated that they had tried some type of non-institutionalized drug, although the current rate of consumption was 8%. Cannabis was the drug most frequently tried (18%) and the drug most often consumed at present (8%), followed by cocaine and heroin. More males than females had tried non-institucionalized drugs.Analysis of the data revealed that adolescent tobacco use is increasingly frequent among females. Alcohol use continues to be widespread among Spanish pre-adolescents and adolescents. Alcohol use begins in childhood and becomes consolidated in adolescence. The results suggest, in relation to gender differences in the use of tobacco, alcohol, and non-institucionalized drugs, that there is a strong tendency toward the homogenization of these habits between genders. It is necessary to emphasize the preventive measures of drug dependence among Spanish pre-adolescents and adolescents.