52 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

THE DIAGNOSIS OF EARLY GASTRIC HERNIATION AT THE (ESOPHAGEAL HIATUS*

BY ALAN STEWART JOHNSTONE, M.D., F.R.C.S., F.F.R. PROFESSOR OF RADIODIAGNOSIS~ THE UNIVERSITY OF LEEDS

RECENT advances in radiology have considerably altered our conception of the diaphragmatic hernia. F rom the numerical aspect one could not do bet ter than quote the Mayo Clinic figures published by Harr ington in 194o. In the eighteen years between 19o8 and 1926 , 3 ° cases of dia- phragmatic hernia were diagnosed and of these 14 were operated upon. In the fourteen years between 1926 and i94o , 650 cases were recorded and 250 came to operation. F rom the clinical side one can recall many cases in which a diagnosis of coronary or bil iary disease, duodenal or

pOSITIONj J . . . . . .

PAPA- QE$OPHAGF-AL • A

C~$ OPHAGUS/~ ELEVATED I ,HERNIAL

i~': SACHERNIAL £ [EVATI:: O ~ ( ( [ ~ 2 NOSAC c~sop~cusL j~ ,~ NORMAL 7 , P O S I T I ~

?--1 L..: PAPA - ESOPHAGEAL

"" t L/CA#DIA ~1 PERITONEUM

Fig. 34.--A, Harrington's diagram of gastric herniae at the oesophageai hiatus These present little difficulty in diagnosis. B, Harrington's diagram of pulsion type of herniae and short oesophagus. The radiological diagnosis in the early stages may be very difficult.

gastric u l ce r - - to quote the commoner les ions--has been erroneously made. The real culprit, a diaphragmatic hernia, has eventually been d i scovered- -due in no small measure to improved rad io logy- -bu t often not before one or more operations have been performed.

I t is not my purpose to survey the radiological appearances of the whole field of diaphragmatic hernia, but to dwell upon the commonest t ype - - the (esophageal hiatus hernia of the s t omach - - describing the radiological anatomy and directing your attention to the difficulties in making a diagnosis.

This part icular l~ernia is at present in vogue and it is difficult to avoid being carried away by over-enthusiasm. A physician, baffled by a normal electrocardiogram in a case of typical coronary thrombosis, or a surgeon, disappointed to find his diagnosis of cholecystitis upset by a normal

* This paper was delivered at the Annual Meeting of the Association of Surgeons of Great Britain and Ireland in Edinburgh in I948. A synopsis was read at the International Congress of Radiology, London, I95o.

D I A G N O S I S O F E A R L Y G A S T R I C H E R N I A T I O N 53

cholecystogram, now expects the radiologist to produce a scapegoat at the oesophageal hiatus. One may find, of course, several varieties of hernia and the recognition of the fundus of the stomach or the pyloric antrum lying above the diaphragm presents little difficulty (Fig. 34). On the other hand the radiological diagnosis of herniation of a small part of the stomach adjacent to the cardia, whether it be due to shortening of the oesophagus or a sliding hernia of the pulsion type, may be equivocal and even impossible (Fig. 35). This is due to the difficulty in localizing exactly the upper margins of the oesophageal hiatus, and also to the confusion caused by the apparent existence of two dilatations at the lower end of the normal oesophagus known as the phrenic ampulla and the cardiac antrum. To visualize the problem it is perhaps an advantage at this stage briefly to review the grounds on which diagnosis of (esophageal hiatus hernia is made.

Firstly, the demonstration of a pouch, larger in calibre than the oesophagus, lying immediately above the diaphragm at the (esophageal hiatus, is suggestive of hiatus hernia. The (esophagus usually enters the apex of the pouch and is slightly constricted for about one centimetre immediately above this junction. Sometimes the oesophagus enters at the side of the Fig. 35.---Lower end of cesophagus and stomach dis- pouch. This removes all diagnostic difficulties, for played in supine position. One small and one large pouch

are seen at the lower end of the (esophagus. Both appear to it is pathognomonic of gastric herniation (Fig. 36). be in th . . . . p h a g u s b u t a gas t r i c herni . . . . . ot b . . . . luded

unequivocany.

A B Fig. 36.--A, Showing pouch above the diaphragm. S, The pouch is no longer symmetrical, due to further

protrusion of the greater curvature. This leaves no doubt that the pouch is stomach.

Secondly, the demonstration of gastric mucosal folds lining the pouch. These folds appear to run continuously with the fine oesophageal folds, but they are larger and coarser (Fig. 37).

54 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

Sometimes they cross transversely like those of the greater curvature and give a very characteristic varicose appearance (Fig. 38). The above criteria for recognition of stomach seem to be clearly

Fig. 37.--Shows large coarse folds Fig. 38.--Shows t ransverseworm-like folds l ining the pouch. Finer segmental folds typical of greater curvature. a r e faintly demonstrated.

defined and acceptable. In order, however, to assess their real value it is necessary to examine them in greater detail.

I. The S u p r a - d i a p h r a g m a t i c P o u c h . - - I n i932 Schatzski published a paper on the incidence of (esophageal hiatus hernia in elderly people. He found that 5 ° per cent of a series of 3 ° unselected

patients between the ages of 65 and 83 years showed herniae on ordinary radiological examination. When the intra- abdominal pressure was increased by air insufflation of the colon the percentage rose to 73- While it is generally accepted that changes associated with old age--such as loss of muscle tone, loss of fat in the peri-(esophageal space, and atrophy of the phreno-(esophageal membrane, together with increased intra- abdominal pressure--all contribute to the formation of a hernia, it has not been my experience to find such a high proportion in elderly patients.

Now it is relatively easy to obtain a radiograph showing a small pouch which appears to lie above the diaphragm, but it may be almost impossible to determine whether it is of (esophageal or gastric origin (Fig. 39)- One of the principal difficulties lies in the confusion which still exists about the anatomy of the lower end of the (esopl~agus. Arnold in I838

Fig. 39.--Illustrates a pouch in the ceso- described a dilatation between two furrows about 3 cm. apart, phagus which was obtained by deep inspiration the lower furrow being the anatomical cardia. This dilatation, after swallowing barium. I t appears to be (esophageal but this patient was 8 months later called the cardiac antrum, was considered by him analogous pregnant and the possibility of hiatus hernia could not be dismissed, t o the 'vor-magen ' of ruminating animals. Luscka in ~857

enlarged upon Arnold's work and suggested that there existed frequently another variation of the lower (esophagus in which two pouches occur (Fig. 4o). The superior pouch was definitely intrathoracic and the inferior corresponded to Arnold's pouch.

D I A G N O S I S O F E A R L Y G A S T R I C H E R N I A T I O N 55

According to Templeton (i944) , who has dealt fully with the historical aspect of this subject, Luscka called the intrathoracic pouch the ' vor-magen' and the inferior pouch the cardiac antrum. Since then many anatomical variations have been recorded, and in I9o 5 Hasse and Strecker used the term 'phrenic ampulla ' for the dilatation of the oeso- phagus found immediately above the diaphragm.

The anatomy of this area, studied on the cadaver, differs so much from that seen either at operation or radiologically that there is little to gain in reviewing this subject further. It is important, however, for later reference to mention that Strecker denied the existence of the abdominal part of the oesophagus. He believed the cardiac antrum to be part of the stomach and to lie within the hiatus.

Fig. 4o . - -D iag rammat i c representation of Arnold 's ' vor -magen ' and the second variety described by Luscka wi th the intrathoracic ' vo r -magen '.

2. Radio log ica l A n a t o m y . - - W h e n a patient, standing erect, is screened while swallowing barium emulsion, the bolus, propelled by peristalsis and the forces of gravity, is seen to pass rapidly into the stomach in a column of uniform calibre. If he takes a deep breath and holds it, or better still performs the Valsalva experiment, the column is cut across at the lower end of the oesophagus by a band i. 5 cm.-2 cm. wide. On relaxing the diaphragm the constriction disappears (Fig. 4r).

Fig 4L- - I l lus t ra tes bar ium passing down the oesophagus into the s tomach dur ing expiration and inspiration. D u r i n g inspiration the column is compressed in the hiatal tunnel.

It can b e assumed that the band localizes the position of the (esophageal hiatus, and any pouch lying above it, although not above the domes of the diaphragm, must be within the thorax. This point needs emphasis, for one is apt to forget when estimating the position of the hiatus that it lies below the level of the domes in both the anteroposterior and lateral radiographs (Fig. 42).

The breadth of the constricting band seems to be unusually large when compared with the relative slimness of the dome of the diaphragm. This is brought about by several factors. The hiatus is formed by a splitting of fibres of the right crus which at each side present a broad edge to the oesophagus. In addition to sending a few fibres which decussate anterior to the hiatus, the left crus, situated between the gastric fundus and the oesophagus at the cardiac incisura, takes part in the pinch-cock action by compressing the oesophagus against the left lobe of the liver. The

56 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

cesophagus lying in this hiatal tunnel passes forwards and to the left and at the same time the broad diameter of the lumen turns slightly from the coronal to the Sagittal plane. These changes may enable the constricting action of the hiatus to be more effective. (Fig. 43")

A B Fig. 42.--Il lustrates the normal position of the hiatus, in relation to the domes of the diaphragm, defined by com-

pression of the (esophagus in full inspiration. A, Anteroposterior view ; B, Lateral view.

It is important to observe how closely the stomach lies in contact with the under-surface of the diaphragm. Contrary to anatomical teaching, there appears to be no infra-diaphragmatic segment of the (esophagus. This is well illustrated radiologically in elderly patients in whom there

is general visceroptosis and a flattening of the diaphragm. In these cases the gastric fundus is cone-shaped, the point being directed to the hiatus. (Fig. 44.)

The efficiency of the diaphragm in hold- ing up the bolus varies with individuals. It sometimes appears that peristalsis may overcome the obstructions and the (esophagus empties, but some of the discrepancies in results may be ascribed to technical faults. Many obser- vations indicated that in young adults peri- stalsis overcame the obstruction and the (esophagus emptied. On later analysis it became apparent that this was due to a slight relaxation of the hiatus when the glottis was closed after suspending respiration at the end of a deep

Fig. 43.--Drav¢ing of the diaphragm as seen from below. The fibres of t he r igh t crus divide to surround the hiatus. Some breath. Assuming that the constriction obliter- fibres from the left crus also pass round medial to the hiatus although the main body of the muscle lies on the lateral aspect, a t e s the lumen completely, the (esophagus

immediately above the hiatus dilates to accommodate the bolus as it is brought down by peristalsis. A moderately large pouch is formed which has been termed the phrenic ampulla. It has a conical apex and occasionally two lateral notches (Fig. 45). When the back pressure within the pouch equalizes the force of the peristalsis ~he wave is halted for a second or two, and then, quite suddenly, the barium floods back up the

D I A G N O S I S O F E A R L Y G A S T R I C H E R N I A T I O N 57

oesophagus. The ampulla collapses, but not completely. A smaller pouch may remain until the diaphragm relaxes and the barium enters the stomach. This pouch is rounder than its predecessor and in shape resembles a gastric herniation. (Fig. 46.)

There is no anatomical explanation for this smaller pouch, but one has the impression that the upper borders coincide with the insertion of the phreno-oesophageal membrane. This membrane arises from the under- surface of the diaphragm and is inserted into the oeso- phagus about z cm. to 3 cm. above the diaphragm. At this point there is said to be a local constriction. The function of the membrane is to prevent the cardia from being dragged through the hiatus by the strong longi- tudinal (esophageal muscles. At the same time it is said to allow free movement of the oesophagus through the hiatus during respiration. Radiologically, however, it is difficult to detect any such movement.

It is worth noting that peristalsis does not travel as far as the stomach but stops at or close to the diaphragm. This suggests that the remainder of the oesophagus takes part in the cardiac sphincter. The smaller pouch,

Fig. 45 . - -Demons t ra tes the phrenic ampulla with two lateral notches,

hiatal segment and not at the anatomical cardia. appear that the gastric mucosa may have a small nipple-like projection at the cardia (Fig. 49). the cardiac antrum or the ' vor-magen ' of Arnold may be lined with gastric mucosa.

Fig. 4 4 . - - T h i s illustrates the absence of in t ra-diaphragmatic port ion o f the oesophagus. T h e hiatal constriction is seen to finish at the eardia.

therefore, may provide us with our first problem. Does it belong to the oesophagus or the stomach ? If we are prepared to accept the fact that there is no infra-diaphragmatic oesophagus, then the cardiac antrum must lie within the hiatus. This antrum can be shown at post-mortem to balloon out when water is injected into the stomach through the pylorus and when the oesophagus is clamped in the thoracic segment. It therefore seems possible for the cardiac antrum to bulge through a relaxed hiatus when the stomach is com- pressed by increased intra-abdominal pressure.

We turn now to the mucosal picture in the hope that it may assist in the differentiation.- The mucosa, however, is very mobile in this segment and many variations occur. Sometimes the folds thicken imperceptibly (Fig. 47) ; at others, the line is clearly defined and may be gathered like a ring (Fig. 48). This ring, moreover, usually lies in the

If it represents the mucosal junction then it would Thus

5 8 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

It is only fair to ask what reliance can be placed on the radiological interpretation just described. In experiments carried out in the Thoracic Surgery Department at Leeds using Allison's clip method

A B Fig. 46. - -A, Shows the appearance after the bar ium floods back into the oesophagus and the pouch collapses but not

completely. S, Shows the phrenic ampulla jus t before the reflux occurs. T h e hiatal tunnel is clearly illustrated.

Fig. 4 7 . - - I n the terminal inch of the oesophagus the mucosal folds are seen to change and becom e thicker as the cardia is approached.

Fig. 4 8 . - - T h e mucosal folds thicken sud- denly after being gathered in a r ing-l ike fashion to a level jus t above the d iaphragm.

the conclusion was reached that the radiograph was reasonably accurate but not unequivocal. The technique employed was to take a biopsy from the mucosal junction and attach a silver clip at the same site. Illustrations of this method of localization are given in Fig. 5 ° . The first series, which

D I A G N O S I S O F E A R L Y G A S T R I C H E R N I A T I O N 59

is typical of the majority, shows accurate localization. Figs. 5 I, 52, 53, however, demonstrate some of the fallacies of the method, wherein the radiological and oesophagoscopic localizations did not coincide. The mucosal junction is often asymmetrical and may be i cm. or more higher on one wall than the other (Fig. 54). It is also extremely mobile; for example, the gastric mucosa is said to slide up the oesophagus through the hiatus during belching. It is possible, moreover, that the hiatal constriction may bunch up the mucosal folds, making them appear thicker than those in the oesophagus immediately above. In spite of all these fallacies it is suggested that gastric mucosa often lines the hiatal segment of the oesophagus --otherwise called the cardiac antrum. Thus the demonstration and identification of gastric mucosa does not necessarily indicate that the organ to which it is attached is the stomach.

So far we have examined two criteria on which the diagnosis of cesophageal hiatus hernia is based and have found that anatom- ical variations may readily lead us into an erroneous diagnosis. At this point it is as well to remember that one of the advantages claimed for radiology is that it provides a method of studying not only anatomy but physiology and the chief importance of the cardia lies in its physiological action in preventing regurgitation. This can be tested during radiological examination by manual com- pression of the abdomen with the patient in the Trendelenburg position. A failure of the protective mechanism will lead to free regurgitation into the oesophagus (Fig. 55).

Regurgitation is normally prevented by the pinch-cock action of the diaphragm and, to a much less extent, by the cardiac sphinc- ter. That such a sphincter exists, even though there is little anatomical evidence to support this statement, can be shown Fig. 49.--Drawing to illustrate the

a u t h o r ' s c o n c e p t i o n of ga s t r i c rnucosa radiologically when a small column of barium remains in the oeso- lining the terminal portion of t h e ceso-

phagus irrespective of respiratory movements of the diaphragm (Fig. p h a g . . . . t h . . . . d i . . . . t . . . .

56). Barium will lodge in the lower oesophagus until moved on by a wave of peristalsis which allows the cardia to relax. Exactly where the sphincter lies is difficult to say. Dick and Hurst (i942), favoured a valvular mechanism produced by the oblique entry of the oesophagus into the stomach. The obliquity disappears with herniation when the oesophagus enters the pouch at the apex allow- ing the valve to become incompetent (Fig. 57). This, however, does not explain why barium is sometimes retained within the pouch even when manual compression is applied to the abdomen, and yet free regurgitation occurs after peristalsis has been induced by swallowing. Lendrum (I937) described an extension of the oblique fibres of the stomach for a centimetre or so along the oesophagus. The fibres form an inverted ' (3 ' at the cardia and he suggested that they might exert some sphincteric control. Carlson deduced from readings made by small balloons in the (esophagus that the cardiac sphincter lay in the region of the diaphragm and was not more than a centimetre in length.

Jackson (i929) considered that the pinch-cock action of the diaphragm protected the oesophagus from regurgitation, but he described in addition special bundles of muscle-fibres extending from the crura and surrounding the ~esophagus. These, he thought, might contribute to the tonic closure, and also co-ordinate the sphincteric opening with the swallowing mechanism.

There is no doubt that the diaphragm exercises the principal control and to bring about free regurgitation one must have primarily a weakness at the oesophageal hiatus. This may be due to developmental or acquired causes. Of the acquired causes I have already mentioned senility.

60 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

Increased intra-abdominal pressure, especially in the hypersthenic type, is most important. Pregnancy has been cited as a frequent cause of herniation and in consequence one would expect to find the lesion commoner in women. This is not borne out by experience for there is no

A B

C D Fig. 5o.--A, Supine film--radiological localization of mucosal change was made at point marked with arrow at upper

margin of hiatus. B, Clip applied to prove mucosal junct ion corresponding to radiological localization. C, D, Clip applied to the mucosal junct ion in a normal patient. Fi lms taken with patient semi-erect : C in inspiration ; D in expiration.

significant difference in the sex incidence. I t is possible, however, that the laxity of the abdominal wall in parous women prevents the intra-abdominal pressure from becoming too great.

It has been shown that in a high proportion of individuals the (esophageal hiatus may be lax. In a thousand cases examined digitally from the abdomen Harrington (i943) found that Io per cent admitted more than one finger. When it is recalled that Findlay and Brown Kelly (I93i) described herniation of the cardia through the (esophageal hiatus to be a normal physio- logical phenomenon, then it is still more difficult to appreciate how far the limits of the normal extend.

In children the recognition of herniation may sometimes be difficult, but when a hernia or hiatal weakness exists regurgitation may take place freely in inspiration due to the increase in negative intrathoracic pressure. Figs. 58, 59 illustrate a case of hiatus hernia with shortening of the

D I A G N O S I S O F E A R L Y G A S T R I C H E R N I A T I O N 6:

Fig. 5: . - - I l lus t ra tes small pouch with typical gastric folds. A diverticulum (D) is seen projecting from the oesophagus about i cm. above the pouch. J marks the radiological site of the mucosal junction.

Fig. 52.- -Same patient as in Fig. 51. Two clips (C) have been applied at the mucosal junction and lie above the diverticulum, showing erroneous radiologieal localization.

Fig. 53.--Point J marks the site where radiologically the mueosal junction was located. The clip is seen to lie about 2 em. distal to this point. Again radiological error,

Fig. 54.--Clips have been placed on the junct ion of squamous and columnar mucous membrane. The clip on the posterior wall is higher than that on the anterior. In this ease both clips are above the diaphragm.

62 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

oesophagus and peptic ulceration. Fig. 58 shows regurgitation into the oesophagus during expira- tion but no definite hernia. The end of a prolonged howl was followed by a sudden deep inspiration which demonstrated perfectly a hiatal hernia and small peptic ulcer in the oesophagus (Fig. 59).

Fig. 55. - -Regurgi ta t ion occurring into oeso- phagus associated wi th small hiatus hernia.

Fig. 56.--I l lust ra tes action of the cardiac sphincter. A small amount of bar ium remained in the oesophagus for several minutes while the patient breathed normally.

Allison (1948) considers that free regurgitation may occur without gastric herniation provided that the hiatal cone is lax and bulges upwards under pressure. This type of case may be impossible

d9 ~tFig. 57 . - -Dick and Hur s t ' s d iagram illustrating the valvular action of the cardia in its normal posit ion and the loss of

the valve after herniation when the oesophagus enters the fundus of the pouch.

to detect radiologically unless we find some method of outlining the hiatal margins. Figs. 6o, 61 illustrate how confusion may arise from another cause. In this case the stomach appeared to be intimately related to the central tendon and an air bubble was persistently retained at this spot. When the patient took a deep breath the air bubble rose like a ball projecting into the thorax. The lining mucosa was obviously gastric and the condition mimicked a hiatal hernia but in fact was a form of herniation analogous to the direct inguinal hernia.

D I A G N O S I S O F E A R L Y G A S T R I C H E R N I A T I O N 63

Fig. 58.--Easy regurgitation into cesophagus. Child Fig. 59.--Appearance at inspiration at the end of crying, a prolonged cry. Arrow marks peptic ulceration. The

dilatation below is due to the thoracic stomach. Prob- able congenital short cesophagus.

(Reproduced from " A Text-book of X-Ray Diagnosis" (ed. Shank~ and Kerley), b v kind permission.)

Fig. 6o.--Demonstrates the fundus of the stomach lying closely related to the central tendon and left dome. F i lm taken in e:¢piration.

Fig. 6 i . - -Same patient as in Fig. 60, film taken in full inspiration. The air in the stomach has been compressed by the dome of the diaphragm bu t has ex- panded a small segment lying adjacent to the central tendon. This is analogous to a direct inguinal hernia.

64 J O U R N A L O F T H E F A C U L T Y O F R A D I O L O G I S T S

A new method of examination, however, provides convincing proof of the physiological defect. After the stomach has been filled with barium the patient, standing sideways to the screen, is asked to bend down and touch the toes. As the intra-abdominal pressure rises the hiatus hernia distends and barium will flood back into the oesophagus on deep inspiration or coughing. (Figs. 62, 63. ) I believe regurgitation to be the most important sign of abnormality, and, if absent, little clinical significance need be attached to any small pouch found at the oesophageal hiatus.

The sequel of free regurgitation of gastric juices is well known. Superficial erosion leads to deep peptic ulceration, fibrosis and stenosis of the oesophagus. Not only does the oesophagus

Fig. 6z . - -Smal l hiatal hernia seen in the erect position.

Fig. 63.--Same case as in Fig. 6z, showing a welt-marked gastric protrusion when bending. Some barium had just flooded back into the oesophagus im- mediately before the film was taken.

narrow but it shortens by contraction of the longitudinal muscles. A hernia which previously had been of the sliding type now becomes irreducible, although the amount of stomach which enters the sac may vary with posture and pressure. Very few of these cases are due to congenital shortening of the oesophagus. There may, however, be other developmental reasons for their existence such as a wide hiatus, an atrophic phreno-oesophageal membrane, or an imperfect gastro-phrenic ligament.

SUMMARY The oesophagus and stomach cannot be separated by a straight line at the cardia. The terminal

part of the oesophagus which lies in the hiatal tunnel behaves in some respects as if it were part of the stomach, conforming to the old anatomical description of the cardiac antrum. This segment may be lined ~vith gastric mucosa. I f barium becomes trapped within it, a small pouch is formed which may lie or appear to lie above the diaphragm. Owing to the uneven contour of the diaphragm it may be difficult to assess the true position of the pouch and the hiatal constriction in inspiration should be used as ~i guide. Thus a small protrusion of the cardiac antrum may extend through the hiatus and resemble a gastric hernia, while the diaphragm may continue to 6~/6rc~ge it s pinch-cock action. Unless, ther~6fore, there is free regurgitation into the oesophagus sucli a pouch has no real clinical significance. Thus ~t iS most important to realize that " the morbidity of hiatus hernia is brought about by a physiological rather than an anatomical defect ". In the absence of clear-cut diagnostic features, I am convinced that the condition cannot be recognized by radiology alone.

D I A G N O S I S O F E A R L Y G A S T R I C H E R N I A T I O N 65

(Esophagoscopy is essential, not only to localize the posi t ion of the mucosa l junc t ion in relation to the hiatal constrict ion, but to exclude msophagitis and ulcerat ion, for these changes provide all the evidence to convict the ' scapegoat '.

In conclusion, I would like to express m y sincere thanks to Phil l ip Allison. W i t h o u t his s t imulat ing ideas, co-operat ion, and unceasing en thus iasm this work could not have been done.

BIBLIOGRAPHY AKERLUND, A. (I926), Acta. radiol., Stockh., 6, 3. ALLISON, P. R. (I942), Proc. R. Soc. Ned., 36, 96. - - - - (I946), J. thorac. Surg., 15, 5, 3o8. - - - - (i948), Thorax, 3, I, 2o. - - - - JOI~NSTONE, A. S., and RoYcE, G. S. (I943), J. thorae. Surg., 12, 432. ARNOLD, Quoted by TEMPLETON. BEIGGS, P. J., DICK, R. C. S., and HURST, A. F. (I939), Proc. R. Soc. Ned., 32, 1423. CARLSON, Quoted by TEMPLETON. CLERF, L. H., and MANGES, W. F. (I933), Ann. Otol., etc., St. Louis, 42, lO58. DICK, R. C. S., and HURST, A. F. (I94Z), Quart. J. Ned., 35, lO5. DUNH[LL, T., (I935) , Brit. J. Surg., 22, 475. FELDraAN, M. (I939), Amer. J. reed. Sci., 198, 165. FINDLAY, L. (I933), Thomson's ' Clinical Study and Treatment of Sick Children '. Oliver and Boyd. - - - - and KELLY, A. B. (I93I), J. Laryng., 46, 797- FRIEDENWALD, J., FELDMAN, M., and ZINN, W. F. (1929) , Amer. J. reed. Sci., 177 , I. HARRINGTON, S. W. (194o), Amer. J. Surg., 5o, 377- - - - - (I943), Amer. J. Roentgenol., 49, 2, 185. HASSE and STRECKER, Quoted by TEMPLETON. JACKSON, C. (I929), J. Amer. reed. Ass., 92, 369. JOHNSTONE, A. S. (I94I), Brit. J. Radiol., 14, 177. LENDRUM, F. R. (I937), Arch. intern. Med., 59, 474- ROBINS, S. A., and JANKELSON, J. B., (1926), J. Amer. reed. Ass., 87, 1961. SCHATZSKI, R. (I943), Fortschr. Roentgenstr., 65, 177. SHANKS, S. COCHRANE, (I948), Brit. J. Radiol., 21, 242. SMITHERS, D. M. (I945), Ibid., 18, 199. STEINER, G. (I946), Ibid., 19, 22o. STEWART, M. J., and HARTFALL, S. J. (i929) , J . Path. Bact., 32, 9. TEMPLETON, F. E. (I944),X-ray Examination of the Stomach. Chicago : University Press. WINKELSTEIN, (I935) , J. Amer. med. Ass., lO9, 9o6.

THE FACULTY OF RADIOLOGISTS FELLOWSHIP EXAMINATION

~I~HE fol lowing candidates satisfied the Fel lowship Board at the examina t ion for the Fel lowship held in L o n d o n in May, 1951 : - -

F. M. Hooper , M.B. , B.S., D .D .R . , S y d n e y : Radiodiagnosis. Margare t D. Snelling, M.B. , B.S., M.R .C .P . , F .R .C.S . , D . M . R . , L o n d o n : Radiotherapy.

T h e next examinat ion will begin on N o v e m b e r 12. En t rance forms, which mus t be sent in by S e p t e m b e r 3 ° , and fur ther part iculars may be obta ined f rom the W a r d e n of the Fel lowship, Facu l ty .of Radiologists, 45, L inco ln ' s I n n Fields, London , W.C.2 .