Search

Each variety of normal cell has a specific range of sensitiveness to roentgen rays. The different varieties of normal cells are listed in the order of their sensitiveness. The action of roentgen rays on cells is briefly described, lymphocytes being used as an example. Then the sensitiveness of different kinds of tumors is mentioned, and stress is laid on the close correspondence in sensitiveness between tumors and the normal cells from which different kinds of tumors are derived. Knowledge of the relative sensitiveness of different tumors often permits one to distinguish some tumors from others, and this is as true of thoracic and intrathoracic tumors as it is of tumors in general. The more common clinical and roentgenologic features of Hodgkin's disease or lymphosarcoma of the chest are reviewed. Then the treatment of these conditions is discussed with reference to the anatomic arrangement of the fields, the quality and quantity of the rays. Finally, the principal factors which govern prognosis are mentioned.

Summary 1.In our judgment, the percentages of staphylococcal infection reported by the medical and surgical services of the Hospital del Torax are of great importance, since they reveal more than 4 per cent of incidence. 2.The usual graveness of a typical staphylococcal clinical picture is another good reason to approach the problem seriously. 3.It seems pertinent to emphasize the risk which compromises the incorrect choice of antimicrobial agents in the genesis of staphylococcal infection. 4.In view of actual therapeutic possibilities, the prognosis of the infection has fundamentally changed. This obliges the physician to make a correct diagnosis, based on the etiologic cause, and adequate understanding of the response of the pathogen to the antibiotics at hand. 5.All the resources aimed at improvement of sanitary environment should be perfected, with the addition of a rational and complete treatment of patients infected with pathogenic Staphylococcus. 6.A methodical, simple and didactic sanitary education should be aimed for and encouraged, especially for hospital personnel in daily charge of infected patients. 7.The administrative group in charge of combating staphylococcal infection with- in the hospital should be efficient. This matter must be considered essential if we want to have a true picture concerning the magnitude of the problem. This will make possible the unification of criteria for prophylaxis and treatment.

The industrial (hospital) therapy program has been in operation for the past five years with 250 participating patients. This is a form of activity which places patients in work areas within the hospital. The activity is in line with patients' post-hospital employment goals. Criteria for selection of patients and organizational procedures are outlined. The specific patient benefits provided by the program are listed. Certain precautions and difficulties are mentioned. The successful results stem from: (1) the coordinated efforts of the various disciplines of the rehabilitation team and the cooperation of the hospital non-medical personnel; (2) preliminary hospital survey of all available types of suitable work as well as preliminary orientation of the hospital personnel as to the purpose of the program; (3) concurrent enrollments of patients in the manual arts, educational and occupational therapy sections of the Physical Medicine and Rehabilitation Service to insure progressive acquisition of theory and skills for application in their work programs. Although this study was done in a chest center, this industrial therapy program can readily be set up in a hospital with various types of disabilities and such a program lends itself to both short and long term patient treatment.

A comparative investigation of the incidence of contralateral roentgenographic pulmonary atelectasis was made in three groups of post-thoracotomy cases. The first 84 cases received adequate aftercare with good tracheobronchial toilet without emphasis on mucolysis. The second 84 cases received acetylcysteine administered by direct intratracheal instillations in 10 per cent concentration in addition to accepted aftercare. The third group of 30 cases received the mucolytic agent administered by intermittent positive pressure breathing apparatus. The incidence of contralateral pulmonary atelectasis for the total series of cases was 14 per cent and did not vary significanty between the groups studied. The incidence of atelectasis is recognizably related to moment by moment supervision of tracheobronchial toilet after thoracotomy, rather than a specific technique or therapeutic agent. However, the addition of acetylcysteine may be a valuable adjunctive agent to promote easier and more rapid elimination of undesirable secretions.

Thoracic empyema has become an uncommon disease in adults, tending to occur in chronically ill debilitated individuals. In this series, pulmonary infection was the underlying cause in more than half the cases, with bronchogenic carcinoma or other serious lung disease present in one fifth of the pulmonary infections. Thoracic surgery preceded almost one quarter of all cases. Staphylococcus aureus and gram-negative bacilli were the most commonly found organisms. Successful therapy is founded on correct choice and adequate dose of antibiotics, prompt institution of adequate drainage, and recognition and treatment of underlying factors. Decortication, with or without pulmonary resection, and thoracoplasty continue to have a place in treating chronic empyema. Empyema contributed to death in less than five percent of this series. However, overall mortality was just under 50 percent reflecting the occurrence of pleural sepsis in patients with a variety of serious neoplastic and degenerative diseases.

Basic objectives of good medical education have changed little in the past 50 years. The tremendous advances in the preclinical sciences and in clinical medicine during this time have made it impossible for a faculty to impart this mass of knowledge or, indeed, to expect or require the student to know all of it. This became more apparent with the accelerated program required for undergraduate medical education during World War II. It was also felt that the social and economic changes that have occurred deserved more recognition. Therefore, in 1946, the faculty of the School of Medicine of Western Reserve University, under the leadership of its Dean, Dr. Joseph T. Wearn, began to plan a new curriculum approaching it as a scientific experiment. In 1952, the new curriculum was implemented, and in 1956, the first class under the new curriculum was graduated. I have drawn largely from the reports of Wearn,1 Ham,2 Patterson,3 and Caughey,4 and my own experience as a participating faculty member. The objectives of this curriculum are to graduate a physician with adequate knowledge and skills, who has proper professional ideals and scientific attitudes. Since knowledge is not static, a strong effort is made to develop habits of self-education which, it is hoped, will continue throughout life. It was realized that the example set by the faculty would play an important role. The idea of total coverage was abandoned from the outset. It was agreed to emphasize basic concepts and their -application to the mechanisms of disease. To do this better, the previously existing more or less sharp separation of teaching along purely departmental lines was altered so that from the first day of medical school, teaching would be on an interdepartmental basis. Therefore, the material has been organized into subject groupings. Each subject is taught by a subject committee made up of members from the departments concerned. It was also felt that the introduction of the student to the patient should be early in the first year rather than at the end of his second year. The course in clinical science, described below, is designed to do this. The usual four year curriculum has been divided into three phases. Phase 1, occupying the first year, is concerned with normal structure and function. Phase 2, in the second year and first half of the third year, studies disorders of structure and function. Phase 3, during the last year and one

SUMMARY Clinical and laboratory data are cited which may lead one to suspect the presence of a collagen disease, and diagnostic points are presented to aid in the differential diagnosis of the various collagen disorders. Clinical and roentgenographic manifestations of involvement of thoracic structures by collagen diseases is more common than has been stressed in the medical literature, including such relatively uncommon conditions as dermatomyositis. Roentgen abnormalities in the chest may quite often lead one to suspect the presence of a collagen disease, and certain combinations or sequential changes may even aid in the differential diagnosis of the various conditions. Roentgenographic and pathologic data support the separation of rheumatic pneumonitis as a specific entity.

SUMMARY Kidney function can be rapidly and serially investigated by osmolality and by double beam infrared spectrophotometry. Osmolality measures total solutes. IR spectroscopy measures urea concentrations. These methods confirm that significant reduction in renal function occurs during surgical procedures, especially those utilizing cardiopulmonary bypass.

SUMMARY The search for chest diseases, especially tuberculosis, in general and mental hospitals and penal institutions, has been accepted and productive. Nursing and convalescent homes and related facilities have been an interesting but somewhat forgotten facet of the total health treatment program. There are more than 23,000 such facilities in the United States with more than 600,000 beds. In 1962, nursing home construction approached 800 million dollars. With the number of beds increasing at the rate of 24,0 annually this is one of the fastest growing medical and economic problems. Only recently the health standards for these homes attracted indicated attention. The state of Illinois revised minimum standards and regulations for nursing homes which became effective February 1, 1962, and require that every patient have a physical examination prior to or within 72 hours after admission. The physical examination shall include a statement dated and signed by the physician that the patient is free from communicable diseases, including tuberculosis. Physical examinations also shall be given all patients at least annually. Most nursing homes are too small to maintain x-ray departments. There also is reluctance on the part of the homes' owners to absorb the cost of x-raying or to pass it on to the resident patients. DuPage county is one of 102 counties in Illinois, located on the outskirts of Chicago. It is the state's most rapidly growing county, with a population of approximately one- third million. The DuPage County Tuberculosis Sanatorium Board initiated in August 1962 a chest x-ray screening program for all residents of nursing and convalescent homes of the county. The data compiled from approximately 1000 resident patients show the importance of continuous studies and detecting unknown tuberculosis, pneumonia, malignancies, cardiovascular diseases, et cetera. It also points up the difficulties encountered in using roentgenographic equipment and the need for development of better diagnostic, more economical and lighter equipment by the x-ray industry. The study emphasizes the need for a standard for detection of tuberculosis—one that is practical from the nursing home's point of view and, at the same time, reliable as a screening device.

1) Like other case-finding chest film mass studies of apparently normal individuals, routine photoroentgenograms done at a separation center are fruitful of uncovering new cases of pulmonary tuberculosis. 2) The majority of such cases found are minimal lesions. 3) Many cases of arrested minimal pulmonary tuberculosis have withstood varied periods of Army life without reactivation of the original lesion. 4) Because of the peculiar location in relation to the heart, cases of left lower lobe bronchiectasis may be easily missed in a survey.

It is with great temerity that I shall attempt to discuss the topic which has been assigned to me, for many of you could present it with greater clarity and authority. It is only the realization of the great debt that we as physicians owe to our colleagues and predecessors who have advanced the knowledge of medicine through research that encourages me to undertake the present task. The term “research” may mean many things to different men. Webster defines research as a studious inquiry, usually with critical and exhaustive investigation and experimentation, having for its aim the revision of accepted conclusions in the light of newly discovered facts. To most of us it simply means “the search for truth.” It is well to note that we live in an age of science, in fact, of adventure and science-an age when science is about to outstrip all other activities. We are fortunate indeed to be offered the privilege of joining in its pursuit. The search for truth is not granted with equal opportunity to physicians throughout the world. We in America live in a land and in a time of opportunity that we often appreciate all too little. We live in a land in which the medical profession is allowed and encouraged to investigate the unknown and bring to fruition the betterment of man, I would therefore begin with a note of gratitude and a hope that we may continue to deserve and cherish the privilege accorded us to attain these ends. Each generation has a tendency to look with envy on the generation that has just passed as having lived in a period when opportunity was most abundant and success most easy to achieve. As a young man entering the medical arena at the end of World War I, it seemed discouraging to try to improve on the knowledge possessed by such giants of medicine and surgery as Osler, Virchow, Mayo, Pasteur and their illustrious confreres. Still, the 30 years that have elapsed since have brought forth advances in medicine and surgery that stagger the imagination. To this period the term “The Golden Age of Medicine” has justly been assigned. One need but recall the discovery of the antibiotics and chemotherapeutic agents which have conquered, in large measure, the infectious diseases, subjugated pulmonary tuberculosis and conquered syphilis, the scourge of man, to realize the truth of such a designation. The hope and courage that have been offered patients with diabetes, pernicious anemia and endocrine disorders by the contributions of investigators

SUMMARY Prescalene lymph node biopsy is a procedure of established value in the diagnosis of intrathoracic disease and in determining resectability of previously diagnosed pulmonary malignant neoplasms. In 62 biopsies in 58 patients, 14 biopsies, or 22.6 per cent yielded abnormal lymph nodes. No operative or postoperative complication was encountered in our series, but three biopsies were inadequately performed as they were reported to contain no lymph nodes. These procedures should be performed by experienced surgeons.

1.Diffuse spasm of the esophagus from undetermined cause may produce symptoms of severe chest pain easily confused with the symptoms of coronary artery disease as illustrated in these seven cases. 2.This diagnosis can be made positively by recording various patterns of esophageal dysfunction on esophageal motility studies. 3.The consideration and diagnosis of this problem may materially reduce the diagnoses of chest pain of undetermined origin. 4.In the present stage of our understanding of this problem caution must be exercised because of great symptomatic overlapping and possible coexistence of these two diseases.

The deformities of the anterior chest wall commonly known as funnel chest, pigeon breast and Harrison's grooves for which the author has suggested the terms congenital chondrosternal depression, congenital chondrosternal prominence and congenital chondrocostal grooves respectively, are discussed as a related group of congenital deformities of the anterior chest wall. The present concepts of the etiology of these deformities, such as rickets, upper respiratory obstructions and severe cough and dyspnea are analyzed and refuted. It is acknowledged that these conditions do aggravate the extent of these deformities. Another concept is suggested to explain the mechanism and production of these deformities. In normal chests the normal muscular portion of the anterior division of the diaphragm contracts and pulls the anterior leaf of the trefoil membranous portion of the diaphragm toward the anterior chest wall which remains stationary. If the anterior portion is underdeveloped or has relatively less muscle fibers or is more tendinous it will be pulled dorsally by the rest of the musculature of the diaphragm and produce an inspiratory retraction of its anterior chest wall attachment. As the character and composition of this anterior portion of the diaphragm varies, so will the pull on the anterior chest wall. The variation in the amount and the site of the pull will correspondingly affect the degree of severity and type of each one of these three deformities.

This study was made to determine the value of the esophageal motility test as a diagnostic procedure in cases of thoracic pain. A review was made of the records of 514 patients undergoing studies of esophageal motility at the Mayo Clinic from May, 1957, through April, 1959. From these varied clinical cases, 45 patients with a diagnostic problem of pain in the thorax were found in whom a definitive diagnosis had not been established by means other than the motility test. These 45 patients were found to form four main groups: (1) eight patients without objective evidence of either myocardial ischemia or esophageal motility abnormalities; (2) two patients with objective evidence of myocardial ischemia, but no abnormalities of esophageal motility records; (3) 17 with abnormalities of the esophageal motility records, but no objective evidence of ischemic myocardial disease, and (4) 18 patients with evidence of both abnormal esophageal motility and myocardial ischemia. The abnormal esophageal motility findings in these patients included, in order of frequency, the patterns for diffuse spasm, hiatal hernia, the hypertensive and the hyperreacting gastroesophageal sphincter. Various combinations of these motility disorders were often found in the same patient. The incidence of hypertensive gastroesophageal sphincter was exceedingly high. Clinical differentiation could not be made consistently between the pain of ischemic heart disease and that of esophageal motility disorders. It is recommended that when patients present a diagnostic problem related to pain in the thorax, ischemic heart disease should be excluded even though the presence of esophageal disorders is proved. The electrocardiogram after exercise may be helpful in the evaluation of such patients.

The accurate diagnosis of intrathoracic diseases is sometimes difficult. When ordinary routine examination methods fail, differentiation often requires biopsy of enlarged superficial lymph nodes. For cases in which no such nodes can be found Daniels (1949) recommended the histological examination of lymph nodes from the mass of fatty tissue between the M. sternocleidomastoideus and the M. scalenus anterior. These nodes forming part of the mediastinal lymphatic system. He reported five cases: a diagnosis of Boecks sarcoid was established in two, carcinoma in two and silicosis in one. He points out that in one with cancer a major operation was prevented and that, in the other a major exploration of the lung would not have been necessary if biopsy had been carried out first. In 1951 Weiss and alii reported a case of pulmonary sarcoidosis in which a clinical impression of sarcoidosis was confirmed by the method of Daniels. Stimulated by these reports which seem not to have been duly appreciated, and convinced that the chance of getting informative material would be great even in cases in which no lymph nodes could be felt when the subclavicular region was exposed and the above mentioned fat pad explored, we have tried this procedure since January 1952 in a series of 56 cases. In all of them the clinical and/or roentgenological pictures suggested pulmonary or mediastinal disease but the diagnosis was not established with certainty. In none of them could enlarged lymph nodes be found, despite careful palpation. Sometimes preoperative palpation gave the impression of an enlarged lymph node in the supraclavicular space close to the lateral border of the sternocleidomastoideus muscle, but exploration showed the supposed node to be the lateral part of the omohyoideus muscle. The surgical technique is simple and the procedure takes only 10 to 15 minutes. In local anaesthesia an incision of 3 to 4 cm. is made on the side of the lesion or, if both sides are equally ihvolved, the right side about two fingerbreads over and paralleling the clavicle through the skin and the platysma. The lateral border of the sternocleidomastoideus muscle may be devided. This muscle is retracted medially and the fat pad on the anterior surface of the scalenus anterior muscle thereby exposed. This space is crossed by the inferior thyroid and transverse cervical vessels and is bordered by the subclavian and internal jugular veins, the omohyoid and scalenus anterior muscles. The phrenic nerve and-on the left sidethe thoracic ducton the right side-the right lymphatic duct are to be considered. Care should be taken to avoid injuring these structures. This

Obviously, it should be our cherished goal to try to establish a positive clinical diagnosis in every case of pulmonary disease. Careful and diligent use must be made of the many useful tests and examinations that are available for this purpose. The close co-operation of the roentgenologist, bronchoscopist, bacteriologist and other specialists is highly important. Despite all this, there will remain a goodly number of patients suffering from pulmonary disease in whom a positive diagnosis cannot be arrived at. It is often unwise, in a case of this type, to procrastinate too long with periods of observation or with tests that require many weeks for completion, because of the danger that the lesion may be malignant in nature, thereby requiring prompt treatment if it is to be eradicated successfully. In properly selected cases of this type, exploratory thoracotomy is often indicated; the pathologist can often furnish a prompt explanation of the underlying cause of the pulmonary lesion. In cases in which the cause is uncertain, bacteriologic studies of the tissue should be employed, as often useful information which might otherwise escape detection may be obtained by this method.

SUMMARY Sixty-nine patients with different types of anthrax were included in this study (23 malignant edema, 15 moderate and 31 slight edema). Five patients with malignant edema of the chest wall and neck who did not receive corticosteroids died, but 18 patients with the same extent of malignant edema who received corticosteroids and penicillin survived. One patient with lung involvement who received Solu-Cortef also died. Seven patients with moderate edema who received corticosteroids had a shorter hospital stay and rapid recovery. We feel that whenever malignant edema involves the thoracic wall and neck, administration of corticosteroids is life-saving and indicated.

It is our hope that eventually the teaching of tuberculosis will accompany the student throughout the four years of his medical school, not as an elective, but as a required course correlated with all his other subjects. In this instance, familiarity will breed not contempt but knowledge of, and respect for, a disease that thrives on ignorance. The success of the courses given was due directly to the enthusiasm and wholehearted cooperation of the Dean and Medical Board of the New York Medical College and the Medical Staff of the Municipal Tuberculosis Sanatorium.

Five cases are presented in which a lymph node biopsy was performed on nonpalpable, deeply situated nodes in the lower neck and upper mediastinum. A diagnosis of Boeck's sarcoid was established in the first two cases. The finding of metastatic carcinoma in the third case prevented a major surgical exploration of the chest. In the fourth case a major exploration was carried out only to find inoperable carcinoma of the lung with metastases. If biopsy had been carried out first this would not have happened. The fifth case illustrates the fact that silicosis as well as sarcoidosis and tumor advance as far as this group of nodes.

An accurate evaluation of the degree of pulmonary function impairment may be made from the following physiological tests: (1) Ventilation measurements from spirogram tracings (total vital capacity, three second timed vital capacity, maximal breathing capacity and the shape of the exhalation curve following a deep breath), (2) the degree of bronchospasm present, (3) the residual air capacity and alveolar nitrogen per cent after seven minutes oxygen breathing, (4) the arterial blood oxygen saturation at rest and immediately after step-up exercise, (5) the oxygen uptake during step-up exercise, (6) the per cent of oxygen extracted from the inspired air breathed and (7) the character and duration of dyspnea after step-up exercise.

SUMMARY The use of physical signs in the diagnosis of diseases of the chest developed rapidly after the discovery of the stethoscope, and reached its acme at the end of the nineteenth century. It has since tended to decline as a result of the greater emphasis on etiological and functional, rather than on purely anatomical aspects of disease and the introduction of more sensitive and reliable endoscopic, radiologic and laboratory methods. Despite the gross fallibility of physical examination, however, neglect of its teaching and application is deplored. The eye, ears, and touch remain the quickest, simplest and most readily available means of detecting pathologic alterations. Suspicion aroused by physical findings is often the necessary precursor to the application of the instrumental, radiologic and laboratory measures which are required to establish the diagnosis. Omission of the more delicate and precise objective methods through excessive confidence in the less trustworthy physical signs can only lead to disaster.

SUMMARY Intrathoracic masses of extramedullary hematopoietic tissue present a diagnostic problem for the clinician and the radiologist. The diagnosis should be considered especially in cases of spherocytic anemia. The pathologic findings in bone marrow and roentgenographic changes in bones due to marrow replacement or abnormal proliferation of marrow are important indicators of the diagnosis. The roentgenographic demonstration of well defined masses in the paravertebral gutter, enlarged spleen, bone changes, and a history of a severe anemia are a tetrad toward a preoperative diagnosis of extramedullary hematopoiesis. Three cases of extramedullary hematopoiesis presenting as masses in the thorax are described. Two of the cases demonstrate mediastinal masses in association with congenital hemolytic anemia. The third case was in association with myelosclerosis and the extramedullary hematopoietic mass compressed the thoracic spinal cord. This is the first known case with such a manifestation to be reported.

The clinical staging of patients with Hodgkin's disease in general, as well as in those with thoracic Hodgkin's disease, seems to be the best factor to evaluate in outlining therapy and seems to be the factor best correlated with prognosis. [See Figures 1D and 1E in Source PDF.] Intensive roentgen therapy, with an attempt to deliver a dosage of at least 2,000 roentgens in two weeks, is indicated in patients of stages I and II. In those with stage III disease, palliative roentgen therapy and clinical agents, such as nitrogen mustards and TEM, may give much symptomatic relief.

SUMMARY In the past three years, 69 patients with intractable asthma have been selected for treatment by glomectomy at the Overholt Thoracic Clinic. Some benefit was found in four out of five patients. Over half were improved to a marked or significant degree. These clinical results parallel closely those reported by Nakayama. The carotid body is a chemoreceptor, sensitive to: (1) hypoxemia, (2) decreased pH, and (3) CO2 retention. Stimulation causes hyperpnea. This is beneficial if airways are clear. In the asthmatic, such a reflex initiates a vicious cycle. An already diminished functional capacity, due to bronchospasm, mucosal swelling, and secretion accumulation, is further reduced by hyperpnea. Removal of one carotid body apparently prevents such an unwanted sequence, as well as partially interrupts pathways of communication to the pulmonary plexus which contains bronchodilator fibers.