SummaryThe temporal relation between the contractions of the left and right heart chambers was studied by means of fluoro-cardiography and simultaneous recording of 2 pulse tracings on one strip. The study was performed on 8 normal subjects and included the observation of the pulsations of the aorta and the pulmonary artery, both auricles and both ventricles. In all observations the contraction of the right auricle preceded that of the left auricle and the contraction of the right ventricle that of the left. The delay of action of the left chambers was found to be between 25 and 30 milliseconds.
THE diagnosis of acute and subacute pancreatitis is often difficult. It is well known that ascites accompanying pancreatitis often contains considerable amounts of amylase. It is less widely appreciated however, that pleural effusion, which frequently occurs with pancreatitis, also contains amylase. Although this fact is not mentioned in recent reviews of pancreatitis1 2 3 4 5 individual positive observations have been reported by Kalser et al.,6 Palmer,7 Werner8 and Roseman, Kowlessar and Sleisinger.9 According to Hammarsten, Honska and Limes,10 who recently collected 7 cases from the literature and added 4 cases of their own, the amylase content of pleural fluid in the acute phase . . .
It is generally agreed that there are no uniformly pathognomonic roentgenologic signs of intrathoracic lymphomas, and that many different types of change may be encountered (9). Previously, investigators (5, 9) have classified the changes generally encountered into six groups: (1) mediastinal tumor; (2) hilar lymphonodular masses; (3) diffuse infiltration of lung parenchyma; (4) isolated nodules in the parenchyma; (5) pleural infiltration; (6) pleural effusion. In our cases of the intrathoracic lymphoma group, we have occasionally observed a retrosternal infiltration, occurring alone or in conjunction with one or several of the usually noted localizations of lymphoma, but not previously described as such. It has been found with and without associated sternal involvement and pre-sternal edema, and in all types of cases classified under the broad heading of malignant lymphoma. Pathology Lymphoid tissue involvement is the common denominator of the lymphoma group and, as Wolpaw et al. (10) have stated, “…the character of the disease in any organ or region of the body will therefore be determined by the location of its lymphoid tissue and the degree to which it is affected by the etiologic factor.” The retrosternal lymphoid tissue distribution is primarily represented by the bilateral, symmetrically arranged internal mammary chain of nodes, receiving afferent tributaries from the anterior parietal pleura and subpleural network on the pulmonary side, from the pericardium, and from the medial part of the chest wall via the intercostal lymph vessels. The bronchomediastinal trunks may also terminate by uniting with the internal mammary chains (Fig. 1) (8). It thus becomes evident that retrosternal involvement may be readily correlated with the anatomical distribution of lymphoid tissue within this region of the chest, arising as a frequent and often early extension from previously affected intrathoracic structures or by invasion from metastatic bone marrow foci in sternum and ribs, and possibly, also, as a primary focus. Dresser and Spencer (4) and others (2, 3, 10) have noted that the sternum and ribs are favorite sites for bone involvement by lymphoma. From the facts presented above, it would seem likely that retrosternal infiltration might be encountered as a preliminary stage before actual bone infiltration, or as part of the soft-tissue reaction secondary to a preceding bone lesion. Several cases have been reported in which massive pulmonary involvement caused tough adhesions of granulomatous tissue to bind portions of the lung solidly against the chest wall, and in some of these cases the process extended transpleurally into the contiguous ribs (9). Bone involvement in malignant lymphoma has been known for a long time, with the sternum, ribs, vertebral spine, and pelvis being most frequently affected. In one series showing bone changes, the lesions appeared early in the course of the disease in nearly 25 per cent of the cases (4).
This essay is presented in an attempt to harvest for the pathology of bronchiectasis knowledge gained since the advent of bronchography twenty-five years ago. “There appears to be no unanimity of opinion regarding anything about bronchiectasis with exception of the definition. All seem agreed that bronchiectasis is nothing more than a condition in which the bronchi show an abnormal dilatation,” was the conclusion in a recent paper on bronchiectasis (21). Even that statement is inaccurate, however, for it has been declared by others that “a bronchiectatic cavity is not a dilated bronchus, but an excavation in the lung substance, starting in a bronchus” (24). It has been widely contended that inflammatory damage to the structures of the bronchial wall precedes dilatation of the bronchi. On the other hand, in surgical specimens, dilated bronchi are often found to have grossly intact walls. In view of such basic misunderstandings, the present analysis must start with an examination of the terminology. It should be stated at the outset that this discussion will deal with bronchiectasis and not with chronic bronchitis. It is generally accepted that irreversible dilatation of the bronchi makes for persistence of infection. Perry and King (29) believe that chronic infection, particularly in such dilated bronchi, determines the serious prognosis as to health and longevity. It seems worth while, therefore, to understand why bronchi become dilated, with the hope that we may counteract this development. Definitions Etymologically, bronchiectasis represents a combination of the words bronchus and ectasis, i.e., dilatation of bronchi. The term is commonly used for the disease entity; occasionally “a bronchiectasis” (plural: bronchiectases) stands for the individual dilated bronchus. The pathologist defines bronchiectasis as a condition characterized by dilatation and usually infection of the bronchi. He recognizes a pulmonary cavity as a dilated bronchus by certain criteria. A cavity in communication with the bronchial tree with a wall composed of bronchial elements might be expected to be a dilated bronchus. Most or all of these bronchial parietal elements, such as mucous membrane, cartilage, smooth muscle, elastic tissue, and mucous glands, must be present in an orderly arrangement. It is not enough to find fragments of muscle or cartilage somewhere in the neighborhood of a cavity; such debris is often encountered in cases of suppurative pulmonary disease and the resultant fibrosis, even though the disease did not originate from bronchi or did not dilate them. By itself, the epithelial lining of a cavity obviously does not characterize it as a dilated bronchus. The following definition is suggested: Bronchiectasis is a condition characterized by dilatation of bronchi.
There has been increasing recognition in recent years that an ileostomy, indispensable in the management of many patients with ulcerative colitis, often leads to a formidable array of serious difficulties, alluded to in Bargen's assertion that “…success of the surgical therapy of chronic ulcerative colitis is still sharply limited by the problems associated with the ileac stoma” (1). Rogers, Bargen, and Black, in a review of the clinical courses of 124 patients in whom ileostomy had been performed at the Mayo Clinic during the period 1940–49, found that patients who survived the operation one year with no serious complication represented but 14 per cent of the entire group (2). Warren and McKittrick, in a study of the Massachusetts General Hospital cases, have noted a similar incidence of ileostomy difficulties (3). The complications of ileostomy are numerous, including major skin excoriations, wound dehiscence, fistulas, prolapse, retraction, and the syndrome of obstruction with prestomal ileitis and fluid and electrolyte imbalance, aptly termed by Warren and McKittrick “ileostomy dysfunction.” This complication, sometimes life-threatening and even fatal, has been reported by Warren and McKittrick in 62 per cent of their patients. Rogers and his associates found intestinal obstruction of marked degree in 46 per cent of their patients and minor degrees of obstruction in many more. Similarly, Colcock and Mathiesen had a 46.3 per cent incidence of obstruction in their ileostomy series (4). Partial or complete obstruction may occur in the early postoperative period. This report, however, deals with the later chronic or relapsing ileostomy dysfunction. Over the years, one of us (F. G. F.) has been called upon from time to time to undertake roentgen examinations in ileostomy patients to demonstrate the site and nature of an apparent obstruction, for which the stoma seemed too patulous to be responsible. Other patients were studied because of severe nutritional depletion or marked abnormalities in ileal discharge. In none of our cases could a cause of obstruction be found in the more proximal portions of the intestine, and the impression was gained that the malfunction was related to the cutaneous ileostomy ring and the dilatation encountered immediately proximal to it. The relative narrowness of the ring, together with diminution or absence of propulsive capacity of the terminal ileum, appeared to be responsible for the dysfunction. These observations prompted a roentgen study of the morphology and function of the small intestine in subjects with a well functioning ileostomy (5). The transit time for orally administered barium and the motility pattern of the small intestine were found to be the same as in normal subjects. The lower ileum was capable of inspissating its contents to soft-solid fecal masses. The prestomal ileum, visualized by barium enema through the ileostomy, was normal in width and contour and showed a normal circular rugal pattern.
AS long as the assumption is valid in most cases that carcinoma is, in its onset, a localized disease, eradication of the local lesion should provide cure. And this, irrespective of disturbing biologic factors beyond understanding and control, justifies the endeavor for early diagnosis. In the field of bronchial carcinoma x-ray diagnosis has been leading for the past few decades, only occasionally overtaken by bronchoscopy. In the past, the mistakes were usually those of interpretation rather than errors of discovery. In fact, it is a common occurrence that, in a roentgenogram of the chest taken as a routine procedure, a . . .
ASSESSMENT of the size of the liver is often erratic. Downward displacement of the lower edge as determined by palpation or the plain roentgenogram is sometimes misleading. It is generally understood that an accurate evaluation of liver size also requires information concerning its upper border as manifested by the position of the diaphragm. What is not commonly appreciated, however, is the fact that other constitutional variations in shape and position of the liver may alter the significance of clinical findings. Thus, in numerous clinical records and published reports one may find statements that "the liver edge was palpable several fingerbreadths . . .
An Hand von Beispielen wird gezeigt, das es im Verlaufe von Tuberkulose der mediastinalen Lymphknoten haufig zu einer exsudativen Pleuritis im mediastinalen und interlobaren Pleuraspalt kommt, mit Vorliebe rechts zwischen Mittel- und Unterlappen. Erklart wird diese Komplikation aus den engnachbarlichen Beziehungen gewisser Drusengruppen zur Pleura. Zum Nachweis dieser Ergusse eignet sich neben querer Durchleuchtung besonders die Untersuchung in Kreuzhohlstellung. In dieser Stellung sammeln sich Schatten von fruher ganz uncharakteristischer Form zu dichten, scharf begrenzten, dem Mittelschatten anliegenden Schatten von Dreieck-, Vogelschnabel- oder Spornform.
