Traumatic diaphragmatic hernia is diagnosed during one of three phases. These are immediately after the trauma, during an interval phase, or when it becomes complicated by obstruction or strangulation of the contents of the hernia (Carter et al, 1951).We report a patient who presented some weeks after the original injury with the unusual complication of gangrene of the stomach. In addition, the basal segments of the left lower lobe of the lung that were in close proximity to the stomach were destroyed, presumably by transudation through the necrotic stomach of gastric secretions, necessitating left lower lobectomy. This complication has not previously been reported. Case reportThe patient, a 68-year-old woman, was on holiday in Wales when she fell down a short flight of stairs. She sustained fractures of the clavicle and the left second to eighth ribs. Within a month she had apparently fully recovered.Four months later she was readmitted as an emergency with severe left-sided chest pain radiating to the left shoulder and arm, and severe colicky pain in the epigastrium. She was not shocked and was apyrexial. The only physical sign in the chest was reduced air entry at the left base. She was slightly tender in the epigastrium. The chest radiograph was thought to show a raised left diaphragm with clear lung fields (see figure);an ECG was normal. She was treated symptomatically. A barium meal the next day showed herniation of the greater part of the stomach into the left chest.

Ventricular fibrillation has been studied by driving the ventricles of the isolated rabbit heart electrically and observing whether fibrillation persisted after stimulation was stopped. The hearts were perfused by solutions of different ionic composition and the proportion of hearts in which persistent fibrillation was seen was determined for each solution. The proportion was controlled from 0 to 100 per cent according to the amount of K + , hearts fibrillating spontaneously in .25 N K + . A similar study was made by varying Ca" 1^" . Fibrillation was arrested by ATP and prolonged by dinitrophenol. Fibrillating hearts lost more K + than when they were not fibrillating. Fibrillation appeared to depend on disturbances of the metabolic processes concerned with ion movements.

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Giant cell arteritis may occasionally affect the aorta and larger pulmonary arteries. This can be part of a systemic disease such as necrotising sarcoid granulomatosis or systemic lupus erythematosus, but may also be due to specific conditions, particularly disseminated temporal arteritis (giant cell arteritis). When the pulmonary arteries alone are affected they are usually medium sized and affected as part of a generalised connective tissue disorder such as rheumatoid arthritis. Takayashu's disease may also affect the larger elastic pulmonary arteries or the main pulmonary trunk. This paper describes a previously unreported condition of aneurysmal dilatation of the ascending aorta and main pulmonary trunk with no concomitant generalised connective tissue disorder. Case reportA 55 year old woman was admitted to hospital after six months of increasing fatigue, three months of shortness of breath, and two recent episodes of paroxysmal nocturnal dyspnoea, although she had no chest pain. She gave no history of rheumatic or scarlet fever.The jugular venous pressure was normal, the pulse regular (82 beats/minute) but collapsing in nature, and the blood pressure 150/50 mm Hg. All peripheral pulses were present. There was moderate left ventricular enlargement.Both heart sounds were present and in the aortic area there was an ejection systolic murmur and a loud diastolic murmur.The results of laboratory tests for rheumatoid arthritis, systemic lupus erythematosus, and syphilis were negative. pulmonary trunk were found. An exudate over the aorta suggested recent active inflammation. The pulmonary artery was extremely thin and densely adherent to the aorta, so that an adequate plane of cleavage could not be found. Dilatation of the aorta continued up to the beginning of the arch and similar pulmonary dilatation was present to the bifurcation of the artery, with considerable thinning of the wall. The right pulmonary artery appeared normal. Frozen section biopsy specimens from both arteries showed active giant cell arteritis. The aortic valve cusps were thickened, allowing considerable regurgitation. The aortic valve was resected and replaced with a 23 mm Bjork-Shiley valve. The aorta was divided longitudinally and replaced with a 32 mm preclotted Dacron graft from the level of the innominate artery to just above the valve. Similarly the pulmonary artery was divided longitudinally (revealing multiple areas of dissection), and replaced from the bifurcation to just above the valve cusps. Subsequent histological examination confirmed the findings from the frozen sections. The patient made a satisfactory postoperative recovery and remained well for three years, with no evidence of recurrent aneurysm formation or valvular incompetence.Histological examination showed the pulmonary artery to be thinned, with a considerable quantity of metachromatic material in the wall. One part of the arterial wall showed early dissection. In the adventitia there was a striking degree of granulomatous arteritis in the form of appreciable adventit...