Anomalies of the position of the kidneys are not infrequent. Ectopic kidneys usually are found in the pelvis, the iliac or low lumbar region; high ectopia, in which the kidney lies in the thorax, is a rarity. Gruber (3) in 1927 had collected from the literature 11 cases of partial or complete thoracic ectopia of the kidney observed exclusively in fetuses or stillborn children; in 2 the anomaly was on the right, in the others on the left side. Kleine (6) in 1928 added a case of thoracic ectopia of the left adrenal and upper pole of the kidney in a newborn female, and Campbell (2) in 1930 found most of the left kidney protruding through a large defect in the diaphragm, in a one-year-old male child who died of marasmus. In many instances other malformations, particularly thoracic displacement of other abdominal viscera, were also present.2 Case Report E. Z., a 65-year-old woman, was first seen in 1942 because of severe upper quadrant pain and jaundice. No opaque gallstones were visible. The gallbladder could not be demonstrated by cholecystography. Roentgen examination of the chest revealed a hemispherical soft-tissue mass protruding above and apparently resting upon the right diaphragm in the posterior medial portion. It was 6 cm. in diameter. The diaphragm showed a normal descent on deep inspiration, while the protruding mass seemed to follow the slight upward movement of the lower ribs. The findings were interpreted as indicating diaphragmatic hernia or, less probably, a tumor of unknown nature (Fig. 1). No further investigation was undertaken. The patient was seen repeatedly in the Out-Patient Department and the previous findings were confirmed. She was readmitted in April 1947 because of another severe attack of epigastric and right upper quadrant pain with jaundice. The icteric index varied from 8 to 54. The patient also had asthma and angina pectoris. Intravenous urography identified the herniated mass as the right kidney. The upper pole lay at the level of the upper edge of the 10th thoracic vertebra, the lower pole at the level of the upper edge of the 3rd lumbar vertebra. The lateral view revealed the kidney lying on the posterior portion of the diaphragm close to the posterior chest wall. The calyces and pelvis were normally outlined (Fig. 2). The left kidney was low in position, the lower pole being about 3.5 cm. below the iliac crest. Other than the abnormally high position of the right kidney, there was no evidence of gross abnormality of the upper urinary tract. Examination of the stomach revealed a small hiatus hernia, with reflux of gastric content into the esophagus. Cholecystectomy for chronic cholecystitis and cholelithiasis was performed. During the operation, the right kidney could not be felt in its normal position. No attempt was made to examine the ectopic kidney and the right diaphragm. The patient recovered uneventfully and was reported in fair health a year later.
(a) Fluorocardiography during normal respiration is possible by the use of an additional electrical filter, the physical basis and principle of which are given.
In the early period of the development of roentgen diagnosis, the impact of new impressions and the urgency to use these in diagnosis led to important discoveries in the field of anatomy, physiology, and pathology, but at the same time there were often unfounded interpretations. It was soon recognized that a close correlation of roentgenologic observation with morphologic and functional facts was a prerequisite to the intelligent use of this new tool, and early research started in two directions. First, it was necessary to translate the details of the "shadow-pictures" into terms of normal and morbid anatomy. On the other hand, many significant details visualized by fluoroscopy or on roentgenograms were not given sufficient attention in the traditional anatomical and pathological descriptions, or were presented in such a way that correlation between roentgenogram and anatomical preparation was not feasible, and comparative roentgen-anatomical studies had to be undertaken to create the fundamental basis of roentgenology. Stimulated by the increasing detection of disease of the ileocecal valve and adjoining structures and by the number and range of variations in this region, with no distinct borderline drawn between normal and abnormal, we have undertaken a comparative roentgen-anatomical study of this area. The present paper deals with the normal ileocecal valve and its variations. A considerable amount of pathological material has also been accumulated due to the interest of the senior author (F. G. F.) in this problem, dating back to before 1928 (4), and this will be the subject of a later presentation. Material and Method In fifty consecutive autopsies the apparently normal ileocecal area was removed en bloc after sectioning of the ascending colon and terminal ileum. The bowel was filled with formalin solution, tied off at both ends, and immersed in formalin for several days. In many instances, after this initial fixation, the specimen was filled with barium and an anteroposterior roentgenogram was taken to simulate the view obtained in a barium-enema examination. Thereafter, the barium within the specimen was evacuated and replaced by air so that double-contrast roentgenograms could be obtained. As the next step, the specimens were opened by an initial incision from the upper cecum, along its lateral aspect, and the ileocecal valve projecting from the opposite medial wall was inspected, measured, sketched, and in many instances photographed. The incision was then extended in the coronal plane to reach the medial wall of the cecum and bisect the ileocecal valve and terminal ileal loop. Further measurements, drawings, and photographs were obtained of the posterior half of the specimen, which is most comparable to the clinical roentgenogram. In individual instances the dissection was modified in order to expose particular features. Histologic sections of the valve and its immediate vicinity were obtained in a considerable number of cases.
Pulmonary microembolism has been increasingly recognized as a significant clinical problem (1, 2). Although the manifestations of massive pulmonary embolism have been carefully characterized, little investigation of the problem of multiple small pulmonary emboli has been carried out. Because the majority of emboli lodge in arteries smaller than 1 mm in diameter (3), they escape detection by the usual radiographic and arteriographic methods. Isotope scintillography, however, offers a method by which the perfusion abnormalities caused by these pulmonary microemboli may be depicted. Observation In patients with pulmonary microemboli, lung scintigrams obtained by using the “gamma camera” have shown a circumferential zone of diminished radioactivity in the periphery of one or several lobes (noted by M. S. P.). The diminished activity may be apparent around the entire circumference of a lobe, causing a “shrunken lobe” (Fig. 1) or may be identified only where accentuated by normal radioactivity in adjacent lung, resulting in “fissural visualization” (Fig. 2). This peripheral border or “peel” of diminished activity on the scintigram is postulated to represent decreased perfusion which results from microemboli lodging in small peripheral pulmonary arteries (4). Method To investigate the mechanism for circumferential diminished perfusion we are studying, in large mongrel dogs, the effects of intravenous administration of polystyrene microspheres from 1 mm to 0.147 mm in diameter, followed at projected time intervals (several minutes to two weeks) by 131I macroaggregated albumin (150 microcuries 131I MAA) (6, 7). In situ pulmonary radiographs (Figs. 3, A and B) and photoscintigraphs (Figs. 3, C–E, and Fig. 4) are then obtained. The animals are sacrificed, and the heart and lungs are removed intact. The pulmonary arteries are injected with a modified Schlesinger mass (8) and the lungs are inflated with 20 per cent formalin. Radiographs of the injected lungs are then obtained (Figs. 5, A and B). Results By this method we have been able to duplicate the scintigraphic pattern of circumferential hypoperfusion with “fissural visualization.” The linear areas of diminished radioactivity (Fig. 4) correspond to the anatomical divisions of the dog's lung and represent the experimental model of diminished radioactivity surrounding a fissure. The radiographs of the injected specimens demonstrate why the radioactivity does not reach the periphery of each lobe via the pulmonary arteries (Fig. 5, B). Those animals in which the microspheres have been injected do not have filling of the peripheral branches with the modified Schlesinger mass as in the animal without microspheres (Fig. 5, A). The effect of pulmonary microemboli appears to be primarily mechanical vascular obstruction (4) although the role of arteriolar vasoconstriction and bronchial collaterals (5) has not been defined.
Pulmonary embolism, with or without infarction, is now recognized in life as well as at autopsy. Only recently, however, has the frequency of nonfatal embolism been appreciated. As awareness has increased, the diagnosis is more often made, in some hospitals ten times as frequently as only a few years ago. The recognition of an infarct, providing almost conclusive evidence of embolism, is the most important roentgen contribution to the diagnosis of pulmonary embolism. Less conclusive signs are pleural effusion, inhibited respiration, often accompanied by atelectasis, acute pulmonary edema, and the signs of acute and chronic cor pulmonale or pulmonary hypertension, including also roentgen evidence of the oligemic lung field and the plump hilar shadow (1–5). An additional observation made in massive unilateral embolism is the subject of this report. Observations Case I: A man aged 39 years was hospitalized for severe idiopathic ulcerative colitis. At that time, Feb. 8, 1956, a routine chest roentgenogram was normal (Fig. 1A). Two weeks later thrombophlebitis developed in the right foot and ankle. On March 16 a sudden sharp right chest pain occurred, with a dry cough. The roentgenogram showed gross changes (Fig. 1B). The right hilar shadow was plump and the bronchial interhilarcardiac zone was obscured. The hilar shadow was less clearly articulate than before. The right lung field showed increased radiance. In the right upper and midlung fields the vascular shadows had almost completely disappeared; in the lower lung field there were narrower vessels, mostly veins. The left lung field contrasted with this right oligemia. The hilar vessels, well articulated, were widened, and dilated vessels were visible, mainly in the mid and lower lung fields, denoting pleonemia2 of the left lung. The diaphragm on both sides was moderately elevated. The cardiac silhouette was dilated, measuring 14.0 cm. across the base, compared with an earlier measurement of 12.9 cm.; suggesting right ventricular dilatation. No further embolic episode occurred under anticoagulant treatment. Five months later (Fig. 1C) the hilar shadows had returned to normal width and configuration. The right upper lung field still showed slightly increased radiance. Otherwise, however, the peripheral pulmonary vessels had returned to even and symmetrical width and distribution. The comparison of the pre-embolic roentgenogram (Fig. 1A) with that at the height of the embolic episode (Fig. 1B), and another five months later (Fig. 1C), clearly reflects the pathologic sequence. In B an embolus had lodged in the right pulmonary artery. The mechanical obstruction and vasoconstriction of the peripheral arteries prevented blood flow to the right lung, which appeared oligemic. The right hilar shadow was increased in size, due either to the embolothrombus lodged there or to the pulmonary hypertension, or to both.
The occurrence of multiple malignant tumors has always attracted the interest of pathologists and clinicians. The problem consists in determining whether the development of a second growth is entirely independent of the first, unrelated either to metastasis or to recurrence following incomplete eradication. In the case of carcinoma of the colon, a particular type of local recurrence has recently been observed. As pointed out by Cole (1), such a carcinoma, even after ample resection, may recur at the site of anastomosis. Goligher, Dukes, and Bussey (2) have also been impressed with the frequent recurrence of carcinoma—particularly carcinoma of the sigmoid and, to a lesser degree, of the descending colon—at the site of the end-to-end anastomosis. Since we have been unable to find any discussion of this problem as it concerns the roentgenologist, our observations are presented. Case I: S. G., a 68-year-old woman, had a constricting annular mucoid adenocarcinoma of the mid-portion of the descending colon, which was resected in 1949 with sleeves of healthy colon, 17 cm. proximal and 5 cm. distal to the lesion. On a routine re-examination in 1950, small irregularities at the site of the end-to-end anastomosis were noticed. These became more pronounced in 1951 and still more so in 1952. Because of the original resection of a wide portion of healthy tissue and the complete freedom from symptoms, the changes were for a long time considered to be due to the surgical intervention. A local recurrence was suspected only when more irregularity and an annular stricture were observed at an examination three years after the operation (Fig. 1). A penetrating colloid adenocarcinoma at the site of the anastomosis was successfully removed on Jan. 11, 1953. Case II: N. S., a 70-year-old woman, was examined because of massive rectal bleeding. A lobulated pedunculated lesion 2.5 cm. in diameter with a stalk 4 cm. in length was discovered in the mid-sigmoid (Fig. 2A). At operation, Oct. 4, 1950, a segment of the sigmoid, including 5 cm. on either side of the insertion of the polyp, was resected and an end-to-end anastomosis performed. Grossly, the lesion was a pedunculated polyp but histologically the lobulated head was found to be a colloid adenocarcinoma, which did not invade the stalk. Several benign polyps were removed from the rectum. The patient was again seen for rectal bleeding in January 1953. Roentgen examination now revealed an annular, moderately constricting lesion in the mid-sigmoid, apparently about the site of the anastomosis (Fig. 2B). On Jan. 23, another sleeve resection of the sigmoid was performed. The pathologist described the lesion as an adenocarcinoma, recurrent at the site of the earlier anastomosis and spreading to the serosa (Fig. 3). Case III: J. S., a 70-year-old woman, underwent a resection of the sigmoid for an annular carcinoma in July 1952. A recurrence was observed in December 1952, less than six months postoperatively.
