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mediate effect).

JPha-i Lucosil
gesin clyster

I %
lO I 6.7
50 I 33.3
- Block, M.
atment of Ul
Quarterly. In
945. - Hille
13, 712, 1950.
ta med. scan
3, 311, 1948.
Acta M.edica Scandinavica. Vol. CXLI, fasc. III, 1951.
From the Medical Department B of the Rigshospitalet, Copenhagen, Denmark.
(Chief: Professor Erik Warburg, M. D.)
Venous Pressure Measurement.
I. Choice of Zero Level.
(Submitted for publication, May 15, 19M.)
Numerous publications on clinical measurement of the venous pressure have
seen the light of day during the past half century, but the procedures have dif
fered widely and the results have often been conflicting. The inaccuracy of venous
pressure measurement is due partly to the hydrostatic correction, partly to the
apparatus, and partly to the failure to eliminate those factors in the physiological
state of the individual which may compromise the measurement. In the present
and a following paper the writers propose to deal with these three SDurces of
error and to describe a new method for direct venous pressure measurement by
means of the T y b j ~ r g Hansen electric condenser manometer.
Reference Level (Zero Le\'el).
In pressure measurements anywhere in the circulation two quantities may be
of interest: One is the locah pressure, i. e. the actual intravascular excess pres
sure as compared with the surrounding outer pressure at the given site and in a
given posture; the other one is the general clinical quantity, the venous pressure
or the arterial pressure following correction for hydrostatic factors, i. e. measured
from a common reference level and under given external conditions. This correc
tion is of little moment in the measurement of arterial pressure, but it is of the
utmost importance in the measurement of the low venous pressures (and in pres
sure measurements during right cardiac catheterisations) and constitutes one of
the main sources of inaccuracy in venous pressure measurements.
The object of establishing a common reference level must be to obtain com
parable values of pressure measurements (from patient to patient), and the ac
14-512849. Acta med. scandinav. Vol. CXLI.
curate placement of this initial level is bound to be arbitrary to a certain extent.
It is generally agreed, however, that for practical reasons the reference level ought
to be at the level where the diastolic filling pressure ends and the systolic ex
cess pressure arises, i. e. on a level with the heart - in the case of venous pressure
on a level with the right auricle - but there is little agreement as to the position
of the latter in the chest.
Of course, the right auricle is of some extent. Its upper and lower borders - in
the horizontal position - are usually considered to be at the attachments of the
3rd and 6th ribs to the sternum and its centre consequently at the sternal end
of the 4th intercostal space. In the sagittal plane its extent (excluding the auric
ular appendage) is presumably somewhat larger than the posterior half of the
heart shadow, seen from the lateral aspect. These data from topograhpic hand
books accord fairly well with experience from cardiac catheterisation and with
the findings reported by Lyons, Kennedy & Burwell (8). In cross sections of 14
frozen cadavers they found the anterior border of the right auricle to be within
40 to 50 mm of the anterior border of the thorax and the antero-posterior dia
meter of the auricle to be 40-70 mm; and Roesler (12), in an orthodiagraphic
study of 150 normal subjects, found a sagittal extent of the heart shadow between
63 and 107 mm.
The level within the heart (or within the right auricle) from which the measure
ments are made is of subordinate importance, but the zero level naturally must,
as far as possible, pass through the same level in the heart in all patients, regard
less of the size of the chest.
The outer pressure to which the zero pressure is referred is usually the atmos
pheric pressure. It has been suggested, however, that for determination of the
effective venous pressure reference should be made to the negative intrathoracic
pressure (4), but experiences from heart catheterisation have shown that the nor
mal pressure in the right auricle corresponds fairly well to the atmospheric pres
sure (1, 2), and in the present paper, therefore, no regard is paid to the intra
thoracic pressure.
Previous Investigations.
Numerous and widely different zero levels have been suggested and employed
in the measurement of venous pressure. Lyons, Kennedy & Burwell (8) have
tabulated the reference levels used by various authors, compared with their meth
ods and normal values. From among the numerous zero levels which have been
suggested in the course of time, the more well-defined ones are divisible into three
(1) A fixed distance from the anterior surface of the chest: Lewis (7) measured
from the suprasternal notch proper. - Moritz & Tabora (9), experimenting on
the cadaver, found the entrance of the caval veins to be 5 cm posterior to the
4th costo-chondral junction. - Bloomfield etal. (1) found the centre of the heart
shadow on lateral X-ray films to be on the average 5 cm below the angle of Louis
with a mean error of about 1 cm.
(2) A fixed
vers Lyons, KE
to be 80-105
42 normal sub
anterior to the
back, and wit!
lower venous ]
(3) A measu
hausen (10) p1
sure) at the ce
of Winsor & 1
has shown to
a plane throu
static level is
- Hooker &
of the antero
used also: H ~
Schleiter (13)
ca theteriza tiOl
Copenhagen C
of the cathete
et al. as well f
tip in the sagi
gested comple
sure as the 11
the same refE
individual caE
two pressure
the centre of
point of view
lowing requir
level in the 1
landmarks. A
necting the j
determine th
making X-ra
passed throu
down into tl
lOur thanks
Rigshospitalet, '
for the permissi
level ought
systolic ex
ous pressure
the position
orders - in
lents of the
sternal end
g the auric
half of the
'thpic hand
n and with
ctions of 14
,0 be within
)sterior dia
low between
he measure
llrally must,
mts, regard
, the atmos
ltion of the
hat the nor
:pheric pres
jO the intra
.d .employed
ell (8) have
1 their meth
h have been
Ie into three
7) measured
imenting on
;erior to the
of the heart
19le of Louis
(2) A fixed distance from the posterior surface of the chest: Studying 14 cada
vers Lyons, Kennedy & Burwell (8) found the posterior border of the right auricle
to be 80-105 mm anterior to the skin of the back, and on fluoroscopic study of
42 normal subjects the posterior border of the cardiac shadow was 65-100 mm
anterior to the skin of the back. They selected a zero level 10 em anterior to the
back, and with this level they found an even distribution of higher and
lower venous pressures on various thoracic diameters in 90 normal adults.
(3) A measure relative to the antero-posterior diameter of the chest: Reckling
hausen (10) proposed a zero level (for indirect measurement of the arterial pres
sure) at the centre of the chest at the xiphoid process. - The phlebostatic axis)}
of Winsor & Burch (14) is the line of intersection between this plane which X-ray
has shown to correspond to the entrance of the caval veins into the auricle, and
a plane through the 4th intercostal space adjacent to the sternum; their phlebo
static level is the horizontal plane through this axis, regardless of the posture.
- Hooker & Eyster (6) selected the junction of the anterior and middle thirds
of the antero-posterior diameter of the chest. - The axillary lines have been
used also: Harris (3) suggested the anterior axillary line, Taylor, Thomas &
Schleiter (13) the midaxillary line which also has been used in about 400 cardiac
catheterizations at the Medical Department B of the University Hospital in
Copenhagen (2).
Catheterizing the hearts of 5 patients Richards et al. (11) found the position
of the catheter tip in the right auricle to accord best with the zero levels of Lyons
et al. as well as of Eyster, but their series is small and the position of the catheter
tip in the sagittal extent of the auricle is not mentioned. Lastly, Holt (5) has sug
gested complete elimination of the hydrostatic factor by stating the venous pres
sure as the mean value of the pressures in the supine and prone position, using
the same reference level (the spine). The zero point is then determined in each
individual case as midway between the tops of the two columns of saline in the
two pressure measurements; in 10 normal subjects this point was very close to
the centre of the thoracic depth. This procedure is interesting from a theoretical
point of view, but hardly applicable as a routine method.
Writers' Investigntions .
According to what has been stated above, the zero level must fulfil the fol
lowing requirements: A plane which as far as possible passes through the same
level in the heart of all patients and which is easy to find by means of external
landmarks. As a reproducible paine de repaire we chose the middle of the line con
necting the junction of the two caval veins with the right auricle. We tried to
determine the position of this point in the chest in the horizontai posture by
making X-ray films during cardiac catheterization, when the catheter had been
passed through the superior caval vein and the right auricle and was reaching
down into the inferior caval vein.
1 Our thanks are due to Drs. H. Gotzsche, P. Eskildsen, and A. Tybjrerg Hansen, Dept. B of the
Rigshospitalet, who carried out the ca theterizations, for their kind assistance in making the films and
for the permission to use the results of the catheterizations set out in Table I.
Fig. 1. One of the X-ray films, lateral view, with catheter through right auricle into inferior caval
vein. The (a) anterior sui-face and (f) posterior surface of the body, (b) anterior border and (d) pos
terior border of the heart shadow, (c) catheter in the right auricle, and (e) anterior surface of the ver
tebral column are plotted on a line drawn horizontally from the small piece of lead gum in the fourth
intercostal spaoe (cf. Table I).
The films are true lateral views, the patient lying on his back on a flat couch
and the tube centred, by means of a water level, horizontally on a level with the
middle of the chest, the cassette being placed vertically against the lateral aspect
of the chest as high up in the axilla as possible. For technical reasons it was im
possible to obtain a focal-film distance longer than 11/2 m, but the position of
the catheter near the median axis of the chest (in the sagittal as well as the fron
tal plane) reduces the consequent distortion. The films were made in mean in
spiration and exposed for 3
-41/2 seconds, i. c. through all phases of the cardiac
cycle. The films show the catheter stretching through the auricle as a direct con
nection between the entrances of the caval veins (i. e. taking an oblique down
ward and backward course, since the superior caval vein is always anterior to the
inferior caval vein).
On the films all the measurements were done on a level with the fourth inter
costal space anteriorly. The site was marked with a small piece of lead gum over
the sternum and another piece over the spine at the same level (Fig. 1). The point
of intersection between the catheter and this plane should be the centre of the line
V E ~ O
connecting the e
and the patientf
The present s
of the zero poin"
(Cases 3, 4, 10, :
confirmed by c;
from the midax
auricular pressu
position of the ,
other cases, wh
11, however, re:
The distance
63 to 111 mm,
tance to the b:
deviation of 16.
(14-15 %of t
at a fixed dist:
from the figure
posterior surfa(
varies from 0.:
other words, b
of the cathete:
was no signifi<
the average fa
for the 10 pai
In the meaf
a distance of
sternum on a .
with employil
to ordinary d
on the water
middle of thE
will result in
It is most
pelvimeter, "
and breathin
between the
the couch wa
usually 1-2
visable to lei
ment and to
to inferior caval
der and (dl pos
trface of the ver
urn in the fourth
. a flat couch
eveI with the
lateral aspect
ns it was im
e position of
1 as the fron
in mean in
)f the cardiac
a direct con
blique down
rrterior to the
fourth inter
lad gum over
1). The point
bre of the line
connecting the entrances of the two caval veins. The results of the measurements
and the patients' data will be seen in Table 1.
The present series of 18 patients differs from previous studies on the location
of the zero point in including several children and young adults. In four patients
(Cases 3, 4, 10, and 11) X-ray showed enlargement of the right auricle which was
confirmed by catheterization; all had an elevated auricular pressure (measured
from the midaxillary line). Case 16, moreover, exhibited a doubtful increase in
auricular pressure without signs of auricular enlargement. In these patients, the
position of the catheter in the chest did not differ significantly from that in the
other cases, where no abnormality of the right auricle was found. Cases 10 and
11, however, represent some of the extreme values at both ends.
The distance of the catheter from the anterior surface of the chest ranged from
63 to 111 mm, averaging 91 mm with a standard deviation of 13.7 mm. The dis
tance to the back ranged from 88 to 170 mm, averaging 122, with a standard
deviation of 16.9 mm - i. e. the mean error in per cent would be about the same
(14-15 % of the distance), if the zero level in these patients were to be placed
at a fixed distance from the anterior or posterior surface. It is clearly apparent
from the figures, however, that the distance of the catheter from the anterior and
posterior surface is a function of the antero-posterior diameter of the chest. The
distance of catheter from anterior surface
antero-posterior diameter of the chest
varies from 0.38 to 0.49, averaging 0.427 with a standard deviation of 0.029. In
other words, by using this average quotient, it is possible to calculate the position
of the catheter with a mean error of about 3 %of the thoracic diameter. There
was no significant difference in the size of this quotient in large and small chests:
the average for the 8 patients with a diameter smaller than 21 em was 0.434 and
for the 10 patients with a diameter exceeding 21 em 0.422 .
In the measurements to be reported below, therefore, we chose a zero level at
a distance of 0.43 times the depth of the chest below the anterior surface of the
sternum on a level with the fourth intercostal space. No difficulties are connected
with employing this average value as a zero level, if the quotients corresponding
to ordinary diameters between 15 and 30 em are written down beforehand (e. g.
on the water level used in the adjustment). To obtain a simpler conversion, the
middle of the chest depth, measured at the same level, may also be used. This
will result in 1 to 2 cm higher pressure.
It is most practical to measure the diameter of the chest with an obstetrical
pelvimeter, while the patient is sitting normally (not straightening his back)
and breathing normally. Repeated measurements showed no definite difference
between the diameter of the chest in the sitting and horizontal position, when
the couch was fairly resilient. On a hard and flat couch the depth of the chest was
usually 1-2 em greater in the horizontal position. For this reason also it is ad
visable to let the patient lie in his own bed during the venous pressure measure
ment and to adjust the zero point to the anterior surface of the chest. The height
X-ray Appearances in 18 Cases. Lateral View. Catheter Introduced through Right Auricle
Sex Age Diagnosis Radiological Findings
1 F 7 Congen. heart dis. (Patent ductus art.) Slight prominence of outflow tract of
, right ventricle.
2 M 6 No heart dis. found. Normal.
3 F 8 Mitral stenosis. Decompensation. Mitral configuration. Marked enlarge
ment of both auricles.
4 12 Congen. heart dis. (Isolated pulmonary Huge right auricle. Small right ven-/
stenosis). tricle.
5 14 Congen. heart dis. (Steno-Fallot's tet- Typical. Right ventricle enlarged.
6 M 13 No heart dis. found. Normal.
7 F 29 Congen. heart dis. (Coarctation of the Slight enlargement of left ventricle.
8 15 No heart dis. found. Normal. I
9 15 Congen. heart dis. (Ventricular septal Slight prominence of outflow tract of
defect.) right ventricle.
10 F 46 Mitral stenosis. Auricular fibril!. De- Heart greatly enlarged (H/Tratio 17/
compensation. 25'/,) with mitral configuration.
11 13 Congen. heart dis. (Auric. septal de- Enlargement of right auricle.
fect; atresia of right ventricle?)
12 19 Congen. heart dis. (Eisenmenger's Enlargement of left ventricle. Pulmon
syndrome.) ary artery normal.
13 18 Congen. heart dis. (Ventricular septal Enlargement of right ventricle and
defect.) pulmonary artery.
14 21 Congen. heart dis. (Coarctation of the Normal.
15 17 Congen. heart dis. (Patent ductus art.) Slight enlargement of right ventriclej'
and pulmonary artery.
16 F 32 Congen. heart dis. (Steno-Fallot's tet- Typical.
17 24 No heart dis. found. Normal.
18 43 Congen. heart dis. (Patent ductus art.) Enlargement of pulmonary artery and
Cor pulmonale (Boeck's disease) both ventricles.
Cfr. WarbiIrg, E: Nordisk Medicin 16: 3550, 1942 (cited in: Willius, F. A: Staff Meetings of the
should be adjusted by means of a water level placed on the sternum on a level
with the fourth intercostal space. We used an ordinary water level, 1 m in length;
when its full length is utilized, the height level may be adjusted with an accuracy
of at least 1/2 cm.
On Fig. 2 the values from Table I are plotted on a diagram and compared with
a few of the most commonly employed reference levels. The diagram illustrates
, VE
into Inferior Ca
Pressure in
Right Auricle
mm Hg
I not measured
I + 4 to + 12
+ 9 to + 18
+ 5 to + 10
-2 to + 4
-3 to + 3
+3 to + 6
+2 to + 6
+ 5 to + 17
o to + 7
+ 4 to + 10
-3 to + 4
+2 to + 7
o to + 12
+4 to + 9
+2 to + 8
Mayo Clinic 2f
the marked
of large chE
& Tabora
well). In 0
and Winso:
der of the
Table I.
Right Auricle into Inferior Caval Vein. All Measurements at the Level of the Sternal End of the Fourth
Intercostal Space. .
Measured on the X-ray Film:
on the
Distance from Anterior Surface of Thorax to:
Pressure in Patient:
Right Auricle
mm Hg Ant.-post. Ant.-post. Catheter Ant. Surface
IAnt. Border I
Post. Barder
Diam. of Diam. of in Right of Vertebral
of Heart
Thorax Thorax
I of Heart I
Auricle Column
utflow tract ofl not measured 13.0 em 15.1 cm 1.7 cm 6.3 cm 7.6 em 8.6 cm
- 3 to + 4 14.0 16.2 1.5 .) 6.5 8.4 9.5
farked enlarge
+ 4 to + 12 15.0 16.8
1.5 ,) 6.5 lOA ,) 11.0
,s. I
nail right ven-
+ 9 to + 18 16.0,) 19.4 2.5 9.6 12.0 12.3
.e enlarged.
+ 5 to + 10 17.0 2004 1.7 9.1 11.2 ,) 13.2
-2 to + 4 17.0 20.6 2.0 9.1 10.5 13.5
'eft ventricle.
-3 to + 3 17.0 20.7 2.4
8.6 10.3 11.8
+3 to + 6 18.0 20.8 2.3 ,) 9.8 10.7 .) 12.1
.utflow tract of
I + 2 to + 6 18.0,) 21.4 2.5
9.4 ,) 11.0 12.3
. (HIT ratio 17/1
+ 7 to + 22 19.0,) 21.7 2.3 9.3 12.0 14.5
nfiguration. I
wricle. I + 5 to + 17 18.5,) 22.0 1.8 ,) 10.2 11.9 13.2
ltricle. pUlmon-1 o to + 7 18.0,) 22.5
2.3 ,) 9.5 12.0 13.5
+4 to + 10 20.0,) 23.0 2.1 ,) 9.3 12.3 13.8
"nmd, ondI
- 3 to + 4 19.5 23.3 2.8 9.3 11.5 ,) 13.5
right ventricle I
+ 2 to + 7 20.5,) 23.5 2.1 9.9 12.8 14.8
o to + 12
20.0 24.1 3.2 ,) lOA 12.8 15.1
+4 to + 9
23.5 25.8 2.3 11.1 13.7 16.5
nary artery and!
+ 2 to + 8
25.0 27.5 2.1 10.5 15.0 18.3
f Meetings of the
Mayo Clinic 23: 316, 1948).
1m on a level
the marked deviation between the various reference levels, particularly in cases
L m in length;
of large chests (at a diameter of 30 em, for instance, the reference level of Moritz
~ an accuracy
& Tabora is not less than 15 em higher than that of Lyons, Kennedy & Bur
well). In our patients one-half depth of the chest (v. Recklinghausen's zero level
)mpared with
and Winsor & Burch's phlebostatic axis) is slightly anterior to the posterior bor
Lm illustrates
der of the heart shadow, i. 6. of the auricle. Eyster's zero level between the an
IJr'crmeier a/ lJzorcrx tDzeasured an X -ro:.Picture}
1 a $

i .lIearlSftadow
A Anterior$ur/IZi!ea
Verle.hra:l Col=...
........ " .
.lJi.danc:e /,elo>v
kisr,"", Surface
Fig. 2. Diagram of the measurements in Table I, compared with some of the commonly used reference
terior and middle third of the chest falls about the middle of the heart shadow,
i. e. presumably somewhere in the anterior part of the auricle. Bloomfield and co
workers' statement that the middle of the heart shadow is 5 cm below the angle
of Louis is not directly comparable with our results, since our measurements were
made from the level of the 4th intercostal space. The zero level of Lyons, Kennedy
& Burwell 10 cm above the couch is in a fairly constant relation to the anterior
border of the vertebral column (in the adults), but the distance from the catheter
increases considerably in the thick-chested subjects.
The situation of the axillary lines was studied in 15 males and 15 females,
selected at random among the patients in the department, excluding, however,
subjects with deformities of the chest or of the vertebral column. The patient
with the largest thoracic depth (32 cm) was suffering from emphysema. The an
tero-posterior diameter of the chest was measured with an obstetrical pelvimeter
on a level with the fourth intercostal space anteriorly, the distance of the an
terior and midaxillary lines from the anterior surface of the chest (average of
right and left side) was determined at the same level. As will be seen from Fig. '3,
these determinations carry a considerable deviation - at least in our hands
but as might be expected in males with a varying thoracic diameter, the distance
of the anterior axillary line is more constant from the anterior than from the
posterior aspect. Of course, this applies also, but to a lesser extent, to the mid
axillary line. In adult, females is a distinct tendency to place the

J1en 11h.ll
J)i.s'ianC'f' .be
Anterior 5z
Fig. 3. Diagram of
Venous Pressure
Measured from
thoracic diame
Referred to ,zero
Referred to zero
Referred to zerc
Referred to zero
lines more' pos
axilla. Thus, t
establishing tl
As mentiOn(
to obtain com
!% J rTa:.bora
used reference
art shadow,
ield and co
w the angle
lments were
lS, Kennedy
the anterior
the catheter
15 females,
g, however,
fhe patient
aa. The an
. pelvimeter
of the an
(average of
'rom Fig. 3,
lr hands
;he distance
n from the
to the mid
}fen W6.m.en
0 AnierzOrAxd!aryLine
'" ,t,. i'1zd=ilta-ry Line



0 0

0 0

Anferlor Surface
of 'lJwraxo.
Fig. 3. Diagram of the position of the anterior and midaxillary lines in 15 men and 15 women,-com
pared with the reference level used in the present study.
'rable II.
Venous Pressure (mm of Water) Referred to Different Zero Levels in Forty Normal Adults.
Thoracic Diameter Thoracic Diameter
18--20'/. em
21-26 em
I (9 men and 12 women) (13 men and 6 women)
Range Mean
! Measured from here suggested zero level (0.43 X
_ thoracic diameter) ........................... 86
Referred to zero level of Moritz & Tabora ...... I 56 39- 67 43 23- 64
1 1
Referred to zero level of Eyster ................ 1
54- 81
50- 84
Referred to zero level of Recklinghausen ........ 1 100 84-114 106 85-123
1 1 1
Referred to zero level of L ons Kenned & Burwell 76-114 117 90-144
___y________y______ __ ___ ___ _______
lines more posteriorly because of the mammary tissue in the anterior fold of the
axilla. Thus, the axillary lines do not appear to afford a quite reliable basis for
establishing the zero level.
As mentioned previously, the practical purpose of a common reference level is
to obtain comparable values of pressure measurements from one patient to an
other regardless of the anatomical differences, especially the size of the chest.
With the technique described in the following paper we have measured the venous
pressure in forty adults, partly normal test subjects and partly patients in the
department with slight and irrelevant disorders (myopathies, gastro-intestinal
disturbances) and with normal electrocardiogram and X-ray configuration of the
heart. It will appear from table II that the best accordance between the values
in patients with small and large chests and the smallest range was obtained with
the reference levels fixed as a measure relative to the size of the chest.
The problem of establishing a common reference level for pressure measure
ments in the circulation has been investigated.
X-ray films made during cardiac catheterisation in 18 patients (including
children) have shown the centre of the line joining the entrances of the two caval
veins into the right auricle to be an average distance of 0.43 times the thoracic
diameter from the anterior surface of the chest, the mean deviation being only
3 % of the thoracic diameter. This average value (or half the thoracic diameter
measured on a level with the fourth intercostal space anteriorly) is proposed as
the reference level of venous pressure measurement in the supine position.
This reference level has been compared with some of the commonly used refer
ence levels and with the position of the axillary lines.
In 40 normal subjects the venous pressure measured from this reference level
showed no significant relationship to the thoracic diameter.
1. Bloomfield, R. A., H. D. Lausen, A. Cournand, E. S. Breed & D. W. Richards:
J. Clin. Investigation 25: 369, 1946. - 2. G0tzsche, H. & E. Warburg: Acta med. scan
dinav. 1951 (in press). - 3. Harris, 1.: Edinburgh M. J. 35: 630, 1928. - 4. Henderson,
Y. & T. B. Barringer: Am. J. Physiol., 31: 352, 1913. - 5. Holt, J. P.: Am. J. Physiol.,
130: 635, 1940. - 6. Hooker, D. R. & J. A. E. Eyster: Bull. Johns Hopkins Hosp., 19:
274, 1908. - 7. Lewis, T.: Brit. M. J., 1: 849, 1930. - 8. Lyons, R. H., J. A. Kennedy
& C. S. Burwell: Am. Heart J. 16: 675, 1938. - 9. Moritz, F. & D. von Tabora: Deut
sches Arch. f. klin. Med. 98: 475, 1910. - 10. von Recklinghausen, H.: Arch. f. exper.
Path. u. Pharmakol. 55: 375, 1906. - 11. Richards, D. W. jr., A. Cournand, R. C. Dar
ling & W. H. Gillespie: Tr. A. Am. Physicians 56: 218, 1941. - 12. Roesler, H.: Am.
J. RoentgenoI. 32: 464, 1934. - 13. Taylor, F. A., A. B. Thomas & H. G. Schleiter:
Proc. Soc. Exper. BioI. & Med. 27: 867, 1930. - 14. Winsor, T. & G. E. Burch: Proc.
Soc. Exper. BioI. & Med. 58: 165, 1945.
From the Depar'
and Biochemistr
It is well-k
conditions are
in many other
be low. In chrl
synthetizing p
impaired. Hov
ulinemia, as it
globulinemia 1
The serum
and quantita1
but the resul1
work that in
alysis. It may
well-known d
these is lymF
A specific d i ~
symptoms arE
by appropriai
ed and from
closely connel
1 Present addJ
Present add:
~ - - - - - -