^ THE \ a LIBRAR8ES % HIALTH SCIESCB8 T.IBKASCf Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/roentgendiagnosiOOgeor ^^ ■ r / r ynsMK^ \ ^ I ^ «::yuoAu)'?*v.K^.rrv^, RESECTED PORTION OF SIGMOID THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS of the GASTRO-INTESTINAL TRACT BY ARIAL W. GEORGE, M.D. Assistant Professor of the Department of Roentgenology, Tufts College Medical School; Con- sulting Roentgenologist to the Carney Hospital ; Boston Dispensary and the Forsyth Dental Infirmary; Fellow of the Massachusetts Medical Society; Member of the American Roentgen Ray Society AND RALPH D. LEONARD, A.B., M.D. Assistant in the Roentgen Department of the Boston City Hospital; Instructor in Roentgenology at Tufts College Medical School; Fellow of the Massachusetts Medical Society THREE HUNDRED AND SIX PAGES Including Seven Three-color Illustrations Eighteen Artist's Drawings, Three Hundred and Forty-three Roentgen Plate Reproductions BOSTON THE COLONIAL MEDICAL PRESS NINETEEN HUNDRED AND FIFTEEN ALL RIGHTS RESERVED Copyright, 1915, by THE COLONIAL MEDICAL PRESS All rights reserved, including that of translation into foreign languages, including the Scandinavian To FRANCIS H. WILLIAMS, M.D. BOSTON IN RECOGNITION OF THE AID WHICH HE HAS GIVEN TO THE SUBJECT OP ROENTGENOLOGY PREFACE The purpose of this work is to demonstrate what one Roentgen chnic has accompUshed toward estabUshing a method for exact diagnosis in the common surgical lesions of the gastro- intestinal tract. We are presenting the typical Roentgen pictures of normal and pathological gastro-intestinal conditions. The text has been kept as brief as possible, and endeavor has been made to use the nomenclature as adopted by the American Roentgen Ray Society. (See page 278 for these terms.) It is hoped that this work will be of value not alone to the Roentgenologist, but to the general practitioner and surgeon. To the physician this book will mean a greater familiarity with the possibilities of Roentgen diagnosis and a better appreciation of the real value of Roentgen evidence. However, we shall rest content if, with any measure of success, prog- ress has been made toward the true classification and standardization of the varied and confusing Roentgen observations. The cases on which this study has been based, with the exception of four gastric ulcers, are all taken from our private clinic. The ultimate diagnosis in each case has been made by operation, autopsy, or unmistakable chnical course. Furthermore, the cases are con- sidered purely from the Roentgen point of view. We have often found the clinical evidence to be so superficial and inaccm-ate that we have practically eliminated, from the text, the whole clinical story. Again, it is not within the scope of this book to enter to any extent into the purely technical details involved in the general practice of Roentgenology. Careful consideration has been given to the method of reproducing the Roentgen plates. The positive half-tone seems to most accurately simulate the original. All reproductions have been made from reduced photographs of the Roentgen plate. Rarely do they equal the briUiancy of the original, but in not a single instance has there been any artificial tampering to improve the appearance of the reproduction. All artist's plates are from drawings made at the time of operation by Miss Blair of the Department of Surgical Pathology, Harvard Medical School, to whom the writers are indebted. These drawings are at least diagrammaticaUj^ correct and have been approved in each case hj the operating surgeon. Finally, we wish to express our gratitude to Doctors C. L. Scudder, E. A. Locke, J. W. Dewis, and George Carroll Smith of Boston, also to Dr. Isaac Gerber of Providence, R. I., for their enthusiasm and material assistance in carrying out this work. ARIAL W. GEORGE RALPH D. LEONARD 43 Bay State Road, Boston. TABLE OF CONTENTS Section I. NORMAL STOMACH. Indirect Method — Direct Method — Meals — Apparatus — General Routine — Normal Stomach. Section II. GASTRIC ULCER. Definition — Technique — Normal Gastric Shadow — Variations from the Normal — Positive Signs of Ulcer — Presumptive Signs of Ulcer. Section III. GASTRIC NEW GROWTH. Classification — Value of the Roentgen Ray in Diagnosis and Prog- nosis — Early Carcinoma — Advanced Carcinoma with Symptoms — and Without Symptoms — Value of the Negative Plate. Section IV. DUODENUM. Definition — Pathology — Possibility of a Positive Diagnosis — "Seven Propositions " — Serial Plates — Presumptive Evidence — Value of Roentgenoscope. Section V. GALL-BLADDER. Percentage of Stones which Show — Technique — Preparation and Position of Patient, Tubes, Plates, Screens, Stereoscopic Plates — Demonstration of Diseased Gail-Bladder — Adhesions. Section VI. SMALL INTESTINE. Jejunum — Ileum — Normal Roentgen Picture — Malposition — Func- tional and Organic Disturbances. Section VII. APPENDIX. Meals — Technique — Pathological Appendices. Section VIII. LARGE INTESTINE. Method of Study — Opaque Meal and Enema — Normal Appearance — Chronic Constipation — New Growth — Malformation and Malposi- tion — Adhesions — Colitis. Section IX. DIVERTICULITIS. LIST OF ILLUSTRATIONS NORMAL STOMACH Fig. No. Page No. 1 Key plate . ■ 7 2 Normal stomach. Variation ot the stomach and duodenum 3 Normal stomach. Lateral view 4 Normal stomach. Lateral view 5 Normal stomach 6 Same case as Fig. 5. Lateral view 7 Same case as Fig. 5 showing pressure on stomach . . . 8 Normal stomach 9 Same case as Fig. 8. Upright position 10 Same case as Fig. 8. Six hours after the bismuth meal 11 Same case as Fig. 8. Twenty-four houi's after the bismuth meal 12 Normal stomach 13 Same case as Fig. 12. Upright position 14 Normal stomach. Ptosis and dilatation 15 Same case as Fig. 14. Upright position 16 Normal stomach. Ptosis 17 Same case as Fig. 16. Six months later 18 Same case as Fig. 17. Six hours after bismuth meal 19 Normal stomach. Dilatation and ptosis 20 Same case as Fig. 19. Upright position 21 Dilated stomach 22 Same case as Fig. 21 23 Normal stomach 24 Same case as Fig. 23. Upright position 25 Normal stomach 26 Same case as Fig. 25 27 Normal stomach 28 Normal stomach 29 Dilated stomach 30 Dilated stomach 31 Normal stomach 32 Same case as Fig. 31 33 Dilatation and ptosis of the stomach 34 Hypernephi'oma causing pressure on a normal stomach 3^ Hypernephroma Hour-glass constriction Lateral view Hour-glass constriction Perforating duo- 13 15 15 15 15 17 17 17 19 19 21 21 23 23 25 25 25 27 27 29 29 29 31 31 31 GASTRIC ULCER 36 Obstruction of cesojjhagus 37 Gastric ulcer near cardia 38 Same case as Fig. 37 39 Gastric ulcer with hour-glass constriction 40 Cbroiiir nMsl lie ulcer 41 Chrome penetrating gastric ulcer. Hom--glass con- striction 42 Chronic gastric ulcer. Hom--glass formation 43 Chronic gastric ulcer. Small perforating ulcer 44 Chronic gastric ulcer, hour-glass formation. Perfor- ating ulcer 45 Hour-glass constriction of the stomach 46 Chronic gastric ulcer 47 Artist's drawing of same case as Fig. 46 48 Chronic gastric ulcer 49 Chronic perforating gastric ulcer 50 Chronic perforating gastric ulcer 51 Chronic gastric ulcer 52 Chronic gastric ulcer . 53 Chronic gastric ulcer. 54 Same case as Fig. 53. 55 Chronic gastric ulcer. 56 Chronic gastric ulcer, adhesions. denal ulcer 56A Artist's drawing of same case as Fig. 56. Plate I. Colored Following 57 Chronic gastric ulcer. Adhesions 58 Chi'onic gastric ulcer. Hour-glass constriction 69 Artist's drawing of same case as Fig. -58 Fig. No. Page No. 60 Chi'onic gastric ulcer. Pathological gall-bladder. ... 51 61 Same case as Fig. 60. Six hours after the bismuth meal 51 62 Chronic ulcer of the stomach 51 63 Traumatic hour-glass constriction of the stomach ... 53 64 Chi'onic gastric ulcer 53 65 Chronic gastric ulcer 53 66 Chi'onic gastric ulcer 55 67 Chronic gastric ulcer with tumor mass 55 68 Ulcer near pylorus 55 69 Chi'onic ulcer at pylorus 57 70 Small gastric ulcer 57 71 Several gastric ulcers. Duodenal ulcer 59 72 Ai'tist's drawing of same case as Fig. 71 59 73 Chronic gastric ulcer near the pylorus 61 74 Same case as Fig. 73. Prone position 61 75 Same case as Fig. 73 after resection of the stomach . . 61 76 Pyloric obstruction. Ulcer of the pylorus 63 77 Ulcer near pylorus 63 78 Same case as Fig. 77. Upright position 63 79, 80, 81, 82 Series of plates of a small gastric ulcer. . 65 83 Gastric ulcer of stomach. Hour-glass constriction . . 67 83A Gastric ulcer near pylorus 67 GASTRIC NEW GROWTH 84 Key plate. Normal stomach 85 Ai-tist's drawing of same case as Fig. 86. Plate IL Colored Following 86 Inoperable carcinoma of the stomach 87 Adenocarcinoma on base of old ulcer 88 Same case as Fig. 87 89 Same case as Fig. 87 90 Ai'tist's ch-awing of resected portion of stomach and duodenum 91 Adenocarcinoma. Chronic ulcer 92 Early carcinoma at pylorus 93 Early carcinoma at pylorus 94 Carcinoma of pylorus and antrum of the stomach. . . 95 Early carcinoma of pylorus 96 Carcinoma of pylorus and antrum of the stomach. . . 97 Ai'tist's di'awing of same case as Fig. 96 98 Earlv rarcinonia nf antrum of the stomach 100 101 102 103 104 105 106 107 107A 108 109 110 111 112 113 114 115 116 117 118 119 120 121 Inoper: Inoper; Inojiei,- Inoili'l': Ino])er; Inoper; IIk stomach. st < )mach . slomach. -lomach. slomach. stcjmach . areuioiiia of (ii(.' Inoperable carcinoma of the stomach Ai'tist's di'awing of same case as Fig. 105 Intragastric tumors Inoperable carcinoma of the stomach Intragastric tumors Inoperable carcinoma of the stomach Adenocarcinoma of the stomach Same case as Fig. 110. Upright position showing intragastric tumor Inoperable carcinoma at cardia Post-operative new growth involving antrum of the stomach Inoperable carcinoma of pars media and cardia Inoperable carcinoma of stomach on base of old ulcer Intragastric tumor of the greater curvature. Adeno- carcinoma Inoperable adenocarcinoma at cardia Small intragastric tumor at cardia Extensive new growt.h at cardia Iiioperable adenocarcinoma of the stomach Inoperable adenocarcinoma of pars media of the stomach LIST OF ILLUSTRATIONS DUODENUM Fig. No. Page No. 122 Key plate. Normal stomach 99 123 Artist's di'awing showing ulcer on anterior wall of the duodenum 99 124 Artist's di'awing showing mucosal sm-face of ulcer. . . 99 125 Chronic ulcer of duodenum 101 126 Chronic ulcer of duodenum 101 127 Chi'onic ulcer of duodenum 101 128 Chronic ulcer of duodenum 101 129 Chi'onic ulcer of duodenum 103 130, 130A Lateral view of stomach showing small chronic ulcer of the superior surface of the duodenum .... 103 131, 131A Lateral view of stomach showing ulcer on the superior and inferior borders of the duodemmi .... 105 132 Small chi-onic ulcer of the duodenum 105 133 Same case as Fig. 132. Fifteen minutes after bismuth meal 105 134 Duodenal ulcer. Beginning new gi-owth in the stomach 107 135 L'lcer of the duodenum. LHcer on lesser curvatm-e of the stomach, posterior wall 107 136 Chronic ulcer of the duodenum 107 137 Lateral view of same case as Fig. 136 107 138 Chi-onic ulcer of the duodemun 109 139 Clu'onie ulcer of the duodenum. Adhesions 109 140 Chrome ulcer of the duodenum. Adhesions 109 141 Clu'onic ulcer of the duodeniim. Gall-stones. Ad- hesions Ill 142 Lateral view of same case as Fig. 141 Ill 143 Chi-onic ulcer of the duodenum with beginning perforation Ill 144 Small chronic ulcer on superior border of duodemmi. Ill 145 Chronic ulcer of duodenum. Obstructive type 113 146 Chronic ulcer of duodenum. Obstructive type 113 147 Small ulcer on superior border of duodenum 113 148 Chronic ulcer of the duodenum. Obhteration of duodenum 115 149 .^I'tist's drawing of same case as Fig. 148 115 150 Chronic ulcer of the duodenum 117 151 Same ease as Fig. 150. Plate III FoDowing 116 152, 152A Same case as Fig. 150. Lateral view 117 153 Chronic ulcer of the duodenum 119 154 Same case as Fig. 153. Lateral view 119 155 Ulcer of the duodenum 119 156, 156A Chi'onic ulcer of the duodenum 121 157 Chronic ulcer of the duodenum, obstructive type . . . 121 158 Chronic ulcer of the duodenum 123 159 Chronic ulcer of the duodenum 123 160 Small ulcer of the duodemmi 125 161 Artist's di'awing of same case as Fig. 160 125 162 Penetrating idcer of the superior border of the duo- denum 127 163 Adhesions about the duodenum, stomach and large bowel 127 164 Artist's drawing of same case as Fig. 163 127 165 Hour-glass constriction. Gastric ulcer at the carcha 129 166 Same case as Fig. 165, six months later. Double hour-glass constriction 129 167 Obstruction of transverse portion of the duodenum. Adhesions 129 168 Fixation of duodenum to subhepatic region 131 169 Adhesions about the descending duodenum 131 170 Adhesions about the descending duodenum 131 171 Adhesions about the descending duodenum 131 172 Extensive adhesions about the first portion of the duodenum 133 173 Small ulcer of the duodenum 133 174 Post-operative adhesions from the gall-bladder 135 175 Same case as Fig. 174 135 176 Same case as Fig. 174 135 177 Obstruction of the transverse portion of the duo- denum. Congenital 137 178 Same case as Fig. 177. Twenty-four hours after the bismuth meal 137 179 Lateral view of the same case as Fig. 178 137 180 Same case as Fig. 179 137 181 Primary carcinoma of the duodenum 139 GALL-BLADDER 182 GaU-stones. Gastric ulcer. Adhesions 147 183 Ai'tist's drawing made at time of operation. Same case as Fig. 182 147 184 Gall-stones 147 Fig. No. Page No. 185 Same case as Fig. 184 147 186 GaU-stones 149 187 One large gall-stone 149 188 GaU-stones 149 189 Gall-stone 151 189A Same case as Fig. 189 151 190 Two large gaU-stones 151 191 Two large gaU-stones 151 192 Gall-stones 153 193 GaU-stones 153 194 GaU-stones 153 195 GaU-stones 153 196 Two small gall-stones 155 197 One large gall-stone 155 198 Gall-stones 155 199 Cholecvstitis. GaU-stones 155 200 Pathological gall-bladder. GaU-stones 157 201 Group of smaU gaU-stones 157 202 Two small gall-stones 157 203 One gall-stone 157 204 Two small gaU-stones 159 205 Pathological gaU-bladder. Adhesions 159 206 One large gaU-stone 159 207 One gall-stone , 159 208 GaU-stones 161 209 Large number of small gaU-stones 161 210 Large number of gall-stones 161 211 Several gaU-stones 161 212 Gall-stones 163 213 Pathological gall-bladder 163 214 Gall-stones 163 215 Galkstones 163 216 Pathological gall-bladder. Extensive adhesions . . . 165 217 Same case as Fig. 216. Patient in upright position 165 218 Two large gaU-stones 165 219 Three gaU-stones 165 220 220A 221 222 223 224 225 226 227 •228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 SMALL INTESTINE Key plate. Anatomical variation of the stomach and duodenmri 169 Key plate showing character of the jejunum 169 Obstruction of jejunum by adhesion 171 Adhesions. Ileal stasis 171 Adhesions. Lane's kink 173 Obstruction of jejunum by annular carcinoma 173 Chronic appendix and adhesions, with fixation of terminal ileum 173 Lane's kink. Chronic appendix 173 Lane's kink 175 Marked obstruction of ileum due to pelvic bands . . . 175 Extensive adhesions about the CEecum and ileum .... 175 Marked rUlatation of the terminal ileum 177 Adhesions foUowing perforating appendix 177 Same case as Fig. 231. Twenty-four hours after the bismuth meal 177 Lane's kink 179 SmaU annular growth of ileum 179 Diverticulum of jejunum 181 Same case as Fig. 235. Twenty-four hours after the bismuth meal 181 Same case as Fig. 235. Enema method 181 Diverticulum of jejunum 183 Extensive adhesions about the appendix involving the transverse colon 183 Fixation of terminal ileum 183 Adhesions about the ileum 183 Extensive membrane formation and chronic appen- cUx -...-..... 185 Tubercular caecum 1S5 Lane's kink. Adhesions 185 Adhesions 187 Displacement of ileum by dilated urinary bladder. . . 187 Displacement of ileum by gravid uterus 187 APPENDIX Key plate. Normal large bowel 193 Chi'onic appendix 193 Clironic appendix 195 Chronic appendix with various concretions 195 Chi'onic appendix 197 Chronic appendix. PericoHc membrane 197 Chronic appendix 197 LIST OF ILLUSTRATIONS XI Fig. No. Page No. 255 Chi-onic appendix 199 256 Same case as Fig. 255. Twenty-foui' hoiu's after the bismuth meal 199 257 Chi-onio appendix 199 258 Chronic appendix 201 259 Chronic appendix 201 260 Chronic appendix. Adhesions about the ascending colon 201 261 Adherent and retrocsecal appendix 203 262 Appendix fixed and kinked in mid portion 203 263 Chronic appendix 203 264 Chronic appendix 205 265 Chronic appendix 205 266 Chronic appendix 205 267 Chronic appendix 207 268 Ai'tist's drawing of same case as Fig. 267 207 26^ Chi-onic appendix. Adhesions about the ascending colon 207 270 Chronic appendix 207 271 Chronic appendix 209 272 Cliiniii,- ;ip|,ciuiix 209 273 Cluoni.' .ippendix 209 274 Clirouic a|)pendix, adherent to the caecum 209 275 Chronic appendix 211 276 Lane's kink. Adherent and kinked appendix 211 277 Chi'onic appendix 211 278 Dilated lumen of the appendix 211 280 Chi-onic appendix 213 281 Chronic appendix. GaU-stones 213 282 Chronic appendix 213 283 Chronic appendix 215 284 Artist's di'awing of same case as Fig. 283 215 285 Appendix retrocEecal and fixed in subhepatic region 215 286 Chronic appendix. Adhesions 215 287 Chi'onic appendix, retrocsecal and adherent 217 288 Chronic appendix with concretions 217 289 Same case as Fig. 288. Forty-eight hovas after the bismuth meal 217 290 Chi-onic appendix 217 291 Chronic appendix 219 292 Chi-onic appendix with adhesions 219 293 Same case as Fig. 292. Twenty-four hours after the bismuth meal 219 294 Chronic appendix. Extensive adhesions 221 295 Chronic appendix. Boy nine years of age 221 LARGE INTESTINE — ADHESIONS 296 Key plate. Normal bowel. Plate made twenty-fom- hom-s after the bismuth meal 227 297 Extensive adhesion formation about the appendix, stomach and large bowel 227 298 Tuberculosis of the csecum and most of the large bowel 229 299 Extensive adhesions about the hepatic flexm-e 229 300 Pericolic membrane. Dilated caecum due to ad- hesions 231 301 Pericolic membrane and adhesions 231 302 Artist's drawing of same case as Fig. 301 231 303 Pericolic membrane and retrocaecal appendix 233 304 Adhesions about caecum and proximal portion of the transverse colon 233 305 Adhesions about the CEecum and transverse colon . . . 233 306 Adhesions. Partial obstruction of the ascending colon due to gall-bladder adhesions 235 307 Adhesions from gall-bladder causing obstruction of the ascending colon 235 Fig. No. Page No. 308 Adhesions about the ascending colon 235 309 Obstruction of ascending colon due to adhesions .... 237 309A Adhesions about ascending colon due to membrane 237 310 Adhesions about ascending colon. Chronic appendix 237 311, 311A Incompetency of the ileocaecal valve 239 312 Obstruction of transverse colon due to abscess of liver 239 313 Hirschbrung's disease. Congenital dilatation of the large intestine. Child six weeks old 241 314 Adhesions about the ascending colon and caecum. . . . 241 315 Artist's di-awing of same case as Fig. 314 241 316 Obstruction of ascending colon due to tubercular peritonitis 243 317 Pericolic membrane. Clironic appendix 243 318 Fixation of transverse colon 245 319 Extensive adhesions in upper right quadrant 245 320 Pericolic membrane of the ascending colon 247 321 Adhesions about the proximal portion of the trans- verse colon 247 322 Adhesions about the ascending and proximal portion of the transverse colon 247 323 Extensive adhesions about the ascending colon caus- • ing incompetency of the ileocaecal valve 249 324 Same case as Fig. 314 249 INTESTINAL NEW GROWTH 325 Ai-tist's drawing. Plale IV. Colored Following 250 326 Small intra-iiilcsliiial new growth of CEecum 251 327 Extensive new ninulli of caicum 251 328 New growth at hcralic flexui-e 253 329 Small annular new growth at hepatic flexiu-e 253 330 Ai'tist's drawing of same case as Fig. 329 253 331 New growth of proximal portion of transverse colon. 255 332 Large inoperable new growth of transverse colon. . . . 255 333 Inoperable intra-intestinal new growth of splenic flexure 257 334 Same case as Fig. 333 257 335 Intra-intestinal tumor at splenic flexm-e 259 336 Inoperable carcinoma involving descending colon and sigmoid 259 337 Small annular carcinoma of descending colon. . ..... 261 338 Extensive involvement of the descending colon due to new growth 261 339 Ai'tist's di-awing of same case as Fig. 338. Plate V. Colored Following 260 341 Small annular new growth of sigmoid 263 342 Ai'tist's drawing 263 343 New growth of the sigmoid 265 344 Extensive new growth of the entire sigmoid 265 345 Complete involvement of the whole pelvic colon due to new growth 267 346 Small annular carcinoma of descending colon 267 347 Small annular carcinoma. Diverticulitis 269 DIVERTICULITIS 348 Diverticulitis of the large intestine 273 349 Diverticulitis 273 350 Multiple diverticula 273 351 Multiple diverticula 273 352 Diverticula of the pelvic colon 275 353 Artist's chawing. Plate VI. Colored ..... Following 274 354 Several large diverticula of the descending colon .... 275 355 Diverticulitis of the entire colon 275 356 Multiple diverticulitis 277 357 Multiple diverticuhtis 277 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS OF THE GASTRO-INTESTINAL TRACT SECT I OX I NORMAL STOMACH Indirect IMethod — Direct AIethod — ]^Ieals — General EorTixE AND Technique — Apparatus — Normal Stomach In the Roentgen investigation of the gastro-intestinal tract, it is evident that two schools have developed. One, the Continental school from which the pioneer work came; the other, the American school Great credit must be given to the early investigators for their very thorough and exact work. Unfortunately they built up their technique on ques- tionable ground and soon arrived at a point where no further advance could be made. To better explain the method carried out in this volume, particularly in the study of gastric and duodenal lesions, let us outline brieflv the two schools. INDIRECT :\IETHOD The Continental investigators, Reider, Rosenthal, Holznecht. Hsenisch and others, were forced by the necessity of their clinics to depend upon the Roentgenoscope almost entirely. Their clinics were large, lacked efficient apparatus, and expense was a considera- tion; so that altogether Roentgenoscopy seemed the simplest and best method to use. Con- sequently their work has been based upon the signs and findings which could be brought out by Roentgenoscopy. From this basis of diagnosis, they evolved what has been caUed the "symptom-complex." That is, a number of Roentgenoscopic and clinical signs, largely of a functional nature, were grouped together, and on these their diagnoses were founded. Among the signs upon which a great deal of stress was laid, for example, in the study of gastric ulcer were peristalsis, antiperistalsis, hj'perperistalsis, increased and cUminished emptying time of the stomach, various spasms, six-hour gastric residue, pressure tender- points, and the clinical history including the laboratory findings. Without doubt, much valuable data was obtained from this study and up to a certain point progress made in the diagnosis of diseases of the gastro-intestinal tract. It has been found, however, that this method of stud}', especially when applied to the duodenal region, has frequently proved inadequate, not altogether in indi\ddual cases, but in studying collectively a series. Many cases were classed as negative which, in the 1 2 THE EOENTGEN DIAGNOSIS OF SURGICAL LESIONS light of our knowledge, must ha^^e jdelded positive pathological data if a more careful study had been made. It is fair to say that the errors of diagnosis were not so much errors of commission as of omission. Alany investigators, especially Americans, felt the neces- sity^ for more accurate diagnosis than was possible with this method. DIRECT METHOD To Le'nds Gregory Cole of New York must be given a great deal of credit, who as pioneer broke away from the early teachings of the Continental school. He was the first to demonstrate, by means of serial plates, the actual anatomical variation produced by the lesion. It was on this direct Roentgen evidence, viz., the exhibition of the very lesion itself, that Cole based his diagnosis. This method is called the direct or American school. It is in contrast to the indirect method, or Continental school, in which the diagnosis is based on a somewhat uncertain combination of clinical symptoms and varied Roent- genoscopic manifestations of motility. In our practice and in the study of this collection of cases, we have endeavored as far as possible to applj' the principles of the direct school. In each case we have tried to show on the plate the actual lesion. MEALS The meal most favored by the Continental workers, and still used today by the ma- jority, is the standard Reider meal. This originally consisted of forty grammes of bismuth subcarbonate and three hundred cubic centimeters of cooked cereal. Later, an equivalent amount of barium sulphate was substituted for the bismuth. Thousands of cases have been studied with this meal and much valuable data has been accimiulated. However, American investigators found the Reider meal too coarse. It failed to fiU out the duodenum completely enough for an accurate observation and made the visualization of the appendix quite improbable and a rarity. Roentgenologists then began to use other media, as arti- ficially prepared milk, buttermilk, etc. With such a medium it was possible to demon- strate lesions from the start. It easily filled out crevices and folds. It is quickly prepared, easily obtainable and quite palatable. IncidentaU}' it was found that the bismuth was kept in suspension a longer time throughout the gastro-intestinal tract than with aU other meals. As a consequence, the constant demonstration of the appendix among other conditions in the right lower quadrant is a fact. It is necessary with the buttermilk meal to use two to three times the amount of bismuth contained in the Reider meal. The writers, for instance, are using ninety grammes of bismuth subcarbonate (slightly increasing this when using barium sulphate) with five hundred cubic centimeters of buttermilk and water. As a result of the marked variation between the two meals, it is incorrect to use the same functional data for diagnosis in comparing the buttermilk meal with the Reider or cereal meal. Conclusions drawn as to the emptying time of the stomach, six-hour gastric stasis, position of the head of the bismuth column in six hours, etc., using the buttermilk bismuth meal, cannot be compared with the same cases if the Reider meal is used. This is a point which has not been appreciated entirely by our own Roentgenologists. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS ' 3 Either through lack of care or interest, they have used all kinds of media, buttermilk, plain milk, water, potato pap, malted milk, soup, cereals, etc., and have varied not only the amount of bismuth or barium, but have given double meals, half of a meal, and divided meals in various ways so that the results obtained in their studies cannot be standardized. Yet, in spite of this, these investigators have continued to publish their observations based on the deductions of the Reider technique, which they did not employ. Obviously they cannot be correct. The only course left for those who wish to use this functional data is to adhere strictly to the technique of Reider, Rosenthal and others, and accumulate a large number of cases. If one attempts to vary the mixture in any way, one must check up one's work by the operative results. This has been done in part bj' one of our American clinics having tre- mendous material. They now are undoubtedly in a position to draw correct conclusions as to the motility of the stomach with their particular technique. Finally, let us emphasize the importance of a standard meal. Only with a uniform meal and technique can the results of different investigators be correlated. We have found the simple buttermilk meal satisfactory, principally because it fills out the duodenal cap and the appendix to better advantage. GENERAL ROUTINE AND TECHNIQUE Our general routine is as follows (special points in the technique will be brought up in the various sections). The patient presents himself for examination in the morning without breakfast. We have found that a cup of coffee and toast at least two hours before the examination in no way interferes. Several plates are first made of the gall-bladder region. Frequently the entire abdomen is examined to rule out kidney stone and also to obtain some idea as to the distribution of gas, the general size and position of the liver, spleen, and kidneys. Such a plate is frequently valuable as a record for comparison with the plates made after the bismuth has been given. The meal is given to the patient in two large glasses. As the first glass is taken the patient is studied with the Roentgenoscope, attention being paid to the oesophagus and the manner in which the stomach fills. The second glass is taken at once and the first plate then exposed. APPARATUS As to apparatus, we have found that any transformer producing energy enough to make an exposure within a second and a half is satisfactory. In passing, we have not found any portable apparatus of sufficient power for gastro-intestinal work. The standard tubes are all satisfactory. Some of the more recently marketed tubes have made the "lateral" view possible with greater precision. It has been our custom to use intensifying screens in all our gastro-intestinal work. The screen allows us to use a softer tube and a shorter exposure. This is of benefit both to the patient and to the owner of the tube. Plates are made routinely after the meal, again at six hours, and again at twentj'- four hours. A light lunch is allowed between the first and six-hour plate. The other cus- tomary meals are not interfered with. 4 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Plates are taken in various positions. The bulk of the work is done routinelj^ with the patient in the prone position. NORMAL STOMACH The normal stomach is a collapsible bag, hanging free in the abdominal cavity. It is fixed at the cardiac orifice and somewhat loosely held along the lesser curvature by the gastro-hepatic ligament. It must be borne in mind that the size of the normal stomach depends absolutely on its contents and that its shape depends, in a great measure, on the surrounding organs. A thorough acquaintance with the normal stomach and its normal variations is fundamental for a recognition of any pathological condition. Our concep- tion of the normal stomach is based on the Roentgen picture made within five minutes following the regular meal. The exposures are made both with the patient upright and prone, the plates always against the abdomen. The stomach can be divided into a larger cardiac part and a smaller pyloric part. The cardiac portion consists of the fundus and body, sometimes called the pars media, the fundus, according to Hertz, being the segment of the stomach which lies above a hori- zontal plane passing through the cardiac orifice. In the erect position the body of the stomach is situated entirely to the left of the middle line and is either vertical or inclined slightly towards the right. The pyloric portion consists of the antrum, or pars pylorica, and the pylorus. The "incisura angularis" has sometimes been described as separating the pars media from the pars pylorica. This is a sharp indentation on the lesser curvature. We have found this incisura to be rather inconstant, particularly' with the full meal. The pars pylorica or antrum is directed upwards and somewhat backwards. It narrows gradually and ends at the pylorus. The pylorus appears as an isthmus of bismuth connecting the stomach with the first portion of the duodenum. It varies from a quarter of an inch in diameter to the size of a thread. It is usually from one quarter to a third of an inch in length. The shape of the stomach depends to a great measure on its muscular tone and on the surrounding organs. The lesser curvature has a more or less rigid attachment so that changes in size and shape take place at the expense of the greater curvature. Various kinds of normal stomachs have been described, such as fish-hook, cow's horn, and text- book type. These terms have no pathological significance. The muscular tone of the gastric walls is one factor in determining the shape. A hy- pertonic stomach is likely to be high up in the abdominal cavity, occupying a horizontal position with active peristalsis. On the other hand, an atonic stomach will be low, the greater curvature may reach almost the pelvic brim, the general axis will be vertical rather than horizontal. There will be little evidence of peristalsis. Such a stomach will be of the "fish-hook" variety. There are all grades between these two types and all within the normal limits. The development of the individual has a bearing on the shape and position of the stomach. For instance, a stout individual with considerable abdominal fat will show a very high stomach. In fact, frequently the body of the stomach will be held so high that in the anteroposterior view it will actually overlie the pylorus and duodenum. On the other hand, in a thin, emaciated individual the stomach, not having any supporting ab- dominal fat, will be found resting down in the true pelvis. Each type of stomach is normal for that particular individual. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 5 Extreme pressure may give a variation to the outline of a normal stomach. Pressure from the spine in a prone position will oftentimes give an apparent defect in the antrum or body of the stomach. Pressure from a distended colon, particularly at the splenic flexure, may give a peculiar irregularity in the greater curvature. Enlarged spleen, or kidney! cysts of the pancreas, ascites,, all these may produce distortions of a perfectlv normal stomach. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS NORMAL STOMACH Figure 1 PATIENT — POSITION: Woman, age 25. Prone. ROENTGEN CONCLUSIONS: Normal. OPERATIVE FINDINGS: Exploratory. Stomach and duodenum found normal. Key plate. 1 Region of cardia distended with air. 2 Pars media. 3 Pars pylorica, or antrum. 4 Pylorus relaxed. 5 First portion of the duodenum. "Bishop's Cap." Roentgenographically the first portion of the duodenum shows the superior and inferior border ahvaj's smooth in outline. The base, or pyloric region, is also smooth. 6 Second portion of the duodenum. Note the valvulse coimiventes which distinguish it from the stomach and first portion of the duodenum. Histologically the stomach and first portion are essentially the same. 7 The third, or transverse portion, of the duodenum. This passes transversely and to the left in front of the vertebral column and is partly obscured by the stomach. Note at the junction of the second and third portions a narrowing which is physiological. In the prone position this is partly due to pressure. Note the tendencj' of the duodenum to dilate before food passes this point. Figure 2 PATIENT — POSITION: Woman, age 23. Prone. ROENTGEN CONCLUSIONS: Anatomical variation of the stomach and duodenum. OPERATIVE FINDINGS: General exploratory. Negative. Kej' plate. 1 Pyloric region, showing in the antrum the effect of pressure from the spine. 2 Poorly filled first portion of the duodenum. 3 Variation in the position of the descending duodenum. 4 Tj'pical plate showing character of the jejunum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 3 PATIENT — POSITION: Man, age 40. Lateral. ROENTGEN CONCLUSIONS: Normal stomach, lateral view. OPERATIVE FINDINGS: None. Key plate. It is to be observed that in the lateral position both the posterior and anterior walls of the stomach are shown. The first, descending, and transverse portions of the duodenum are relatively in the same position in the lateral view as in the prone. This is particularly true in well-nourished individuals, of whom this patient was one. 1 Cardia. 2 Pars media. 3 Posterior wall. 4 Anterior wall. 5 Antrum of the stomach. 6 Pylorus. 7 First portion of the duodenum, or bulbus duodeni, or "cap." 8 Second portion, or descending duodenum. Q Third or transverse portion of the duodenum. Figure 4 PATIENT — POSITION: Woman, age 34. ROENTGEN CONCLUSIONS: Normal stomach, lateral view. OPERATIVE FINDINGS: No operation. Key plate. 1 Pylorus. 2 First portion of the duodenum. 3 Descending portion of duodenum which is poorly filled. In a poorly nourished individual the stomach may be obscured in part by the vertebrae, as also the descending portion of the duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 10 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 5 PATIENT — POSITION: Man, age 27. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: No operation. A Pylorus. B Poorly filled first portion of the duodenum. This lack of filling of the first portion of the duodenum may be in part due to spasm after the bismuth meal. Figure 6 Lateral view of Figure 5. 1 Antrum. 2 First portion of the duodenum. 3 Beginning of descending portion of duodenum. This lateral view shows how well the first portion of the duodenum can be demonstrated. Figure 7 The same case as Figure 5. A The effect of pressure of the spine upon the stomach which occurred throughout the examination. This can be overcome by examining the case in the upright position. B Pjdorus. C First portion of the duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 11 12 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 8 PATIENT — POSITION: Woman, age 27. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: No operation. A Pylorus. B First portion of the duodenum. C Junction of the descending and transverse portions of the duodenum. Figure 9 The same case as Figure 8 taken in the upright position. This plate shows the extreme dilatation and ptosis of the stomach, also the difficulty of showing the first portion of the duodenum if one were to e.xamine with the Roentgenoscope. A First portion of duodenum. Figure 10 Same case as Figures 8 and 9 six hours later with a small amount of gastric residue, most of the bismuth being in the ileum and large bowel. A Gastric residue. B Terminal ileum. C CEecum. D Transverse colon. Figure 11 Same case showing marked ptosis of the transverse colon, twenty-four hours after Figure 10. A Csecum. B Transverse colon. C Rectum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 13 FIGURE 10 FIGURE U 14 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 12 PATIENT — POSITION: Woman, age 23. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: No operation. It was impossible to fill the first portion of the duodenum in the prone position. Note the well-filled descending portion of the duodenum. A Pylorus. B Poorly filled first portion of the duodenum. C Descending duodenum. Figure 13 The same case in the upright position demonstrating the changed relations which the stomach, duodenum, and jejunum assume in this position. A Rugae of the stomach coated with bismuth. B Pylorus. C First portion of the duodenum. D Jejunum. Figure 14 PATIENT — POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: Normal stomach. Ptosis and dilatation. OPERATIVE FINDINGS: No operation. This plate illustrates the effect of our usual bismuth meal. Owing to the dilatation of the stomach and a certain amount of ptosis, the bismuth meal given was not enough to fill the stomach completely and to relieve the pressure effect from spasm. A Cardia. B Antrum. C Pylorus. D First portion of the duodenum. Figure 15 The same case as Figure 14 taken in the upright position. There is considerable ptosis and dilatation of the stomach. A Antrum. B First portion of the duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 15 FIGURE 12 FIGURE 13 FIGURE 14 FIGURE 15 16 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 16 PATIENT — POSITION: Woman, age 23. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: No operation. This plate shows the average tj'pe of stomach in the poorly-nourished individual. The upright position shows considerable ptosis, a general dilatation with some six-hour gastric stasis. A Antrum. B First portion of the duodenum with beginning of the second and descending portions. C Descending portion. Figure 17 The same case six months later. This plate is used to demonstrate the fact that the stomach Roentgenographically has an individuality and unless diseased will always appear the same in successive examinations employing the same technique. A Antrum. B Note how the duodenum at this time is an exact duplicate of Plate 16. Figure 18 The six-hour plate of Figures 16 and 17. A Gastric residue. B Bismuth in the ileum. C Caecum. D Transverse process. THE ROENTGEN DIAGNOSIS OF SURGIGAT. LESIONS 17 FIGURE 16 FIGURE 17 FIGURE 18 18 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 19 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Normal stomach. Dilatation and ptosis. OPERATIVE FINDINGS: No operation. A Antrum. B Pylorus. C First portion of duodenum. Figure 20 The same case, upright position. A Area of hypersecretion. B Level of bismuth. THE ROEXTGEX DIAGXOSIS OF SURGICAL LESIONS 19 FIGURE 19 FIGURE 20 20 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 21 PATIENT — POSITION: Woman, age 22. Prone. ROENTGEN CONCLUSIONS: Dilated stomach. OPERATIVE FINDINGS: Cholecystitis. No evidence of disease of the stomach or duodenum. A Antrum of stomach. B First portion of duodenum. Figure 22 The same case standing which shows the relative amount of ptosis. A Greater curvature of stomach. THE ROEXTCxEX DIAGNOSIS OF SURGTCAL LESIONS 21 FIGURE 21 FIGURE 22 22 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 23 PATIENT — POSITION: Woman, age 30. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: Chronic appendix. No evidence of disease of the stomach or duodenum. A Poorly filled duodenum, partly due to pressure of the duodenum. Figure 24 The same case standing shows a well defined antrum, pylorus, and first portion of the duodenum. A Note the fluid level. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 23 FIGURE 23 FIGURE 24 24 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 25 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: Cholecystitis. No evidence of disease of the stomach or duodenum. A Poorly filled antrum. B First portion of the duodenum. Figure 26 By waiting a short time after the bismuth meal a compl(>te filling of the antrum and duodenum can l)e shown. A and B show a complete filling of the antrum and duodenum. Figure 2 7 PATIENT — POSITION: Woman, age 28. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: Cholecystitis. No evidence of disease of the stomach or duodenum. This plate serves to illustrate the normal contraction of the pyloric sphincter. It is not pathological, Init merely a large sphincter. A Antrum. B Pyloric sphincter. C First portion of the duodenum. D Second portion of the duodenmii. E Pressure of the gall-bladder. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 25 FIGURE 25 FIGURE 26 26 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 28 PATIENT — POSITION: Woman, age 23. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: Chronic appendix. Lane's kink. This plate should be contrasted \vith Figure 27. Here a larger amount of bismuth is seen passing a small sphincter. A Effect of pj'loric sphincter on bismuth mass. B First portion of the duodenum. C Character of jejunum as demonstrated on the Roentgen plate by the passage of bismuth. D Character of the ileum as compared with the jejunum. Figure 29 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Large dilated stomach. OPERATIVE FINDINGS: No operation. A Antrum. B Pylorus. C First portion of the duodenum. THE ROEXTGEX DIAGNOSIS OF SURCtICAL LESIOXS 27 FIGURE 28 FIGURE 29 28 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 30 PATIENT — POSITION: Woman, age 27. Prone. ROENTGEN CONCLUSIONS: Large dilated stomach. OPERATIVE FINDINGS: No operation. A Antrum. B Pylorus. C First portion of the duodenum. Figure 31 PATIENT — POSITION: Man, age 43. Prone. ROENTGEN CONCLUSIONS: Normal stomach. OPERATIVE FINDINGS: Chronic appendix. A Antrum of stomach. B Pylorus. C First portion of duodenum. Note the pressure of the first portion of the duodenum against the antrum of the stomach. This was considered at first pathological but with subsequent plates and a change in position of the patient this apparent defect disappeared. Figure 32 The same case as Figure 3L This shows a complete filling of the antrum of the stomach and first portion of the duodenum owing to the changed position of the patient. A Antrum of stomach. B First portion of duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 29 FIGURE 30 FIGURE 31 FIGURE 32 30 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 33 PATIENT — POSITION: Woman, age 32. Prone. ROENTGEN CONCLUSIONS: Normal stomach. Dilatation and ptosis. OPERATIVE FINDINGS: No operation. This plate illustrates the pressure defect of the ascending colon upon the greater curvature of the stomach. It sometimes becomes verj^ confusing to differentiate between involvement of the stomach wall and the effect of pressure due to the large intestine. A Effect of pressure. Figure 34 PATIENT — POSITION: Man, age 47. Prone. ROENTGEN CONCLUSIONS: Hypernephroma causing a pressure effect on a normal stomach. OPERATIVE FINDINGS: Hypernephroma of the kidney. The plates show displacement of the stomach to the right Ijy a large tumor mass on the left side which was diagnosed bj" the Roentgen method as probable hj-pernephroma. Note the displacement of all the abdominal contents bismuth filled to the right. A Upper boundaries. B Lower boundaries. C Pressure due to the mass. Figure 35 PATIENT — POSITION: Man, age 40. Prone. ROENTGEN CONCLUSIONS: Retroperitoneal tumor. Possible gumma. OPERATIVE FINDINGS: Hypernephroma. Note the displacement of the stomach upwards to the right as well as the jejunum and ileum. A Pressure of mass on greater curvature of the stomach. B Outline of mass against jejunum. C Jejunum. D Ilemn. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 31 FIGURE 33 FIGURE 34 FIGURE 35 32 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS SECTION II GASTRIC ULCER Definition — Technique — Normal Gastric Shadow — Variations from the Normal — Positive Signs of Ulcer — Presumptive Signs of Ulcer The lesion commonly known as gastric or peptic ulcer is a circumscribed area, varjang in size from a pinhead to half a dollar. It is usually situated near the pylorus and, with few exceptions, involves either the lesser curvature or posterior wall. This lesion is char- acterized by a loss of tissue involving the mucosa and frequently the deeper layers. These ulcers, which clinicallj^ and pathologically are distinct from "erosions," tubercular, syphilitic and various traumatic ulcerations of the stomach wall, show little tendency to healing. Consequently all gastric ulcers become "chronic" ulcers before healing takes place. Shortly after the onset of an ulcer, nature attempts repair. The result is a disposition of chronic inflammatorj' tissue in and about the lesion. This inflammatorj' reaction within a few weeks may become a palpable induration, which in turn causes more or less deformity in the stomach wall. It is the demonstration of the presence of this deformity that permits us to make a positive Roentgen diagnosis of gastric ulcer. The ease and accuracy with which the diag- nosis is made varies directly with the degree of deformity. In so far as chronic gastric ulcer is concerned we rely, as in the case of duodenal ulcer, on the direct method; namely, the exhibition on the Roentgen plate of the actual anatomical defect. Technique. For the demonstration of gastric ulcer we use the same meal previously described; in brief, two ounces of bismuth subcarbonate or the speciall}'' prepared barium sulphate to two glasses of buttermilk, amounting to one pint. This is taken on an empty stomach. While we appreciate the value of the Roentgenoscope in competent hands, and, in fact, all our patients are examined in this way, still in the last analysis it is the serial plate upon which we rely for our diagnosis. In the first place, the problem of gastric ulcer in a large measure is a study of detail. We look for minute changes and slight irregularities in the bismuth outline. These can be seen with greater accuracj^ and ease on the plate than on the fluorescent screen. Then again, in the plate we have a permanent record, while with the screen our opinion has to be based on an uncertain remembrance of a passing vision. Without doubt the screen is of great value in demonstrating motion and is, therefore, our greatest aid in show- ing abnormalities of gastric phj'Siolog^'. But such abnormalities, at best, interest us only when considering the presumptive or indirect evidence of gastric ulcer. Repeated or serial plates are essential to demonstrate the permanency of a shadow. A typical hour-glass appearance, for example, may be seen on two or three plates, but on the fourth plate we may get the shadow of a normal stomach. In the demonstration of the constancy of large defects, the Roentgenoscope serves well and is, to be sure, a saving in plates and time. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 33 As for the best position in which to take plates, we find the ordinary anteroposterior position the most useful, the patient standing with the plate against the abdomen. It is in this position that ulcers are hkely to show, for the reason that seventy-five to eighty per cent occur on the lesser curvature of the stomach. In the upright, anteroposterior position the lesser curvature is brought into profile. However, in this position there is often diffi- culty in filling out the antrum. In such a case an anteroposterior plate with the patient prone will remedy this difficulty. Twenty to twenty-five per cent of gastric ulcers occur on the posterior wall. These ulcers are frequently shown to a better advantage by taking the plate with the patient in the lateral position, either standing or lying, the plate against the patient's right side. Each patient is an individual problem and the plates must be taken as the needs of the case indicate. This is of special importance in considering the interval between plates and the num- ber of times a patient should be examined by the Roentgenologist. In general, a patient should be studied by the Roentgenoscope while taking the bismuth meal and serial plates made immediately after and again at six and twenty-four hours. The Positive (or Direct) Evidence of Gastric Ulcer. The following five varia- tions from the normal gastric bismuth shadow are of fundamental importance in the diag- nosis of peptic ulcer and appearing singly or associated they are nearly pathognomonic of this lesion. A Bismuth in the ulcer crater. B Passage of bismuth through the gastric wall due to a chronic perforation. C Defect in the bismuth shadow from induration in the gastric wall. D Permanent hour glass. E Pyloric obstruction, other than from new growth. Demonstration of the Ulcer Crater. Plates taken in the ordinary anteroposterior position, either standing or lying, bring into profile the lesser and greater curvature. Any break in the outline of the curvatures will be detected at once. Frequently a small speck of bismuth can be seen apparently exuding from the main bismuth shadow. This represents bismuth actually in the crater of the ulcer. This is unquestionably pathognomonic of ulcer. Only when the ulcer is in profile can its crater be shown in this way. Even though eighty per cent occur on the lesser curvature and are naturally thrown into profile in the anteroposterior position, still the crater is likely to be filled with secretions or food debris that the bismuth may not penetrate. Demonstration of Chronic Perforating Ulcers. Occasionally ulceration proceeds so far that there is actual perforation of the gastric wall. The Roentgen picture of the chronic perforated ulcer is characteristic. It merely represents a stage later than the simple ulcer. The picture of the perforated ulcer shows bismuth actually outside the stomach wall, confined in a small sack or pouch. This sack is formed by walls of connective tissue. It is the result of nature's endeavor to heal and prevent the impending perforation. The pouch may vary from the size of a pea to that of a walnut. UsuaUj^ there can be seen the thread-like isthmus connecting the pouch with the stomach. Along with the bismuth, the pouch may contain a gas bubble. It is frequently noted that the bismuth in the pouch will be retained long after the stomach is empty. This condition is also favorable for demon- stration in the ordinary anteroposterior position from the fact that perforations almost invariably occur on the lesser curvature. Demonstration of Area of Induration. While in many cases we cannot demon- strate the ulcer itself, we can, however, demonstrate the area of induration about the ulcer. 34 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS This area of induration produces a local rigidity in the stomach wall. It is this local rigidity, or lack of flexibility, which we demonstrate on the plate. The taking of several plates is important. On the several plates will be seen an area, usually on the lesser curvature, half an inch to two inches in diameter, over which there is no evidence of peristaltic waves. Sometimes repeated exposures at one-quarter second intervals on the same plate with the position of the patient unchanged will demonstrate this condition. Such a plate shows a blurred outline of the stomach, save over the area where there is no movement. This localized area of rigidity indicates pathology involving the stomach wall. We have here found the Roentgenoscope and palpation useful in checking up the Roentgenograms. The question may be asked, does an indurated area such as this occur only in chronic ulcer? Theoretically, no, but for practical purposes, yes. It is conceivable that a new growth might give a similar picture, but it is not the characteristic picture of new growth, as we shall show later. And further, a chronic ulcer showing this induration will invariably present one or more characteristic signs of ulcer. In addition to rigidity, the indurated area may produce a filling defect causing an ir- regularity in the gastric shadow. This irregularity simply means infiltration and of itself is not characteristic of ulcer. Demonstration of Organic Hour-Glass Deformity. The organic hour glass must be differentiated from the functional or spasmodic hour glass. Repeated plates are usually sufficient to rule out spasmodic hour glass. Then again, the Roentgenoscope and palpation can show whether or not the contraction is permanent. In doubtful cases the administra- tion of atropine will relax the spasmodic hour glass. The organic hour glass is practically pathognomonic of chronic ulcer. Actual irritation from the ulcer produces spasm of the circular muscle fibres in the plane of the ulcer. Later, there is undoubtedly stiffening or actual infiltration in the fibres, making the contraction rigid or permanent. The exceptions are rare cases of hour-glass deformitj^ due to new growth and adhesions. But, as Crane has pointed out, the hour glass caused by new growth has certain character- istics which help to differentiate it from the hour glass of chronic ulcer. The hour glass of new growth usually presents a funnel-like form, while that of chronic ulcer is sacculated. The sulcus in new growth is likely to be broad and irregular, while that of ulcer is band-like and smooth in outline. The connecting isthmus in the hour glass from ulcer is eccentric, usually being a part of the lesser curvature, while the isthmus in malignant hour glass is in the center, producing a sjTnmetrical annular defect in the gastric shadow. Rarely indeed do adhesions produce an appearance simulating hour glass. Occasionallj- post-operative adhesions will tie the stomach to the abdominal wall at the site of the inci- sion, which may produce an hour-glass appearance. It is possible that mesenteric bands may also distort the stomach in such a way as to suggest a constriction. Demonstration of Pyloric Obstruction. The normal stomach with our meal empties within six hours. However, we do not laj' much stress on any gastric residue under twelve hours. Certainly an eighteen to twenty-four hour residue means organic stenosis at the pylorus. We have never seen spasm or simple atony produce twenty-four hour stasis. Benign cicatrix, new growth and adhesions are the three causes of pyloric obstruction. Benign cicatrix or chronic ulcer, in the majority of cases, has its own characteristic picture. First, it is of long standing and therefore is associated with a secondarj^ dilatation and hypertrophy of the stomach. Violent peristaltic waves suggest chronic ulcer. Obstruc- tion from new growth is of short duration and is associated with a small stomach. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 35 Careful study of the pyloric region in the different positions mil usually show the characteristic deformity of cancer. As is discussed elsewhere, the deformity of cancer is quite pathognomonic, being an inroad on the gastric shadow and usually annular. The Peesumpti"ve (or Indirect) Evidenxe of Gastric Ulcer. We believe that every case of gastric ulcer, if carefully studied in the way that has been suggested, mil always give some positive evidence of its presence. However, we realize full well that it is on the chronicity of the ulcer that the accuracy of the diagnosis depends. And it is reasonable to suppose that there may be certain acute ulcers of such recent origin that there has been insufficient time to produce any appreciable deforming induration. We are led to suspect the presence of such ulcers by certain presumptive or indirect e\ddence. And we emphasize the word "suspect," for this e\ddence is indeed far from being pathognomonic. Spasm of the pyloric sphincter is indicated by a greater or less period of delay before the stomach begins to empty. The normal stomach begins to empty immediately on tak- ing the meal. This delayed relaxation of the pyloric sphincter results in a delayed emptying of the stomach, so that an eight to ten-hour gastric residue is worthy of note. Spasm of the circular fibres in other parts of the stomach is shown on the plate as an incisura, usually on the greater curvature. These indentations are more or less persistent and the greater their persistency, the more valuable they are as evidence. Without much doubt most acute gastric ulcers are accompanied by a certain amount of spasm of the circu- lar fibres lying in the same plane as the ulcer. The Roentgen picture is simply that of an indentation on the greater curvature opposite the site of the ulcer. It must be borne in mind that these incisurse may be produced reflexly from any lesion throughout the gastro- intestinal tract. They may also be produced by various drugs and even by nervousness. An extreme spasm may produce such a marked incisura that the stomach assumes an hour-glass appearance. This spasmodic hour-glass condition means nothing more than a simple incisura and must not be confused with the organic hour-glass deformity. As is mentioned elsewhere, the administration of atropine mil easily differentiate spasm from organic deformity. In our experience the various abnormalities in peristalsis or abnormal conditions of gastric tone bear no certain relation to the presence or absence of acute gastric ulcer. Also in our experience, a tender-point over the gastric shadow, demonstrated by Roent- genoscopic palpation, bears no relation to the presence or absence of ulcer. 36 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS GASTRIC ULCER Figure 36 PATIENT — POSITION: Woman, age 28. Prone. ROENTGEN CONCLUSIONS: Obstruction of oesophagus due to ulcer at cardia, possible cardio-spasm. OPERATIVE FINDINGS: Passage of bougie and subsequent history suggest ulcer as a cause rather than spasm alone. A Dilatation of oesophagus at cardia. B Obstruction at cardia. All plates showed a marked filling defect in cardia of stomach. Figure 37 PATIENT — POSITION: Woman, age 30. Prone. ROENTGEN CONCLUSIONS: Gastric ulcer. OPERATIVE FINDINGS: Confirmatory. A Incisura on greater curvature. Note the sharply defined area of induration on lesser curvature. This plate is characteristic of a large gastric ulcer high up on the lesser curvature. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 37 FIGURE 36 FIGURE 37 38 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 38 Same case as Figure 37. POSITION: Upright. A Shows incisura to be an actual involvement of the stomach rather than simple spasm. Figure 39 PATIENT — POSITION: Woman, age 30. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer with hour-glass constriction. Penetrating ulcer high on lesser curvature. OPERATIVE FINDINGS: Two ulcers on lesser curvature, posterior wall, a chronic indurated ulcer, and a small ulcer of perforating or penetrating type. A Hour-glass constriction from old ulcer. B Small perforating ulcer on lesser curvature. Figure 40 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer, posterior wall, and lesser curvature. OPERATIVE FINDINGS: Large florid ulcer on posterior wall, lesser curvature. A Incisura from old chronic ulcer. B Antrum of stomach poorly filled. Figure 41 PATIENT — POSITION: Woman, age 34. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer causing hour-glass constriction with small perforating ulcer high in stomach. OPERATIVE FINDINGS: Marked hour-glass constriction with small recent ulcer on lesser curvature. Adhesions about pylorus. A Hour-glass formation. Note the contraction of scar tissue. In this case it is almost identical with ulcer higher on lesser curvature. (Figure 39.) B Similar to Figure 39, except that this case is undoubtedly more chronic. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 39 FIGURE 38 FIGURE 40 FIGURE 39 FIGURE 41 40 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 42 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Hour-glass formation due to chronic ulcer of stomach on lesser curvature. OPERATIVE FINDINGS: Large chronic ulcer on lesser curvature, posterior wall. A Incisura due partly to spasm, and partly to actual contraction of the wall. B Note the effect of the rigid stomach wall. In a series of plates this straight hne contour is constant. Figure 43 PATIENT — POSITION: Woman, age 31. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with small ulcer on lesser curvature, beginning per- foration. OPERATIVE FINDINGS: Large indurated ulcer on lesser curvature, posterior wall. Small perforating ulcer on lesser curvature. A Contraction of stomach due to ulcer. B Area sho\Adng outcropping of bismuth, suggestive of perforation. Figure 44 PATIENT — POSITION: Woman, age 39. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with complete hour-glass formation. Perforating ulcer on lesser curvature. OPERATIVE FINDINGS: Hour-glass formation with almost complete stenosis of pars media of stomach. In this mass of inflamed tissue the " saddle back " type of ulcer is seen. A — B Note almost complete obUteration of stomach. C Perforating ulcer. At times during the examination this area showed a Haudek niche. Figure 45 PATIENT — POSITION: Man, age 36. Prone. ROENTGEN CONCLUSIONS: Hour-glass formation with stenosis of whole of pars media due to ulcer. possibly beginning degeneration. OPERATIVE FINDINGS: Chronic gastric ulcer forming hour glass of stomach. Many adhesions about stomach and duodenum. Not malignant. A Hour-glass formation from cicatrix of duodenal ulcer. B Extent of ulcers. C Dilatation of duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 41 FIGURE 42 FIGURE 43 FIGURE 45 42 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 46 PATIENT — POSITION: Woman, age 42. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with probable beginning new growth in antrum of stomach. OPERATIVE FINDINGS: Chronic gastric ulcer, posterior wall, lesser curvature. Extensive adhesions about duodenum and antrum. No evidence of new growth. A Incisura, mostly due to spasm. B Filling defect suggestive of infiltrating carcinoma. Figure 47 Artist's drawing of same case as Figure 46. Figure 48 PATIENT — POSITION: Man, age 38. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer. OPERATIVE FINDINGS: Stomach externally appeared normal. On opening stomach a redundancy of mucous membrane was found with actual stenosis. A This case illustrates a rare condition found in only one case of the writers' series, and seen in one other case operated upon at the Carney Hospital, Boston. The only differential point suggested between chronic indurated ulcer and this condition is that with involvement of the mucous membrane alone a perfectly uniform contraction is seen in the Roentgenogram. Figure 49 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS : Chronic ulcer on lesser curvature perforating at time of bismuth examination. OPERATIVE FINDINGS: The lesser peritoneal cavity was found at operation to be mostly filled with chronic inflammatory tissue. A Ulcer on lesser curvature. It \\"ill be noted that the ulcer is perforated. Bismuth is seen passing out as though ejected by a hypo- dermic needle. Perforation was not proven absolutely at time of operation on account of marked inflammatorj^ changes found, but strongly corroborated. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 43 FIGURE 46 FIGURE 47 FIGURE 48 FIGURE 49 44 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 50 PATIENT — POSITION: Woman, age 39. Prone. ROENTGEN CONCLUSIONS: Chronic perforation on lesser curvature of stomach due to old ulcer. OPERATIVE FINDINGS: Large perforating ulcer found on lesser curvature adherent and involving pancreas. A Perforating ulcer which filled mth and emptied itself of bismuth throughout the examination. Figure 51 PATIENT — POSITION: Man, age 41. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the stomach. OPERATIVE FINDINGS: Chronic gastric ulcer on the lesser curvature of the stomach, posterior wall. A Induration and contraction of the stomach wall due to ulcer. Figure 52 PATIENT — POSITION: Woman, age 43. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer. OPERATIVE FINDINGS: Chronic gastric ulcer. A Area of constriction due to ulcer. This is more marked than one would expect from the size of the ulcer found at operation. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIONS 45 FIGURE SO FIGURE 51 FIGURE 32 46 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 53 PATIENT — POSITION: Woman, age 50. Prone. ROENTGEN CONCLUSIONS: Hour-glass type of stomach due to chronic gastric ulcer. OPERATIVE FINDINGS: Chronic gastric ulcer. Almost complete obliteration of the lumen. Ulcer of the duodenum. A Hour-glass formation clue to ulcer. B Dilatation of antrum due to an obliterative and obstructive type of duodenal ulcer. Figure 54 Same case as Figure 53. Lateral view. A Anterior wall of stomach. B Posterior wall of stomach . C Second portion of duodenum. Figure 55 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with hour-glass formation. OPERATIVE FINDINGS: Chronic gastric ulcer probably mahgnant in character. Adhesions. A Hour-glass formation due to ulcer. The writers found nothing to suggest malignancy, but the subsequent clinical history apparently con- firms the surgical observations. Figure 56 PATIENT — POSITION: Man, age 38. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with adhesions about antrum of the stomach. Small perforating ulcer of the duodenum. OPERATIVE FINDINGS: Large chronic ulcer of stomach on lesser curvature. Extensive adhesions. Small ulcer of duodenum. A Perforating ulcer on lesser curvature. B Effect of adhesions. C Pylorus. D Perforating ulcer of the duodenum. Figure 56A See colored insert, Plate I. PLATE I — FIGURE 56A CHRONIC GASTRIC ULCER WITH ADHESIONS ABOUT ANTRUM OF THE STOMACH. SMALL PERFORATING ULCER OF THE DUODENUM THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 47 FIGURE S3 FIGURE 54 FIGURE 55 48 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 57 PATIENT — POSITION: Man, age 41. Standing. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with possible adhesions. OPERATIVE FINDINGS: Chronic gastric ulcer. Extensive formation of adhesions. A Effect of ulcer deforming antrum of stomach. B Contracting due to adhesions. Figure 58 PATIENT — POSITION: Woman, age 52. Prone. ROENTGEN CONCLUSIONS: Hour-glass formation due to chronic ulcer primarily, possibly beginning degeneration. OPERATIVE FINDINGS: Chronic gastric ulcer with hour-glass formation, no evidence of malignancy. A small ulcer of the duodenum noted. A Hour-glass formation due to ulcer. Filling defect seen in plate and malignancy suggested therefrom due to pressure of the tail of the pancreas and in part due to adhesions. No Roentgen evidence of the duodenal ulcer found. Figure 59 Artist's drawing made at time of operation. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 49 FIGURE 57 FIGURE 58 FIGURE 59 50 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 60 PATIENT — POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of antrum of stomach. Possible pathological gall-bladder. OPERATIVE FINDINGS: Probable chronic gastric ulcer. Adhesions so extensive about gall-bladder and stomach as to make detailed inspection of stomach impossible. A Hour-glass formation at antrum. B Pylorus. C Pressure by visualized gall-bladder on duodenum. Figure 61 Same ease as Figure 60. A Six-hour plate showing residue in antrum of stomach that persisted for more than eighteen hours. Figure 62 PATIENT — POSITION: Man, age 39. Standing. ROENTGEN CONCLUSIONS: Ulcers of stomach, at pars media, and near pylorus on lesser curvature. OPERATIVE FINDINGS: Chronic gastric ulcer on lesser curvature, small ulcer in antrum near pylorus, and an ulcer of duodenum extending to pylorus, with adhesions. A Ulcer on lesser curvature, pars media. B Ulcer on lesser curvature near pylorus. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 51 52 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 63 PATIENT — POSITION: Man, age 61. Standing. ROENTGEN CONCLUSIONS: Traumatic hour-glass stomach, extensive chronic inflammatory tissue. OPERATIVE FINDINGS: Hour-glass stomach due to inflammation about stomach. A Narrowing of the stomach due to a large band of adhesions. B Antrum dilated, which is due to moderate obstruction at pylorus. C Pylorus. Figure 64 PATIENT — POSITION: Man, age 52. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer. OPERATIVE FINDINGS: Chronic ulcer in lesser curvature of stomach. A Deforming effect of cicatrix of ulcer. Figure 65 PATIENT — POSITION: Man, age 63. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with adhesions. OPERATIVE FINDINGS: Gastric ulcer of antrum with extensive adhesions. A Effect of ulcer and adhesions about antrum of the stomach. B Deformity of pylorus due to adhesions. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 53 FIGURE 64 54 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 66 PATIENT — POSITION: Man, age 48. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer near pylorus, possibly malignant. OPERATIVE FINDINGS: Chronic gastric ulcer of stomach, resected but no evidence of malignancy. A Effect of cicatrix. It was suspected by the characteristic deformity that there was possibly a beginning degeneration. Figure 67 PATIENT — POSITION: Man, age 51. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer with small tumor mass. OPERATIVE FINDINGS: Chronic gastric ulcer with marked contraction of stomach. A benign tumor the size of an egg, and extragastric, was found. A Pressure on stomach due to effect of tumor. B Narrowing due to cicatrix and adhesions. C Pylorus. Figure 68 PATIENT — POSITION: Man, age 43. Prone. ROENTGEN CONCLUSIONS: Ulcer near pylorus on lesser curvature. OPERATIVE FINDINGS: Chronic gastric ulcer near pylorus. Marked dilatation of first portion of duo- denum. Pathological gall-bladder with adhesions. A Deformity of antrum due to ulcer. B Constriction due to ulcer. C Pressure of gall-bladder on duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 55 FIGURE 66 FIGURE 68 56 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 69 PATIENT ^POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer at pylorus. OPERATIVE FINDINGS: Extensive adhesions about pylorus and antrum of stomach. Small ulcer found near pylorus on lesser curvature. A Series of plates showed rigidity of wall of stomach at this point. B Constriction due partly to adhesions and partly to contraction, which is due to ulcer on lesser curvature. Figure 70 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Small ulcer on lesser curvature. OPERATIVE FINDINGS: Six months after Roentgen examination operation revealed a large ulcer on lesser curvature, posterior wall. A Incisura on greater curvature. B Area on lesser curvature due to ulcer. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 57 58 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 71 PATIENT POSITION: Man, age 52. Prone. ROENTGEN CONCLUSIONS; Small perforating ulcer on lesser curvature. Ulcer near pylorus on lesser curvature. One on greater curvature near pylorus. Duodenal ulcer. OPERATIVE FINDINGS: Roentgen findings confirmed in detail. (See artist's drawing, Figure 72.) A Perforating ulcer, lesser curvature, posterior wall, positively demonstrated on lateral plate. B Ulcer on greater curvature. C Ulcer on lesser curvature, near pylorus. D Ulcer of duodenum on inferior border. Figure 72 Artist's dra\ving. Same case as Figure 71. Arrows point to lesions found at operation. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 59 FIGURE 71 60 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 73 PATIENT — POSITION: Woman, age 38. Upright. ROENTGEN CONCLUSIONS: Chronic gastric ulcer near pylorus. OPERATIVE FINDINGS: Confirmatory. A Ulcer at pylorus on lesser curvature. Note that the deformity, due to connective tissue, in antrum and about pylorus, is constant both in the upright and the prone position. Figure 74 Same case as Figure 73, taken prone, which reproduces accurately the size and detail of ulcer. Figure 75 Same case as Figures 73 and 74, after resection of stomach. A Lesser curvature. B Ostium. THE ROEXTGEX DIAGXOSIS OF SURGICAL LESIOXj 61 FIGURE 73 FIGURE 74 62 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 76 PATIENT — POSITION: Man, age 50. Prone. ROENTGEN CONCLUSIONS: Pyloric obstruction due to ulcer of duodenum or pylorus or both. OPERATIVE FINDINGS: Ulcer of pylorus causing obstruction. A Note the dilatation of antrum, the so-called prognathion dilatation characteristic of pyloric obstruction. Figure 77 PATIENT — POSITION: Man, age 49. Prone. ROENTGEN CONCLUSIONS: Ulcer in antrum near pylorus. OPERATIVE FINDINGS: Chronic ulcer in antrum of stomach. A Ulcer. Note sharp incutting along lesser curvature. Figure 78 Same case as Figure 77, standing. A The deformity due to ulcer is even more distinct than in prone position. B First portion of the duodenum shomng less filling defect. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 63 FIGURE 76 FIGURE 77 FIGURE 78 64 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figures 79, 80, 81 and 82 PATIENT POSITION: Woman, age 39. Prone. ROENTGEN CONCLUSIONS: Small gastric ulcer near pylorus on lesser curvature. OPERATIVE FINDINGS: Small acute ulcer on lesser curvature. A Defect in antrum due to ulcer. Note : In this series of four plates this defect is constant throughout. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 65 FIGURE 79 FIGURE 80 FIGURE 81 FIGURE 82 66 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 83 PATIENT — POSITION: Woman, age 36. Prone. ROENTGEN CONCLUSIONS: Gastric ulcer producing hour-glass type of stomach. OPERATIVE FINDINGS: Large gastric ulcer on the lesser curvature of the stomach, posterior wall. Hour-glass formation due to scar tissue. A Hour glass. B Penetrating ulcer of the duodenum. Figure 83A PATIENT — POSITION: Woman, age 45. Prone. ROENTGEN CONCLUSIONS: Gastric ulcer near pylorus on lesser curvature. OPERATIVE FINDINGS: Gastric ulcer. A Gastric ulcer. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 67 FIGURE 83 FIGURE 83A THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS SECTION III GASTRIC NEW GROWTH Classification — Value of the Roentgen Ray in Diagnosis and Prognosis — Early Carcinoma — Advanced Carcinoma with Symptoms — and without Symptoms — Value of the Negative Plate The routine use of the Roentgen ray in the diagnosis of gastric cancer has now come to be recognized as one of tlie most important means of diagnosis. We beheve it is fair to state that the newer methods of chemical examination of the stomach contents, such as the glycltrj-ptophan test and the phosphotungstic acid reaction of Wolff, give results which are unstable and upon which no firm foundation can be laid. The same is true of the present status of the serum tests for cancer, such as the haemolysis test and the modified Abderhalden reaction. Even if positive, the latter give no hint of the location of the growth. In short, the situation at the present time as regards the possibihty of making a reason- ably early diagnosis of gastric cancer from clinical data alone is practicalh' hopeless. Smithies of Chicago, in a paper before the American Association of Gastroenterologists, stated that there was no one dependable sign on which to base the diagnosis. All this, however, refers to the usual methods of gastro-intestinal study. With the Roentgen method, on the other hand, we have a means at our disposal which we believe has already shown itself to be of distinct value in detecting early carcinoma. It is not to be inferred that the method is todaj^ an absolutely positive one, or that every case can be detected in its incipiencj^; but we do Mash to state emphatically that we are alread}^ in the possession of certain evidence which pushes the limits of diagnosis much further than can be done today hj any other methods of examination. The Roentgen diagnosis of gastric carcinoma can be classed under two headings. First, there is the early recognition of earl}' cancer. Secondly, there is the recognition of latent cancer, which is usually advanced cancer without symptoms. In this second group may also be included those cases about whose diagnosis there is no doubt clinically. Such cases are usually advanced and the Roentgen vay is useful as confirmator}' evidence, or in giving a more accurate prognosis. The Roentgen examination in cases of this second group, while interesting and settling matters for the patient, does not help much because this type of case is not early enough to give hope of cure. The recognition of early cancer is the diagnosis that is of real value both to the patient and to the surgeon. In this instance we have distinct hopes of detecting the cancer early enough to obtain radical cure by surgerj'. This is the type of lesion which gives verj' ob- scure and few gastric sjTnptoms. There is usually no obstruction, the acidity maj^ be practi- cally unchanged, there is, of course, no lactic acid, and there may be no blood in the gastric contents or stools. The data upon which even an exploratory' examination could be advised are therefore slight. These lesions are quite small and are situated at the pylorus, or rather just pre-pyloric. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIOXS 69 They may be primary cancer, or the result of malignant degeneration of old ulcer: which in the ^Titers' experience is most common. The extension of the gro^nh is from the pylorus and is not anntilar in character. The method to be considered in the Roentgen examination of these cases is extremely important. The Roentgenoscope, while of some value in this connection, shotild by no means be depended upon exclusively. These lesions are so .small that their direct detection upon the Roentgenoscopic screen is, in the majority of cases, almost impossible. The screen study of the indirect manifestations, such as h^iDermotihty. lack of peristalsis, antiperistalsis, etc., while important, certainly does not warrant any positive cUagnosis. and is apt to lead to many errors. In other words, a diagnosis of carcinoma of the stomach made by the fluorescent screen is usually only inferential and is dangerotis. The chief danger is the chance of missing lesions that could be detected by other methods of Roentgen ex- amination. The only safe and exact method of diagnosis is b}" the direct demonstration of the lesion upon plates. The techniciue in the early chagnosis of early cancer of the stomach varies in no essen- tial detail from the routine examination for other gastric lesions. The bismuth stibcarbonate (or bariima substitute) and buttermilk is the routine meal. Plates are made at once follow- ing the ingestion of the meal. The patient is examined in both the standing and prone positions. If any filling defect is observed plates are made mth the patient in the lateral position. Repeated or serial plates are essential to demonstrate the permanency of any defect. It must always be borne in mind that even one plate which shows a normal fiUing of the stomach carries more weight than twenty others which may show a defect. The Roentgen picture consists of a filhng defect in the gastric shadow. This defect in the early case is small and is usually at or near the pylorus. A small percentage of these primary new growths occiu" at the cardiac end, being situated usually at the cardiac orifice. Cases in this group are detected first dm-ing the study of the oesophagus, obstruction at the cardia being their most common manifestation. Primary carcinoma in the pars media is comparatively rare. These filling defects, when they occiu- near the pylorus, are annular in character, resem- bling in the very early cases a greater elongation of the pyloric gap. This annular appear- ance is the fundamental characteristic which distinguishes these lesions from the ordinary chronic ulcer in this region. Just why these lesions should give this annular defect we are not at present ready to state. It is barely possible that the extension of the cancer cells through the lower layers of the stomach wall affects the contractihty so as to exaggerate the defect and give the annular appearance. Of course this is only suggestive. The characteristic defect must be seen on a number of plates, although not neces- sarily a large niunber of plates. It is advisable to confirm the presence of the defect at another stomach examination, usuaUy made after the twent}"-four hoiu' plate. It is especially important to show the defect in the lateral view of the stomach, as this disposes definitely of the problem of pressiu-e from liver, gaU-b ladder, etc. Xext in importance to the annular character of the le.sion is the irregular ■'bitten-out'" appearance. This is seen most frequently in the advanced gro-n-ths, but should be searched for even in the smaUest lesions. An annular defect associated -n-ith this characteristic ir- regularity is pathognomonic of growth. It is very rarely simulated to any extent by chronic ulcer. Of course the problem of mahgnant degeneration of old ulcer is always present. Om- observations of the defects in this region have led us to the conclusion that whenever this irregular, annular defect is found rachcal surgery should be urged. By this we mean 70 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS resection of the lesion if it is surgically possible and not a mere palliative gastroenterostomy. Of course resection will depend upon the mobihty of the part, lack of adhesions, absence of liver metastases, glands, etc. No doubt in many cases the possibiUty of cancer is of less consequence than the added risk of resection. These lesions, whether actually chronic ulcers or not, as far as treatment is concerned, should all be considered new growth. With the lesions, however, which give a definite Roentgen sign of probable or possible mahgnancy, we beUeve no surgeon has the moral right to deny his patient the chance of cure that is afforded by resection. The decision of malignancy should not be allowed to rest with the surgeon who has only external inspection and palpation to guide him. The Roentgenologist has, in addition, the evidence from the mucosal side of the stomach. The sole judge of the case should be the pathologist after he has examined the microscopic sections from the excised lesion. We beheve these observations can be summarized briefly. The best chnicians today are agreed that the early diagnosis of gastric carcinoma is hopeless with chnical methods alone. With the Roentgen method properly applied, we are sure we have one means at our disposal that will enable us to detect the cases when they are still amenable to surgery. The lesions are small and located near the pylorus, showing small filling defects, annular in character. With such findings present, the Roentgenologist should urge resection, as only in this way can the diagnosis be helped and the problem of gastric cancer be solved. The negative aspect has not been emphasized enough. The negative Roentgen plate is today of as much value in diagnosis as the plate with positive evidence of disease. This negative value depends upon only one important factor; that is, the technique. Investi- gators must adhere to one well-tried technique and have the certainty of conclusive evidence from this technique. With our routine every normal stomach must give a normal Roentgen picture and no normal picture will be obtained if the stomach contains within its walls any organic changes. A normal stomach on the Roentgen plate absolutely rules out any growth beyond the microscopic stage. This is of great practical benefit, for many of our patients come suffering from a fear of cancer. A negative gastro-intestinal examination cures the sufferer. The appearance of advanced carcinoma is merely a more extensive and pronounced picture of early carcinoma. The elements are the same. First, the annular deformity may have extended so far that instead of a simple elongation of the pylorus, we now have marked canalization involving a half or two-thirds of the stomach. Second, the irregular outline, with its "bitten-out" appearance, now assumes an appearance of finger-like projections extending into the body of the bismuth shadow. In extreme cases, the whole stomach may be involved so that the picture shows a rigid tubular canal extending the whole length of the stomach. This canal may vary in diameter from half an inch to two or three inches. In the latter condition, the stomach has been described as a "leather bottle." The walls are absolutely rigid, due to the neoplastic infiltration. The plates show no evidence of peristaltic waves and, under the screen, its shape is not affected by moderate pressure and there is usually an accompanying palpable tumor. The size of the stomach, in such a condition, is usually constant. Its walls are no longer elastic so that there is no yielding of the walls when the patient attempts to eat. The patient can therefore eat only a small amount at a time, even with the very rapid emptying of the stomach which is a characteristic feature. The writers have in mind a case where the patient could take only half the meal. A plate taken within one minute after the last swallow showed at least two-thirds of the meal to be in the small intestine. These advanced cases sometimes show an hour-glass deformity. This need not be confused with the hour-glass deformity produced by chronic ulcer. In ulcer, the outline THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 71 of the constricted portion is smooth and the sulcus usually narrow, while with new growth the sulcus is broad and the outline irregular. Furthermore, the connecting isthmus of the hour-glass deformity in ulcer is displaced to one side. Usually it corresponds to the lesser curvature. The deformity is not symmetrical. With new growth, however, the connecting isthmus is usually central and the hour-glass deformity is quite symmetrical. This de- formity in chronic ulcer is due to a contraction of a band of circular muscle fibres, while in new growi;h it is an annular infiltration of the stomach wall with new tissue. A few cases of early carcinoma will produce early symptoms. This occurs when the lesion is at the pylorus and there is produced early pyloric obstruction. Such patients come to the Roentgenologist early and the examination shows principally a gastric stasis, with more or less deformity about the pylorus. These cases maj' be confused with obstruc- tion from chronic ulcer. However, the e\ddences of muscuJar hypertrophy, gigantic peristalsis, marked enlarge- ment of the stomach, etc., are usually found with chronic ulcer and not with cancer, prin- cipally because obstruction from cancer is of shorter duration and these secondare" changes have not had time to take place. The history may be of great value in helping to dif- ferentiate these two conditions, chronic ulcer or new growth. 72 THE EOENTGEN DIAGNOSIS OF SURGICAL LESIONS GASTRIC NEW GROWTH Figure 84 PATIENT— POSITION: Woman, age 25. Prone. ROENTGEN CONCLUSIONS: Normal. OPERATIVE FINDINGS: Exploratory. Stomach and duodenum found normal. Key plate 1 Region of cardia distended with air. 2 Pars media. 3 Pars pylorica, or antrum. 4 Pylorus relaxed. 5 First portion of the duodenum. " Bishop's Cap." Roentgenographically the first portion of the duodenum shows the superior and inferior border always smooth in outline. The base, or pjdoric region, is also smooth. 6 Second portioii of the duodenum. Note the valvulee coimiventes which distinguish it from the stomach and first portion of the duodenum. Histological^ the stomach and first portion are essentially the same. 7 The third, or transverse portion, of the duodenum. This passes transversely and to the left in front of the vertebral column and is partly obscured by the stomach. Note at the junction of the second and third portions a narrowing which is physiological. In the prone position this is partly due to pressure. Note the tendency of the duodenum to dilate before food passes this point. Figure 85 Artist's dra^\ang of Case 86 — Plate II. Figure 86 PATIENT — POSITION: Man, age 58. Prone. ROENTGEN CONCLUSIONS: Extensive involvement of the greater and lesser curvatures of the stomach due to gastric new growth. Probable adenocarcinoma. OPERATIVE FINDINGS: Inoperable carcinoma of practically the entire antrum and pars media. A Extension of growth towards cardia. B Antrum. C Pylorus. See colored drawing made at time of operation. (Plate II.) PLATE II— FIGURE 85 EXTENSIVE INVOLVEMENT OF THE GREATER AND LESSER CURVATURES OF THE STOMACH DUE TO GASTRIC NEW GROWTH THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 73 74 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 87 PATIENT — POSITION: Man, age 63. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer at the pylorus with beginning degeneration. Probable early carcinoma. OPERATIVE FINDINGS: Resection; chronic gastric ulcer at pylorus. Pathological report, adenocar- cinoma on the base of old ulcer. A Elongation of the pylorus, also the marked annular defect which is characteristic of carcinoma and not of ulcer. B First portion of duodenum, normal. This is constant throughout a series of plates, in the prone, lateral, and standing positions. The same case as Figure 87. A Defect of filling. The same case as Figures 87 and : A Defect of filling. Figure 88 Figure 89 Figure 90 The artist's drawing made at the time of operation from the resected portion of the stomach and duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 75 ^^'■ w 76 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 91 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer with beginning degeneration. Probable carcinoma. OPERATIVE FINDINGS: Resection; chronic ulcer at the pylorus. Pathological report, chronic ulcer, adenocarcinoma. A Area which shows definitely the annular deformity, characteristic of early carcinoma. (See Figures 87, 88 and 89.) Figure 92 PATIENT — POSITION: Woman, age 34. Prone. ROENTGEN CONCLUSIONS: Early carcinoma at pylorus. OPERATIVE FINDINGS: Annular growth about pylorus and antrum of the stomach. Pathological report, adenocarcinoma. A Characteristic annular defect. (See Figures 87 and 91.) Figure 93 PATIENT --POSITION: Man, age 38. Prone. ROENTGEN CONCLUSIONS: Annular carcinoma at pylorus. OPERATIVE FINDINGS: Chronic ulcer. Pathological report, adenocarcinoma. A Characteristic annular defect due to early carcinoma. It is worthy of note in this case that the operating- surgeon would not have performed a resection of the stomach on the surgical findings but was influenced solely by the Roentgen observations. Figure 94 PATIENT — POSITION: Man, age 52. Prone. ROENTGEN CONCLUSIONS: Carcinoma of the pylorus and antrum of the stomach. OPERATIVE FINDINGS: Inoperable carcinoma of the stomach. A Extent of growth on greater and lesser curvature. Plate made five minutes after the bismuth meal shows a very rapid emptying of the stomach. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 77 FIGURE 91 FIGURE 92 FIGURE 93 FIGURE 94 78 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 95 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS: Early carcinoma at pylorus. OPERATIVE FINDINGS: Autopsy. Extensive carcinoma of the oesophagus with secondary involvement in the stomach. A Pylorus. B — C Extent of growth in pyloric region and antrum. Figure 96 PATIENT — POSITION: Man, age 60. Prone. ROENTGEN CONCLUSIONS: Carcinoma at pylorus and antrum of the stomach. OPERATIVE FINDINGS: Resection of stomach. Adenocarcinoma. A Extent of process. Figure 97 Artist's drawing of Figure 96. Figure 98 PATIENT — POSITION: Man, age 48. Prone. ROENTGEN CONCLUSIONS: Small annular carcinoma at antrum of the stomach. OPERATIVE FINDINGS: Resection of stomach. Adenocarcinoma. A Extent of process. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 79 FIGURE 95 A FIGURE 97 FIGURE 96 FIGURE 98 80 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 99 PATIENT — POSITION: Man, age 60. Prone. ROENTGEN CONCLUSIONS: New growth in antrum of stomach. OPERATIVE FINDINGS: Inoperable carcinoma of stomach. A Extent of process. Figure 100 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS : Carcinoma extending practically the whole length of the lesser and greater curvature. OPERATIVE FINDINGS: Inoperable carcinoma of the stomach. A Pylorus. B Extent of process on lesser curvature. C Extent of process on greater curvature. Note intragastric tumor mass which displaces the bismuth. This case illustrates the obstructive type of new growth. Figure 101 PATIENT — POSITION: Man, age 60. Prone. ROENTGEN CONCLUSIONS: Extensive carcinoma of the stomach with obstruction. OPERATIVE FINDINGS: Inoperable carcinoma of the stomach. A Pylorus. B Extent of process. This case illustrates the obstructive type of new growth. Figure 102 PATIENT — POSITION: Man, age 60. Prone. ROENTGEN CONCLUSIONS: Probable inoperable carcinoma of the stomach. OPERATIVE FINDINGS: Inoperable carcinoma of the stomach. A Pylorus. B Extent of process on greater and lesser curvature. Obstruction of pylorus causing marked dilatation of whole stomach. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 81 FIGURE 99 FIGURE 100 FIGURE 101 FIGURE 102 82 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 103 PATIENT — POSITION: Woman, age 56. Prone. ROENTGEN CONCLUSIONS: Probable inoperable carcinoma of the stomach. OPERATIVE FINDINGS: No operation. Subsequent history confirmed Roentgen diagnosis. Death three months after examination. A Pylorus. B Extent of growth on greater and lesser curvature. Figure 104 PATIENT — POSITION: Man, age 63. Prone. ROENTGEN CONCLUSIONS: Penetrating gastric ulcer of lesser curvature. Involvement of pylorus and antrum by new growth. OPERATIVE FINDINGS: Inoperable carcinoma of the entire stomach. A Result of the old ulcer on the lesser curvature which some time in the past penetrated or formed the sacculation. The obstruction about this area was constant throughout the examination. B Pylorus. Showing small intragastric tumors at the pylorus and involvement at the gall-bladder and lesser curvature. Figure 105 PATIENT — POSITION: Man, age 63. Prone. ROENTGEN CONCLUSIONS: Extensive new growth in antrum of the stomach. OPERATIVE FINDINGS: laoperable carcinoma of the stomach. A Extent of new growth in stomach. B Pylorus. Figure 106 Artist's drawing of Figure 105. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIONS 83 FIGURE 103 FIGURE 104 Dfrdeiu 5ca ^oC^% FIGURE 105 FIGURE 105 84 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 107 PATIENT — POSITION: Man, age 54. Prone. ROENTGEN CONCLUSIONS: Intragastric tumor. OPERATIVE FINDINGS: Inoperable carcinoma of the stomach. A Pylorus. B Extent of process. It is interesting to note in this case the intragastric tumors suggesting a polypoid condition. At operation no investigation of the stomach was made to determine the character of this growth. This case was examined six months later and found not only to have gained in weight 45 pounds, but the Roentgen plate showed the process more extensive. Figure 107A PATIENT — POSITION: Man, age 58. Prone. ROENTGEN CONCLUSIONS: Complete involvement of the whole stomach due to new growth. OPERATIVE FINDINGS: Inoperable carcinoma of the entire stomach. A Pylorus. B Extent of process, extending to and including the cardia. Figure 108 PATIENT — POSITION: Man, age 63. Prone. ROENTGEN CONCLUSIONS: Intragastric tumor, pars media. OPERATIVE FINDINGS: Inoperable carcinoma of the antrum of the stomach. A — B Extent of intragastric tumors. Figure 109 PATIENT — POSITION: Woman, age 61. Prone. ROENTGEN CONCLUSIONS: Gastric new growth. OPERATIVE FINDINGS: No operation. A Pylorus. B Extent of growth. It is interesting to note in this case that there was no obstruction at the pylorus. In fact there was marked hypermotility. Stomach was empty in one hour. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIOXt 85 FIGURE 107 FIGURE 10:A FIGURE 108 FIGURE 109 86 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 110 PATIENT — POSITION: Man, age 48. Prone. ROENTGEN CONCLUSIONS: Hour-glass stomach. OPERATIVE FINDINGS: Adenocarcinoma of stomach. A Hour glass. See Figure III. Figure 111 The same case as Figure 110, standing. This shows the hour glass in pars media due to intragastric tumor. A Extent of tumor. B Narrowing of stomach due to lumor mass. The operation showed a large intragastric tumor. Adenocarcinoma. Figure 112 PATIENT — POSITION: Man, age 64. Prone. ROENTGEN CONCLUSIONS: Large new growth at cardia involving the upper half of the stomach. OPERATIVE FINDINGS: No operation. Death within three months. A Extent of tumor mass in cardia. Figure 113 PATIENT — POSITION: Man, age 48. Prone. ROENTGEN CONCLUSIONS: Postoperative new growth involving the entire stomach antrum. OPERATIVE FINDINGS: Inoperable carcinoma of the antrum of the stomach. This case was operated upon eight years before for gastric ulcer. Good recovery. No recurrence of gastric sj'mptoms until three months before our examination. It is to be noted that the growth has progressed even to the ostium within that short period. A Antrum. B Ostimn. C Duodenum. D Lesser curvature. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 87 FIGURE 110 FIGURE 112 FIGURE 111 FIGURE 113 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 114 PATIENT — POSITION: Woman, age 53. Prone. ROENTGEN CONCLUSIONS: Chronic gastric ulcer of pars media with probable beginning degeneration. OPERATIVE FINDINGS: Inoperable carcinoma of pars media and cardia. Extensive inflammatory- tissue about this area suggesting but not proving the Roentgen diagnosis of chronic ulcer. A Roentgen evidence of old penetrating ulcer. B Involvement of the stomach by new growth. C Extent of new growth. D Pylorus. Figure 115 PATIENT — POSITION: Man, age 43. Prone. ROENTGEN CONCLUSIONS: Inoperable carcinoma of the stomach on base of old ulcer. OPERATIVE FINDINGS: Chronic gastric ulcer and inoperable new growth. A Old penetrating ulcer. B Extent of growth. Figure 116 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS: Intragastric tumor of the greater curvature. Not positive but suggestive Roentgen evidence. OPERATIVE FINDINGS: Extensive involvement of the greater curvature of the stomach by intragastric tumors. A Beginning of filling defect in stomach. B Extension along greater curvature. Figure 117 PATIENT — POSITION: Man, age 63. Prone. ROENTGEN CONCLUSIONS: Inoperable carcinoma at cardia. OPERATIVE FINDINGS: Autopsy. A Involvement of cardia. THE ROEXTGEN DIAGNOSIS OF SURGICAL LESIOXS 89 FIGURE 114 FIGURE 115 FIGURE 116 FIGURE 117 90 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 118 PATIENT — POSITION: Man, age 52. Prone. ROENTGEN CONCLUSIONS: Small intragastric tumor in cardia. OPERATIVE FINDINGS: Small intragastric tumor in cardia. A — B Outline of tumor mass without bismuth. C Diaphragm. D Cardia. At first the lesion was not detected in presence of the bismuth meal but further inspection of the Roentgen- ograms of bismuth series revealed a small tumor mass. Figure 119 PATIENT— POSITION: Man, age 58. Prone. ROENTGEN CONCLUSIONS: Extensive new growth at cardia. OPERATIVE FINDINGS: Autopsy. A — B — C Extent of involvement about cardia. Figure 120 PATIENT — POSITION: Man, age 58. Prone. ROENTGEN CONCLUSIONS: Extensive new growth of entire stomach. OPERATIVE FINDINGS: Inoperable new growth of stomach. Figure 121 PATIENT— POSITION: Man, age 56. Prone. ROENTGEN CONCLUSIONS: Inoperable new growth of pars media of the stomach. OPERATIVE FINDINGS: Extensive new growth of stomach. A Beginning of the process. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIONS 91 FIGURE 118 FIGURE 119 FIGURE 120 FIGURE 121 92 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS SECTION IV ULCER OF THE DUODENUM Definition — Pathology — Possibility of a Positive Diagnosis — "Seven Propositions" — Serial Plates — Presumptive Evidence — Value of Roentgenoscope Since the brilliant work of Moynihan, Patterson and William Mayo was accepted by the medical profession, no new evidence in the diagnosis of duodenal ulcer that was positive in character was presented until Cole of New York proved the possibility of the direct diagnosis of pathological lesions in the first portion of the duodenum by serial Roent- genography. The writers have agreed with Cole in all his contentions, but have modified somewhat his technique in the study of the duodenum. The diagnosis of duodenal ulcer by the Roentgen ray, especially by the direct method, is one of simpUcity. It offers no particular difficulties other than that of care in technique. For convenience and clearness, the whole question depends upon the following propositions, which are substantially based upon the work of Cole and his observations, which have stood the test better than all other methods up to date. First. The direct method consists in demonstrating adequately the anatomical con- dition of the first portion of the duodenum. This is opposed to the conception of the symptom-complex, which emphasizes only inferential evidence and is not conclusive as compared with the direct method where we actually try to demonstrate the lesion. Second. Ninety-five per cent of all duodenal ulcers occur in the first portion of the duodenum. Third. Anatomically, the first portion of the duodenum is a constant entity. Fourth. If normal, the first portion of the duodenum can always be demonstrated on a plate with characteristic shape and smooth outline. There is no exception to this rule. Apparent exceptions are due to improper technique. Fifth. A constant defect in this duodenal cap on the plate means a pathological con- dition. This may be ulcer, adhesions due to cholecystitis, or anatomical or accidental varia- tions such as pressure from adjacent organs. Sixth. Any duodenal ulcer which is more than a simple mucous membrane erosion will deform the outhne of the bismuth mass. To this statement there is no exception. Seventh. A normal "bulbus duodeni," or duodenal cap on the plate, rules out chronic indurated or surgical ulcer. There is one exception to this rule: that is the minute recent ulcer which perforates without prodromal symptoms. However, we are not obhged to consider this from a Roentgen point of view. In the direct method of examination of duodenal ulcer, no little effort must be made to show the anatomical condition of the first portion of the duodenum on the plate. In the average case it is simple, but occasionally the problem of pjdoric spasm, pressure from adjacent organs such as a large and distended gall-bladder, enlarged lobes of the liver, spasm due to cholecystitis, gall-stones, pelvic conditions, chronic appendicitis, and obstructive conditions of the large and smaU bowel may make it more difficult. The size of the indi- THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 93 vidual, the amount of mesenteric fat and general condition of the abdominal cavity, all play an important part in the ease with which the duodenmn can be demonstrated on the Roentgen plate. No set rule can be made as to how this can be accomplished. Plates should be made with the patient in the prone position at first, and in the majority of cases the first portion of the duodenum will completely fill with no angulation of the smooth edges of the superior and inferior borders, as well as the pjdoric sphincter. Time must be given for the stomach to start emptjdng. This may vary from the mo- ment of taking the first mouthful to the first hour. In the average case, as soon as the patient has had the meal and is in position on the table, the first portion of the duodenum should be visualized. If one is sure there is no other lesion but the possibility of duodenal ulcer, we have found that half the usual meal wiU show the deformity better than the complete meal. If the duodemun does not fill out completeh" and one finds a picture of apparent deformit}^, by placing the patient right side down on the table with the plate underneath, using a small cjdinder, localizing for the average stomach midway on the costal cartilage, the plate will show the first portion, the beginning of the descending and part of the transverse duodenum in practically the same relations as one sees these parts on the plates when taken in the prone position. In the difficult cases it may mean ten to fifteen minutes with the patient on the side before the duodenum will fill completely. These are the cases in which the patient is large or spasm is present. As a rule, plates should be made at intervals for an hour before passing an opinion of duodenal ulcer on the deformity alone. In showing a normal first portion, effort should be made to carry out the technique over a period of at least an hour. One of the plates shoidd show the duodenum completely fiUed if it is normal. To this there is hardly an exception unless a large liver, new growth of the gall-bladder, or some other factor causes deformity by compression. Occasionally the only way the first portion of the duodenum can be shown is in the upright position. With all mixtures except the buttermilk mixture, it is difficult to fill the duodenum completely in the upright position. This has been one of the great sources of error in the inferential studj' by the Roentgenoscope. One should not change from the prone to the lateral and to the upright position without an effort being made for a reason- able length of time to get the cap in some one position. But it is only in the exceptional case that the first portion of the duodemmi is slow to fill. That the first portion of the duodemmi is a constant entity is the criterion of the truth of the direct method. From a large series of examinations of the duodemmi by the serial method, we are not alone in being convinced that the first portion of the duodenum is constant unless there is some pathology of the duodenum itself or of neighboring structures, as of the pylorus, and, whether the duodenum is large or small or average size, its borders Roentgenographically will always be smooth when normal. If it be admitted that with a series of plates, or Cole's serial method, a normal duo- denal cap can be shown when it is normal, then the converse of the proposition must be true. It is quite remarkable that practically^ all the investigators on the Continent did not seem able to reproduce the first portion of the duodenum on the photographic plate, or at least they laid a great deal of stress on the fact that it is difficult to do. We believe it to be solely a matter of improper technique, in part due to the kind of meal used. It would seem, then, that only one important question remains; that is, mil all ulcers of the duodenum show on the Roentgen plate? Dr. Wilhani Maj'o published a pathological study of a nmnber of cases of ulcers ex- cised from the anterior waU of the first portion of the duodenum (Annals of Surgery, 1913, Ivii, p. 691) that seemed to have a different character from the classical gastric ulcers, which 94 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS show a relatively broad, punched-out, callous defect in the mucosa with extensive indura- tion. These duodenal ulcers, however, often showed merely a pinpoint defect on the mu- cosal surface with some mucous membrane heaped about them. Though we do not make . bold to claim that a pinpoint mucosal defect will always show on the Roentgen plate, we do not feel it to be overstating the case to say, that if proper technique is used in a majority of the cases such a mucosal defect will show. It should be remembered that in this type of ulcer the amount of callus in the submucosal, muscular and peritoneal coats bears absolutely no relation to the minute size of the ulcer itself, which probably accounts for the Roent- genographic appearance of these ulcers, which seems exaggerated when compared with the operative findings. In no other part of the gastro-intestinal tract is the deforming effect produced by connective tissue upon the bismuth mass so apparent as in the first portion of the duodenum. The Roentgenologist knows that the amount of deformity shown on the plate taken when the bismuth is passing through the duodenum may seem to belie the appearance of the duodenum as presented at operation. A certain percentage of cases show on the Roentgen plate, opposite the ulcer, an incisura partly spastic in character, but mostly due to the involvement of the deep muscle layers by connective tissue or cicatrix. If a plate could be obtained in every case while the descending portion of the duodenum were held to one side so that it would not underlie the view obtained of the first portion of the duo- denum, then the incisura would be more apparent than it is in the majority of cases. The problem of whether an ulcer can exist as a simple erosion is, we believe, academic. Such an ulcer would be unlikely to give any symptoms and hence is of no immediate interest to the clinician or to the Roentgenologist. The pitfall for the novice in the Roentgen study of the duodenum is the differentiation of the deformity due to ulcer to that due to adhesions. Differentiation can be made readily between simple adhesions and ulcer of the duodenum. But where one finds a combination of ulcer of the duodenum and adhesions, one cannot say always, nor is it necessary, whether these adhesions are due to the ulcer, or to gall-bladder disease, or to both. It is sufficient to pass the opinion, which we can do from the Roentgen plate, that there is a surgical lesion. In simple adhesions, no matter how extensive, the deformity of the bismuth mass is greater at the beginning of the examination, gradually lessening as the stomach empties, and while the stomach when first filled will be found in the subhepatic region, it will be found in successive plates to move back to the median line as it empties. When the degree of deformity remains the same from the beginning of the examination until the stomach has almost emptied itself, it is more characteristic of ulcer. A constant deformity of the duodenum is peculiar to ulcer and to no other lesion. That a normal first portion of the duodenum rules out indurated or surgical ulcer in- creases many times the negative value of a Roentgen diagnosis by serial plates. Whenever we demonstrate the first portion of the duodenum to be free from deformity, we pass a negative opinion. Once only, out of a series of over a hundred cases which came to opera- tion, was our opinion unconfirmed. Much of the usefulness of the Roentgen method lies in this negative aspect. Negative evidence, however, is of greater value as referred to the duodemmi than to the stomach. We find, then, that the Roentgen diagnosis of duodenal ulcer by the direct method basically rests upon the demonstration by serial Roentgen plates of the continuity of the first portion of the duodenum, or the demonstration of a constant defect in its contour. There is no better argument for the plate method than that this can be accomplished un- failingly. The indirect method, as emploj^ed by Dr. R. E. Carman of the Maj^o Clinic, demands careful review because the large number of cases examined by that method THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 95 under his direction give credence to the accuracy of the data drawn therefrom. He has divided the Roentgen signs of duodenal ulcer into major and minor groups. The major signs consist of "hyperperistalsis, six-hour gastric residue and demonstrable diverticulum of the duodenum." Gastric hyperperistalsis has been emphasized more than any other sign. The writers have stated, "abnormally marked peristalsis is an important sign if found." The difficulty is that even with Carman's large series it was present in only fifty-seven per cent of the proved cases of duodenal ulcer. It was found in pyloric stenosis due to other causes than ulcer, as early carcinoma and abnormal nervous conditions. We have seen violent hyper- peristalsis in individuals with no organic disease present. Its presence is hardly more than suggestive and its absence certainly does not warrant a negative diagnosis. We believe it a very treacherous basis upon which to found a diagnosis of duodenal ulcer. Six-hour bismuth residue in the stomach depends to a large degree, as has been already stated, upon the character of the bismuth meal used. The large number of Roentgen ex- aminations made by Carman justifies him, no doubt, in attaching a definite significance to the presence of a six-hour stasis with his particular meal and technique. He found this residue, however, in only 33.3 per cent of his cases of duodenal ulcer. This corresponds fairly well with the observations of other investigators. Indeed, Holzknecht and Haudek found this residue in onlj' twenty per cent of their duodenal ulcers. Thus it would seem that at the very best, about two thirds of duodenal ulcers give no positive information as to this major diagnostic sign. A diverticulum of the duodenum, so-called, is undoubtedly important when present. Carman found it in only two cases out of one hundred and ninetj^-eight. The writers have seen this condition in about six cases. Its raritj^ militates against its effectiveness as a con- stant factor in diagnosis. IncidentaU}', we do not believe that this diverticulum is due at all to a penetrating duodenal ulcer in the sense that "Haudek's niche" is produced by a penetrating gastric ulcer. Such a penetration is extremely rare in duodenal ulcer and onlj^ two cases have been noted. In our experience these diverticula have been caused by a pull of adhesions for a considerable length of time which finally resulted in the production of small saccula- tions. Sometimes, also, such sacculations may be the result of a cicatrizing process which involves all the duodenal cap except one small section in which the wall is normal and which contains a bismuth residue. We are forced to the conclusion, in respect to these so-called "major signs," that the one sign which is considered most valuable, gastric hyperperistalsis, leaves us without help in at least forty-three per cent of cases. The combination of hyperperistalsis and six-hour gastric residue was found in only 24.7 per cent of his cases, yet Carman states they are "worth more than ninety-five per cent in the diagnosis of duodenal ulcer." This, on the face of it, seems hardly compatible with his statistics. Again he states that "the combination of hyperperistalsis and six-hour residue or diverticulum, when found in an otherwise normal stomach, constitutes about the only evi- dence on which a purely radiologic diagnosis of duodenal ulcer may safelj^ be advanced." If this is true, then in at least seventy-five per cent of cases a purely Roentgen diagnosis is impossible. The results of the direct method certainlj- do not support this statement. As a matter of practice, the writers know these so-caUed major signs are not depend- able and, as a matter of deduction. Carman's own statistics are open only to the same conclusion. 96 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Let us examine what he calls "minor signs" in Roentgen diagnosis and accord at once with him as to their relatively inferior value in all but one instance, which we shall consider last. Hypermotility of the stomach is a sign which we agree is by no means pathognomonic of ulcer, since it occurs in achylia gastrica, carcinoma, and motor neuroses. In duodenal ulcer the presence of hypermotility results from a physiological tendency towards rapid emptying of the stomach due to duodenal irritation on one hand and the mechanical ob- struction from the cicatrized portion of the duodenum on the other. The results are so variable that they offer no basis for definite conclusions to be appUed to any particular case. Hypertonus of the stomach, the presence of pressure tender-points and the lagging of bismuth in the duodenum we are agreed are minor signs in the Roentgen diagnosis of duo- denal ulcer and no one of them is pathognomonic. Reliance on these signs is certain to lead to errors of diagnosis. When, however, we consider the last of Carman's minor signs; namely, deformity of the outline of the duodenal cap, we must emphatically protest against including this among the minor signs. The word "irregularity" does not convey sufficiently the idea as to just what we are attempting to demonstrate by the direct study of these cases. What we try to show in every instance is either a normal duodenum or the exact size, extent and character of the lesion. The entire problem revolves about the method of study of the duodenum. In the application of the Roentgen ray to surgery generally, the development has always been along the lines of attempting to obtain positive data and eliminating all bases for diagnosis that are uncertain and indefinite. This trend is seen already in the Roentgen study of fractures, bone disease, and renal calculi. The same point of view is equally true when applied to duodenal ulcer. The only basis for a definite opinion should be the actual demonstration of a normal or abnormal duodenum. The direct school of diagnosis disre- gards all the indirect, so-called "major" or "minor" signs, and restricts itself to one prob- lem; namely, the attempt to demonstrate adequately the anatomical condition of the duo- denum and the determination as to whether the duodenum so demonstrated is normal or pathological. This problem is largely one of careful and exact technique. The Roentgenoscopic method, when applied to the study of the duodenal ulcer from this point of view, is entirely unsatisfactory. It is true that sometimes the duodenum can be seen in its entirety, but it can never be seen for a long enough time to satisfy one as to its anatomical completeness. It certainly cannot be shown in all cases, especially in well- nourished individuals. In the standing position in which the Roentgenoscope is ordinarily used, this demonstration is usually impossible. All that can be shown is the pressure of the bismuth into the cap, which is speedily emptied. It is only with the plate method, carefully carried out, that the duodenum can be demonstrated in its entirety. We do not mean to infer that the Roentgenoscopic study of the gastro-intestinal tract is worthless. The Roentgenoscope has undoubtedly its valuable appfications in the study of the stomach and many other parts of the alimentary tract. However, when it comes to the study of the duodenum and the problems involved in duo- denal ulcer, the Roentgenoscope must really be considered as of minor value. Serial Roentgen plates are the ideal method of studying these cases and it is not necessary always to take an extremely large number of plates. Only enough plates need be taken as will convince the investigator of either the normal condition of the duodenum or its constant abnormal condition. No set rules can be given as to the position of the THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 97 patient during the examination. All the positions, prone, standing and lateral, may have to be used in order to obtain the desired information. The exact procedure to be followed must be worked out in each individual case as the problems present themselves. This requires the use of rapid developers and the development of plates during the progress of the examination. Of course, this is a more troublesome process than the indirect method, but the more accurate results obtained are certainly worth the bit of extra labor and expense. Note. Since going to press Dr. R. C. Carman in a paper read at the annual meeting of the American Roentgen Ray Society, September, 191.5, at Atlantic Citj', stated that he now considers deformity of the duodenal cap a major sign in the diag- nosis of duodenal ulcer and that since accepting this he has made more diagnoses of duodenal ulcer which have been confirmed at operation. 98 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS DUODENUM Figure 122 PATIENT — POSITION: Woman, age 25. Prone. ROENTGEN CONCLUSIONS: Normal. OPERATIVE FINDINGS: Exploratory. Stomach and duodenum found normal. Key plate. 1 Region of the cardia. 2 Pars media. 3 Pars pylorica or antrum. 4 Pylorus. 5 First portion of the duodenum. 6 Second portion of the duodenum. 7 Third portion of the duodeniun. This plate is used as an average normal Roentgenogram of a normal individual. It shows the superior and inferior borders of the duodenum perfectly smooth and regular. The pyloric region of the duodenum is regular in outline. Figure 123 Artist's dra"ning. Extensive surface of ulcer on the anterior wall of the duodenum. Figure 124 Artist's' dra-R-ing. Mucosal surface of ulcer on anterior wall of the duodenum. (Permission of Dr. William Mayo.) THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 99 FIGURE 122 FIGURE 123 FIGURE 124 100 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 125 PATIENT — POSITION: Man, age 38. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic ulcer of the anterior wall of the duodenum. A Mucosal defect of the superior border of the duodenum. B Deforming effect of scar tissue. Figure 126 PATIENT — POSITION: Man, age 42. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic ulcer of the duodenum. A Effect of coimective tissue about the ulcer. B Mucosal defect. C Incisura partly due to spasm but mostlj' to the deforming effect of tissue. Figure 127 PATIENT — POSITION: Woman, age 38. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic ulcer of the duodenum with extensive involvement of the duode- num due to chronic ulcer of the anterior wall. A Large mucosal defect. B Effect of connective tissue deforming the outline of the duodenum. Figure 128 PATIENT — POSITION: Man, age 3L Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic ulcer of the duodenum with extensive scar formation. A Mucosal defect. B Deforming effect of scar tissue. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 101 FIGURE 125 FIGURE 126 FIGURE 127 FIGURE 128 102 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 129 PATIENT — POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Extensive involvement of the duodenum by scar from old ulcer and adhesions. A Pjdorus. B Almost complete obliteration of the duodenum. Figures 130 and 130A PATIENT — POSITION: Woman, age 40. Lateral. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: A small chronic ulcer of the superior wall of the duodenum. A The deforming effect of connective tissue. B Mucosal defect. This case could not be diagnosed in either the upright or prone positions as there was no apparent deformity. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 103 FIGURE 129 FIGURE 130A 104 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figures 131 and 131 A PATIENT — POSITION: Man, age 48. Lateral. ROENTGEN CONCLUSIONS: Ulcer of the superior and inferior borders of the duodenum. OPERATIVE FINDINGS: Extensive involvement of the duodenum due to an ulcer both of the superior and inferior borders of the duodenum. A Mucosal defect of the superior border of the duodenum. B Mucosal defect on the inferior border of the duodenum. Figure 132 PATIENT — POSITION: Man, age 40. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic ulcer of the duodenum. A Large mucosal defect. B Deforming effect of connective tissue. Figure 133 Same case as Figure 132. Plate made fifteen minutes after Figure 132. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 105 FIGURE 131 FIGURE 131A FIGURE 132 FIGURE 133 106 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 134 PATIENT — POSITION: Man, age 55. Prone. ROENTGEN CONCLUSIONS: Duodenal ulcer; probably beginning carcinoma at the pylorus and antrum of the stomach. OPERATIVE FINDINGS: Annular carcinoma of the antrum of the stomach. A Scar of old ulcer of the duodenum. Figure 135 PATIENT — POSITION: Woman, age 48. Standing. ROENTGEN CONCLUSIONS: Ulcer of the duodenum, also ulcer of the lesser curvature of the stomach, posterior wall. OPERATIVE FINDINGS: Chronic ulcer of the duodenum, also a large florid ulcer of the lesser curvature of the stomach, posterior wall. A Deforming effect of ulcer in duodenum. B Deforming effect of ulcer of posterior wall of the stomach. Figure 136 PATIENT — POSITION: Woman, age 39. Prone. ROENTGEN CONCLUSIONS: Probable ulcer of the duodenum with adhesions. OPERATIVE FINDINGS: Operation six months after examination revealed involvement of the duodenum due to old ulcer. No adhesions. A Duodenum showing deforming effect due to ulcer. The characteristic ulcer deformity was not visualized in the prone position. Figure 137 Same case as Figure 136, lateral view. A — B Deforming effect of ulcer in the duodenum. Note the more characteristic appearance of ulcer in this position. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 107 FIGURE 134 108 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 138 PATIENT — POSITION: Man, age 33. Prone. ROENTGEN CONCLUSIONS: Complete obliteration of the duodenum due to ulcer. OPERATIVE FINDINGS: Chronic ulcer of the duodenum. A Obliteration of duodenum due to coimective tissue. Figure 139 PATIENT — POSITION: Man, age 43. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum with probable adhesions. OPERATIVE FINDINGS: Extensive involvement of the duodenum by adhesions from the gall-bladder and liver. A^B The serrated effect about the duodenum is suggestive of adhesions and not of ulcer. Figure 140 PATIENT — POSITION: Man, age 32. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Obliteration of duodenum due to chronic ulcer and adhesions. A Small amount of bismuth filling duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 109 FIGURE 138 FIGURE 139 FIGURE 140 110 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 141 PATIENT — POSITION: Man, age 62. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum with probable adhesions. Gall-stones. OPERATIVE FINDINGS: Perforation of gall-bladder into duodenum with extensive adhesions and narrow- ing of duodenum. Sixty-seven gall-stones. A Outline of one gall-stone. B This was supposed to be a mucosal defect but proved to be a perforation into the gall-bladder of the duodenum. C Effect of pressure from the gall-bladder on the duodenum. Figure 142 Lateral view of same case (Figure 141). A Pylorus. B This was supposed to be a mucosal defect; at operation proved to be perforation of the gall-bladder into the duodenum. Figure 143 PATIENT — POSITION: Man, age 40. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum with possible beginning perforation. OPERATIVE FINDINGS: Beginning perforation of ulcer of the superior border of the duodenum. A Pylorus. B Perforation. Figure 144 PATIENT — POSITION: Woman, age 32. Prone. ROENTGEN CONCLUSIONS: Very small ulcer on the superior border of the duodenum. OPERATIVE FINDINGS: Very small ulcer of the anterior wall of the duodenum. A A fine pinpoint mucosal defect. B Defect partly due to spasm and partly due to the involvement of the duodenum by connecting tissue. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 111 FIGURE 141 FIGURE 142 FIGURE 143 FIGURE 144 112 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 145 PATIENT — POSITION: Man, age 50. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum, the obstructive type. OPERATIVE FINDINGS: Complete obliteration of the first portion of the duodenum with marked adhesions. The stomach was greatly dilated and contained bismuth residue after thirty-six hours. A Ulcer of the duodenum. B Pylorus. C Fixation of the duodenum in the subhepatic region. Figure 146 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum, obstructive type. OPERATIVE FINDINGS: Extensive ulcer of the duodenum involving the pyloric sphincter. A Effect of ulcer upon the first portion of the duodenum. B Pylorus. This case showed a marked twenty-four hour gastric stasis, probably due to the involvement of the pyloric sphincter by connective tissue arising from the ulcer in the duodenum. Figure 147 PATIENT — POSITION: Man, age 28. Prone. ROENTGEN CONCLUSIONS: Small ulcer on the superior border of the duodenum. OPERATIVE FINDINGS: Small ulcer and a large adhesion arising from anterior wall of the duodenum. A Pyloric sphincter. B Defect in the first portion of the duodenum due to ulcer probably brought about more bj^ the adhesions than by the ulcer itself. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 113 FIGURE 1"15 FIGURE 146 FIGURE 147 114 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 148 PATIENT --POSITION: Man, age 39. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer and obliteration of the duodenum. OPERATIVE FINDINGS : Extensive involvement of the first portion of the duodenum by ulcer and adhesions. A Pyloric sphincter. B A small amount of bismuth retained in the duodenum. Six and eight hours after the bismuth meal, when the stomach was empty, this fleck of bismuth remained. Its significance is that that portion of the duodenum is normal whereas the remainder is obliterated by connective tissue and adhesions. Figure 149 Artist's drawing of Figure 148. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 115 FIGURE 148 FIGURE 149 116 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 150 PATIENT — POSITION: Man, age 52. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic ulcer of the duodenum. A Ulcer. Figure 151 Plate III, colored plate of Figure 150. Figures 152 and 152A The same case as Figure 150. Lateral view. Obliteration of the first portion of the duodenum due to ulcer. A Pylorus. B Area of ulcer. C Descending duodenum. \ i PLATE III — FIGURE 151 CHRONIC ULCER OF THE DUODENUM J'^ THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 117 FIGURE 150 FIGURE 152 FIGURE 152A 118 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 153 PATIENT — POSITION: Man, age 38. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Small ulcer of the posterior wall of the duodenum. A Small mucosal defect on the superior border of the duodenum. Note the poor filling of the antrum, mostly due to pressure. Figure 154 The same case as Figure 153 showing a more complete filling of the antrum of the stomach and first portion of the duodenum. A Pylorus. B — C Deforming effect of connective tissue engirding the first portion of the duodenum. Figure 155 PATIENT — POSITION: Woman, age 28. Prone. ROENTGEN CONCLUSIONS: Ulcer of the duodenum. OPERATIVE FINDINGS: Extensive involvement of the first portion of the duodenum with involvement of the stomach and pylorus with adhesions. A Complete obliteration of the duodenum and involvement of the antrum by adhesions. THE ROENTGEN DLIGNOSIS OF SURGICAL LESIONS 119 FIGURE 153 FIGURE 154 120 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 156 PATIENT ^POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic ulcer of the duodenum. A Mucosal defect on the superior border of the duodenum. B Contraction due to scar tissue. C Pylorus. Figure 156A Same case as Figure 156. This shows how constant is the deformity of the duodenum. A Mucosal defect. B Contraction due to scar tissue. Figure 157 PATIENT — POSITION: Man, age 53. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum, obstructive type. OPERATIVE FINDINGS: Extensive adhesions about the duodenum, probably ulcer. Stomach markedly dilated. A Pylorus. This plate was made six hours after the bismuth meal showing practically no passage of the bismuth towards the small bowel. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 121 FIGURE 156 FIGURE 156A FIGURE 1S7 122 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 158 PATIENT — POSITION: Man, age 36. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Chronic duodenal ulcer. A A filling defect of the duodenum due to connective tissue. B Mucosal defect. C Incisura opposite the site of the ulcer. Figure 159 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Chronic ulcer of the duodenum. OPERATIVE FINDINGS: Ulcer of the duodenum. A Pylorus. B Ulcer of the duodenum. Three years previously this case was operated upon for gall-stones. An examination of the stomach at that time revealed what was thought to be an ulcer on the lesser curvature of the stomach near the pylorus and the subsequent clinical history of the case seemed to confirm it. Our examination, however, gave no Roentgen evidence of gastric ulcer but a defect in the first portion of the duodenum. Operation then showed a duodenal ulcer, and a careful exploration of the stomach was made for a gastric ulcer but no evidence of any could be found. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 123 FIGURE 158 FIGURE 159 124 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 160 PATIENT — POSITION: Man, age 38. Prone. ROENTGEN CONCLUSIONS: Small ulcer of the duodenum. OPERATIVE FINDINGS: A very small ulcer on the posterior wall of the duodenum. A Mucosal defect of an ulcer of the superior border of the duodenum. Figure 161 Artist's drawing of Figure 160. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 125 FIGURE 160 KKoenTfen Ef Dr Grtorfc \ 126 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 162 PATIENT ^POSITION: Woman, age 36. Prone. ROENTGEN CONCLUSIONS: Penetrating ulcer of the superior border of the duodenum. OPERATIVE FINDINGS: Confirmed Roentgen findings. A Pylorus. B Point of perforation of ulcer. C The sacculation due to perforation. D Incisura on inferior border. Figure 163 PATIENT — POSITION: Man, age 28. Prone. ROENTGEN CONCLUSIONS: Adhesions about the duodenum, stomach, and large bowel. OPERATIVE FINDINGS: Involvement of the stomach, duodenum, and large bowel in a mass of adhesions. No evidence of ulcer. A Pylorus. B Apparent defect in first portion of the duodenum. C Defect in antrum of the stomach. Figure 164 Artist's drawing of Figure 163. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 127 FIGURE 163 128 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 165 PATIENT — POSITION: Man, age 33. Prone. ROENTGEN CONCLUSIONS: Hour-glass stomach and beginning gastric ulcer at the cardia. OPERATIVE FINDINGS: No operation. A Hour-glass contraction. B Pylorus. C Girding of the stomach due to recent ulcer at the cardia. Figure 166 ROENTGEN CONCLUSIONS: Double hour-glass stomach. There was a marked increase of the narrow- ing at the cardia with obstruction of the transverse portion of the duodenum. A Hour glass as seen in first examination. B Marked narrowing of the stomach due to a new ulcer which formed a second hour glass. Pylorus apparently perforated. C Point of obstruction at transverse portion of duodenum. (Note dilatation of descending portion of duodenum.) OPERATIVE FINDINGS: Double hour glass of the stomach. Ulcer of the duodenum, obstruction of the transverse portion of the duodenum due to adhesions. Figure 167 PATIENT — POSITION: Man, age 48. Prone. ROENTGEN CONCLUSIONS: Obstruction of the transverse portion of the duodenum due to adhesions. OPERATIVE FINDINGS: Extensive involvement of the head of the pancreas and first portion of the duodenum. A Point of obstruction at the transverse portion of the duodenum. B Dilatation of the descending portion of the duodenum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 129 FIGURE 165 130 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 168 PATIENT — POSITION: Woman, age 58. Prone. ROENTGEN CONCLUSIONS: Fixation of the first portion of the duodenum within the subhepatic region, probably due to gall-bladder involvement. OPERATIVE FINDINGS: Marked dilatation of the first portion of the duodenum with fixation to the gall-bladder and liver. A Pylorus. B First portion of the duodenum. C Pressure of the large gall-bladder upon the superior border of the duodenum. Figure 169 PATIENT — POSITION: Woman, age 37. Prone. ROENTGEN CONCLUSIONS: Adhesions about the descending duodenum. OPERATIVE FINDINGS: Fixation of the mid-portion of the duodenum to the gall-bladder. A Point of fixation of the duodenum. Figure 170 PATIENT — POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: Adhesions about the second portion of the duodenum. OPERATIVE FINDINGS: Extensive adhesions about the duodenum and throughout the right upper quadrant. A Pulhng effect of mass of adhesions at the junction of the descending and transverse portions of the duodenum. Figure 171 PATIENT — POSITION: Woman, age 29. Prone. ROENTGEN CONCLUSIONS: Adhesions about the descending duodenum. OPERATIVE FINDINGS: Extensive involvement of the right upper quadrant with adhesions. A Pylorus. B First portion of the duodenum. C Showing irregular arrangement of the second portion of the duodenum due to adhesions. D Beginning of third portion of duodenum. Note: This plate was made with patient on the back on the plate. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 131 FIGURE 16 FIGURE 169 FIGURE 170 FIGURE 171 132 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 172 PATIENT — POSITION: Woman, age 38. Prone. ROENTGEN CONCLUSIONS: Probable ulcer of the duodenum. Possible adhesions. OPERATIVE FINDINGS: Extensive adhesions about the first portion of the duodenum arising from gall-bladder region and a chronic ulcer of the duodenum. A Antrum of the stomach. B First portion of the duodenum. This shows the contraction of the first portion of the duodenum due to ulcer or adhesions or both. This deformity is more characteristic of extensive adhesions than of ulcer alone. Figure 173 PATIENT— POSITION: Man, age 60. Prone. ROENTGEN CONCLUSIONS: Small ulcer of duodenum. OPERATIVE FINDINGS: Ulcer of duodenum. A Deformity of the duodenum due to connective tissue from ulcer. B Mucosal defect of ulcer. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 133 FIGURE 172 FIGURE 173 134 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 174 PATIENT — POSITION: Man, age 39. Prone. ROENTGEN CONCLUSIONS: Ulcer of the duodenum. OPERATIVE FINDINGS: Extensive post-operative adhesions from gall-bladder operation ten years previously. No positive evidence of ulcer found. A Pylorus. B Contracted area about the duodenum which is constant throughout the series of plates assumed to be contraction about the ulcer. C Descending portion of duodenum. Note in Figures 175 and 176 how constant this defect is. Figure 175 The same case as Figure 174. A Pylorus. B Defect in duodenum, due to adhesions. Figure 176 The same case as Figures 174 and 175. A Pjdorus. B Defect in duodenum due to adhesions. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 135 FIGURE 174 FIGURE 175 FIGURE 176 136 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 177 PATIENT — POSITION: Premature infant, 4 days old. Prone. ROENTGEN CONCLUSIONS: Obstruction of transverse portion of duodenum, probably congenital in origin. AUTOPSY: Four days after the Roentgen examination autopsy showed marked dilatation of oesophagus and stomach, and especially the first and second portions of the duodenum with obstruction due to a tumor at the junction of the descending and transverse portions of the duodenum. The lumen of the bowel would allow only a small probe. A Dilatation of the oesophagus. B Cardia. C— D Stomach. E First portion of the duodenum. F Obstruction of the descending portion. Figure 178 The same case as Figure 177 taken twenty-four hours after the bismuth meal. This shows the passage of but a very small amount of bismuth into the small bowel. A CEsophagus. B Cardia. C— D Stomach. E Point of obstruction and dilatation of the duodenum. F Slight amount of bismuth in the small bowel. Figure 179 Lateral view of the same case as Figures 177 and 178. This shows the passage of a stomach tube in an effort to remove the gastric contents. Figure 180 The same case as Figures 177, 178 and 179. A The patient is lying on the back and this shows the passage of the stomach tube through the pylorus. B — C Stomach tube following along greater curvature toward cardia instead of pyloric region. D Dilated duodenum. E Bismuth in jejunum and ileum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 137 FIGURE 177 FIGURE 178 FIGURE 180 138 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 181 PATIENT — POSITION: Man, age 62. Prone. ROENTGEN CONCLUSIONS: Primary carcinoma of the duodenum. OPERATIVE FINDINGS: Extensive involvement of the first portion of the duodenum with inflammatory tissue considered at the time of operation to be chronic ulcer. The autopsy showed an extensive involvement of the duodenum by carcinoma. A Pylorus. B — B — B Multiple areas of involvement in the first portion of the duodenum. C Extension of this portion into the antrum of the stomach along the greater curvature. The multiphcity of filling defects is not characteristic of chronic ulcer. The same defect is found in the duodenum and extends to the greater curvature of the stomach. At autopsy this proved to be partly pressure due to new growth. D A loop of jejunum fixed above the stomach by adhesions. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 139 FIGURE 181 140 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS SECTION V GALL-BLADDER Percentage of Stones which Show — Technique — Preparation and Position OF Patient, Tubes, Plates, Screens, Stereoscopic Plates — Demonstration of Diseased Gall-Bladder — Adhesions Up to three years ago gall-stones were detected by the Roentgenologist in such a small percentage of the suspected cases that most Roentgenologists did not recommend the examination and only made it when urged to do so. Several of us, however, found that gall-stones containing calcium could be detected much more frequently than we had sup- posed, and this discovery stimulated the search. While as yet few Roentgenologists have published reports, the general opinion seems to be that from fifty to seventy-five per cent of gall-stones will show. With our present technique we feel that eighty-five to ninety per cent can be demonstrated. This percentage naturally increased the value of the negative plate. TECHNIQUE The technique is not radically different from that employed for soft tissue work in any other part of the body; but it requires conscientious attention to the most minute points. One must not be satisfied with the plates unless detail is shown to the greatest possible degree. Roentgen plates obtained by improved technique show extraordinary detail. In two cases the pelvis of the kidney, the blood vessels going to and from it, and the upper part of the ureter were remarkably distinct. Opinions differ as to the advisability of catharsis prior to the examination. The writers consider that the gas resulting from the cathartic is a more disturbing factor in the inter- pretation of the Roentgen plate than the fecal contents of the colon. The vast improvement in tube construction which has been made in recent years enables one to obtain an accuracy and degree of penetration which has hitherto been unat- tainable practically. Roentgen plates showing brilliant bone detail with considerable density of the soft parts are not desirable for the diagnosis of gall-stones. Soft "monotonic" Roentgen plates obtained with the later model tubes are deprecated by some critics because marked contrast in the bony strueti*Fe is lacking; but they show re- THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 141 markable graduations in the soft tissue — a result for which one strives when in search of gall-stones. Minor condemned fine Roentgen plates of the lungs as compared with the fluoroscopic image because they showed so much detail in the soft parts as to make them difficult to interpret. It is the interpretation of these very details that increases the accuracy of diagnosis, whether it be the chest or gall-bladder that is under consideration. The necessity of using an extremel.y small cone, showing only a limited area in each Roentgen plate, is strongly emphasized. The length of the cone is not an essential factor. By means of such a cone secondary rays are generated in the patient to a much less degree, and the fogging effect being proportionately diminished it is then possible to show dis- tinctly a calculus that would be quite invisible if a large or moderate-sized blend were used. The cone may be pointed obliquely downward so that the axis of the rays is parallel with the under surface of the liver. When- this is done, the under surface of the liver appears as a clear-cut and well-defined line; and the gall-bladder, if normal, can usuallj^ be detected, or the relation of the patient to the tube may be altered by a slight rolling from side to side. Sometimes, particularly when the gall-bladder is high, a lateral position will show the gall-stones against the background of the liver. It matters very little whether screened or unscreened plates are used. Some plates may be made with screens, and some without them. The unscreened plates should be ex- posed face to face, and shghtly undertimed, with a view to matching up the shadows thereon after development. Double screened plates also may be made in a special holder, con- structed to carry screens of different rapidity. Two plates and two screens of different speed are used in the same holder. The plates are placed back to back. The under one, face down, lies against a fast screen, whilst the upper one lies face upward against a rela- tively slow and thin screen. A very short or even undertimed exposure is made, and after development the plates are superimposed and matched together, whereupon by transmitted light one gets the plastic effect up to a certain point. This method ehminates screen and plate defects to a great extent. Roentgen stereoscopy adds very materially in the interpretation of the Roentgen plates. Four exposures may be made, preferably with each exposure on the two plates face to face, giving a slight lateral shift to the tube between the first and second exposures. Then move the tube down about two inches and make two more exposures, shifting the tube once more in the lateral direction between the third and fourth. In this manner, one can stereo- scope the various exposures with each other, that is to say, 1-2 and 3-4 stereoscoped with each other laterally, and 1-3 and 2-4 stereoscoped with each other vertically. DEMONSTRATION OF DISEASED GALL-BLADDER Comparison from behind avails little; but small areas may be brought close to the plate for detailed examination, by the use of a circular plate holder about the size of the end of a small compression blend. This holder, with or without a screen, may be pushed up under the edge of the rib, thereby materiallj^ diminishing the thickness of that part of the abdomen. The entire region from the eleventh rib to the crest of the ileum, or even lower, should be included in the examination. As repeated exposures are required, and as some of the plates are not screened, the total exposure is considerable, and a filter should always be 142 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS used to prevent dermatitis. If after carefiil study of at least fifteen or twentj^ Roentgen plates of the gall-bladder, no evidence of the calculi is found, the patient should be sub- mitted to an examination of the stomach, duodenima, and colon, in a search for adhesions from cholecystitis -ndthout stones, or for the purpose of differentiating this condition from post-pyloric ulcer and appendicitis with reflex gastric symptoms. Even when there is direct evidence of the stone, this additional information is of great value in determining whether or not there is a concomitant lesion, whether or not surgery is indicated and how difficult the operation may be. Although the technique herein described greatly facihtates the interpretation of the Roentgen plates, gall-stones may be detected in the ordinary Roentgen plate in a large percentage of cases if one is familiar with their Roentgen appearance. ADHESIONS Of late, a re-examination has been made of those Roentgen plates taken during the last four or five years in which direct evidence of gall-stones was insufficient or undetected, but which showed enough evidence of adhesions from the accompamdng cholecj^stitis to justify surgical procedure. In the re-examination, our increased knowledge of the Roentgen appearance of soft gall-stones has enabled us to detect direct evidence of the calculus on the Roentgen plate, in a large number of cases where calculus was found at operation. The same results have been obtained from a restudj^ of those cases where the gall- bladder onl}^ was examined, and a negative diagnosis was made. The gall-stones found at operation in these patients can now be identified in the original Roentgen plates. The evidence was there before, but we were then unable to recognize it. Of all the aids to be suggested for detecting calciili, the method of matching together the shadows by superimposing one Roentgen plate over another is probably the most im- portant. By far the best illumination can be obtained by holding the plate obliquely at an arm's length against a northern light. A concave lens, or better stiU a pair of opera glasses, used in the reverse direction wall accentuate contrasts. For examining a small area a magnifpng glass may be helpful, especially in identifying the faceted side of small calcuh. A lantern slide made of superimposed Roentgen plates will sometimes accentuate the contrast and bring out details not observed in the original plates. Thus very faint shadows may sometimes be shown w^ell enough for lantern slide demonstration or reproduction; whereas others cannot be demonstrated or reproduced for publication because the shadows concentrated on the shdes are diffused by enlargement. Identification of the gall-bladder aids materially in the detection of calculi, and is a detail which one should alwaj^s try to obtain. It can be detected in nearly every case where it exists normal in size or dilated. The gall-bladder may be found anjTvhere from the region of the eleventh rib to the fifth lumbar vertebra. In one case, it was located as far down as the sacrimi. As a rule, it will be seen below the lower border of the liver. If, after taking a number of Roentgen plates, the gall-bladder is not found in the normal position, it can sometimes be located when a subsequent bismuth examination is made by noting the position of the transverse colon. GaU-stones are divided into two definite groups: (1) Stones which contain considerable calcium, and (2) cholesterine stones which contain no calcium, or only a trace of it. Gall- stones containing a large proportion of calcium can be shown without much difficulty and are sometimes so dense as to be mistaken for renal calculi. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 143 The dense calcareous gall-stones are a type of calculi infrequently found; this perhaps explains why the study of gall-stones has made little advance since thej^ were first observed. Bj^ far the greater number of gall-stones consist of cholesterine nucleus, with a calcareous coating, or vice versa. When the peripheral concretions are thin, which is true in about fifty per cent of the cases, the stones are difficult to detect. With increasing density of the coating, the ring-like appearance is proportionally more marked and relatively easier to discover; but it is probably safe to say that the absolutely pure cholesterine stone is a rare entity. Unless unusual care is used in making and interpreting Roentgen plates, cholesterine stones containing only a trace of calcium will be entirely overlooked in the future, just as they have escaped observation in the past. It is not the shadow-producing quality of the stone as a whole that concerns us in this class of case, but rather the shadow cast by the long diameter of the periphery of the stone. Whether the stone be faceted, spherical or a combination of both, in some particular diameter there will be sufficient density to cast a peripheral shadow. This explains in part why a single Roentgen plate of a series will often reveal a perfectly characteristic gall-stone, whereas all previous plates of the same region show only questionable shadows. If each individual stone in a mass of small stones does not cast a well-defined shadow, the shadow of the entire mass will often give the clue. The interpretation of suggestive shadows in the region of the gall-bladder is fraught with difficulties, similar to those experienced when positive diagnosis of kidney stones was first attempted. The present accuracy in diagnosing renal stones is the result of experience gained through numerous errors. Some of the disturbing factors in the gall-bladder region, such as intestinal contents, calcified mesenteric glands, costo-chondral ossification, and stones in the kidney and liver, have been enumerated in previous articles. Recent experience has added to our knowledge of possible pitfalls. Food in the first portion of the duodenum is a particularly confusing finding, because its density corresponds to the faint shadow of a stone, and its size and position add to the illusion. Upon minute examination, however, it will be found that the shadow of food lacks the ring-hke circumference of the choles- terine stone with a calcareous shell; neither has it the homogeneous character of the calcium stone, but is rather mottled in appearance. Moreover, it is usually possible to completely identify the shadow by tracing the outlines of the adjoining pars pylorica. Where the shad- ows are obscure several Roentgen plates matched together will increase the density. A disturbing element of the same character is food contained in a single haustrum of the colon at the hepatic flexure. Being broad at one end and tapering to a fine point at the other end, it resembles an almond-shaped calculus. Abstinence from food eliminates results from this error. Another interesting finding, and one which is visible only to the eye trained to pick up the slightest variation in density, is the presence of little rings, often no larger than a good-sized pinhead, sometimes found in groups, sometimes isolated, in varying shapes of round, oval or even quite irregular form. It is quite possible that these infinitesimal find- ings are the walls of blood vessels seen in cross section. It is a mistake to study Roentgen plates when they are wet, not only because reflected light cannot be avoided, but also because there is risk of damaging the plate. A careful study of the clinical history of cases in which gall-stones are definitely shown by Roentgen methods reveals the futility of expecting the classical gall-bladder symptoms to agree with the Roentgen diagnosis. Before the advent of the X-ray, renal colic and renal calculi were considered almost synonymous terms. But surgical procedure for renal colic in cases where no calculus was 144 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS shown on the Roentgen plate eventually proved that only about one-fourth of the cases having typical attacks of renal colic had a calculus of sufficient size to be found by surgical exploration. On the other hand, only about one-fourth of the cases in which kidney stones were definitely demonstrated by Roentgen methods had anything simulating renal cohc. Our present experience indicates that the same observation will hold true in the gall- bladder region; that only when a gall-stone passes or engages does it cause the typical gall- stone cohc, and this is relatively rare compared with the frequency of gall-stones. The chnical indications of cholecystitis compare with those of pyelitis, except that one does not detect the presence of pus in the stools as readily as one detects it in the urine. Some of the cases of gall-stones give practically no characteristic symptoms of gall-stones, but are associated with obscure gastric or neurotic symptoms. Therefore, any case presenting gastro-intestinal symptoms with absence of Roentgen evidence of an organic lesion of the stomach or intestines should be submitted to a careful Roentgen examination of the gall-bladder. This is particularly true if, as Deaver suggests, the patient is "fair, fat and forty and belches gas." It is much easier to detect the stone in this class of case than in thin, wiry, poorly nourished people who have no fat to outhne the gall-bladder, and whose muscle is nearly as dense as bone. In persons under twenty-five, the peripheral coating of the stone is not usually dense, and the stone is so soft that it does not show even a dim peripheral ring or edge. Post-operative cases with extensive adhesions, carcinoma of the liver or gall-bladder, and ascites also render negative diagnosis exceedingly difficult if not impossible. Diagnostic accuracy is directly in proportion to the care exercised in making the ex- amination, and one's experience in detecting and interpreting the findings. Statistics are of little value until thousands of cases have been observed by methods as careful and detailed as those described above. By that time the value of the method wiU be generally acknowl- edged, and statistics will not count for any more than they do now in cases of renal calcuh or fractures. The Roentgen method of diagnosing gall-stones has become so accurate that if there is no direct Roentgen evidence of gall-stones, or indirect evidence of adhesions involving the stomach, cap, duodenum or colon, as a result of cholecystitis, the surgeon should have a preponderance of chnical evidence as a warrant in operating for gall-stones. RESUME 1. Until within three or fom- years, gall-stones were rarely detected by Roentgen rays. 2. During the last few years several Roentgenologists, including ourselves, consider that they have detected gall-stones in from fifty to eighty-five per cent of the cases examined. This was estimated in different ways by different men. 3. Experience has shown that gall-stones may be detected about twice as frequently as formerly by: (a) A special technique for making the Roentgen plates; (b) a minutely care- ful study of the Roentgen plates by various methods; (c) a thorough intimacy with the Roentgenographic appearance of gall-stones. 4. By applying the new method of interpretation, gall-stones have been detected on many Roentgen plates made by the old technique and formerly diagnosed as negative. 5. By means of the special technique for making and interpreting Roentgen plates, a positive diagnosis may be made in so many cases that the negative diagnosis has become of considerable significance. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 145 6. Much care and study will be necessary to properly interpret the additional detail which can be obtained by the special technique and undoubtedly some erroneous diagnoses will be made. (Cole has made two such erroneous diagnoses, and has thereby learned to differentiate the food in the cap and the feces in the haustra of the colon from evidence of calculi, a most difficult problem.) 7. If there is no direct Roentgen evidence of gall-stones, the stomach, cap, duodenum and colon should be examined for adhesions from an accompanying cholecystitis. 8. If there is no direct or indirect Roentgen evidence of gall-stones, the clinical history should be more characteristic than usual before one resorts to surgical procedure. 146 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS GALL-BLADDER Figure 182 PATIENT — POSITION: Woman, age 28. Prone. ROENTGEN CONCLUSIONS: Gall-stones. Gastric ulcer. Duodenum fixed in the upper right quad- rant. OPERATIVE FINDINGS: Gall-stones. Fixation of duodenum to gall-bladder. Adhesion about antrum of stomach. A Faint shadow caused by increased density in the gall-bladder region. B Ulcer of the stomach near the pylorus. C A portion of the descending duodenum fixed in the subhepatic region. Figure 183 Artist's drawing made at the time of operation. (See Figure 182.) Adhesions between the descending duodenum and gall-bladder. The cystic duct is full of small stones. The lesion in the stomach is an adhesion, probably due to old ulcer of the lesser curvature, posterior wall. Figure 184 PATIENT — POSITION: Woman, age 33. Prone. ROENTGEN CONCLUSIONS: Gall-stones. OPERATIVE FINDINGS: A large number of gall-stones. A Cystic duct filled with inspissated bile. B One or more small gall-stones scattered through the duct. C Gall-bladder full of stones. Figure 185 Same as Figure 184. This plate was made three months later and shows no evidence of inspissated bile in the cystic duct. The patient had had several attacks between the first and second examinations. This plate shows the gall- bladder full of various sized calculi, making it chfKcult to define individual stones. A Gall-bladder. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 147 FIGURE 182 FIGURE 183 FIGURE 184 FIGURE 185 148 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 186 PATIENT — POSITION: Woman, age 23. Prone. ROENTGEN CONCLUSIONS: Gall-stones. OPERATIVE FINDINGS: Thirty-seven small calculi. A Gall-bladder full of small stones. B Effect of pressure of the gall-bladder on antrum of the stomach. Figure 187 PATIENT — POSITION: Woman, age 40. Prone. ROENTGEN CONCLUSIONS: A large gall-stone. OPERATIVE FINDINGS: One large gall-stone. A One cholesterine stone about the size of a fifty-cent piece. Diagnosed Roentgenographically by the peripheral shadow. This could not be diagnosed in the gall-bladder series of plates vdth certainty, but after a bismuth meal the stone was held in such a position that it could be easily detected on the Roentgen plate. Figure 1{ PATIENT — POSITION: Woman, age 40. Prone. ROENTGEN CONCLUSIONS: Two gall-stones. OPERATIVE FINDINGS: Gall-stones. A — B Outline of two gall-stones. THE ROENTCxEN DIAGNOSIS OF SURGICAL LESIONS 149 FIGURE 186 FIGURE 187 FIGURE 188 150 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 189 PATIENT — POSITION: Woman, age 35. Prone. ROENTGEN CONCLUSIONS: A mass of gall-stones. OPERATIVE FINDINGS: A mass of forty-seven gall-stones. One found in cystic duct. A Gall-bladder full of gall-stones. This plate also illustrates the singularly low position of the gall-bladder. One gall-stone faintly seen lying close to the spine which was thought to be in the cystic duct. This was proven at operation. This case presents one noteworthy fact. A gall-bladder in this position may give rise to clinical symptoms simulating appendicitis. Indeed this patient had had an appendectomy without relief of her symptoms. Figure 189 A Same case as Figure 189. This plate made without an intensifying screen. Figure 190 PATIENT — POSITION : Woman, age 52. Prone. ROENTGEN CONCLUSIONS: Two large gall-stones. OPERATIVE FINDINGS: Two large gall-stones. A — B Two large dense gall-stones. Figure 191 PATIENT — POSITION: Woman, age 35. Prone. ROENTGEN CONCLUSIONS: Gall-stones. OPERATIVE FINDINGS: Two large gall-stones. A — B Peripheral shadows which represent a large number of gall-stones; though no individual gall-stone is distinct, the collection of gall-stones shows positively on the Roentgen plate. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 151 FIGURE 189 FIGURE 189A FIGURE 190 FIGURE 191 152 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 192 PATIENT — POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: One large gall-stone. OPERATIVE FINDINGS: One large gall-stone. A Gall-stone. Figure 193 PATIENT — POSITION: Woman, age 40. Prone. ROENTGEN CONCLUSIONS: Probable gall-stones. OPERATIVE FINDINGS: Gall-bladder full of very small gall-stones and a large number of cholesterine crystals. A — B Calcareous material in the gall-bladder which was distinct from the shadows produced by the costal border. The Roentgen conclusions should have been "pathological gall-bladder." Figure 194 PATIENT — POSITION: Man, age 45. Prone. ROENTGEN CONCLUSIONS: One large gall-stone. OPERATIVE FINDINGS: One gall-stone. A Peripheral shadow of a large gall-stone. Note that the nucleus is no denser than the surrounding tissue, although a portion of it overhes the rib. The patient weighed over 200 pounds. Figure 195 PATIENT — POSITION: Woman, age 80. Prone. ROENTGEN CONCLUSIONS: Several large gall-stones. OPERATIVE FINDINGS: Two gall-stones the size of small eggs and about twenty others varying in size from a ten-cent piece to a quarter. A Outhne of the largest gall-stone. B Outline of a gall-stone. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 153 A/ FIGURE 192 FIGURE 193 FIGURE 194 FIGURE 195 154 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 196 PATIENT — POSITION: Woman, age 32. Prone. ROENTGEN CONCLUSIONS: Two small gall-stones. OPERATIVE FINDINGS: Two small gall-stones and various small stones. A Definite peripheral shadow produced by two stones. Figure 197 PATIENT — POSITION: Woman, age 62. Prone. ROENTGEN CONCLUSIONS: One gall-stone. OPERATIVE FINDINGS: One large gall-stone. A One large gall-stone. Figure 198 PATIENT — POSITION: Woman, age 32. Prone. ROENTGEN CONCLUSIONS: One gall-stone, probably others. OPERATIVE FINDINGS: Four gall-stones. A One stone which made the diagnosis positive. In the original plate shadows were seen which suggested other stones. Figure 199 PATIENT — POSITION: Woman, age 28. Prone. ROENTGEN CONCLUSIONS: Probably gall-stones in the common duct. OPERATIVE FINDINGS: Cholecystitis with very small gall-stones in the gall-bladder. One moderate size gall-stone found in the common duct. A Suspicious area in the region of the common duct. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIONS 155 FIGURE 196 FIGURE 197 k\ FIGURE 19 FIGURE 199 156 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 200 PATIENT — POSITION: Man, age 42. Prone. ROENTGEN CONCLUSIONS: Pathological gall-bladder with probable gall-stones. OPERATIVE FINDINGS: Very large and thickened gall-bladder containing a large number of gall-stones. A Gall-bladder outlined very definitely and shows increased density. B Lower border of the gall-bladder. Figure 201 PATIENT — POSITION: Woman, age 43. Prone. ROENTGEN CONCLUSIONS: Group of small gall-stones. OPERATIVE FINDINGS: Large number of small dense gall-stones. A — B Position of the gall-bladder containing gall-stones. Figure 202 PATIENT — POSITION: Man, age 48. Prone. ROENTGEN CONCLUSIONS: Two small gall-stones. OPERATIVE FINDINGS: Gall-stones. A — B Gall-stones. See Figure 281 showing a pathological appendix. Figure 203 PATIENT — POSITION: Man, age 40. Prone. ROENTGEN CONCLUSIONS: One gall-stone. OPERATIVE FINDINGS: One gall-stone. A OutUne of one gall-stone. This patient weighed over 200 pounds. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 157 FIGURE 200 FIGURE 201 FIGURE 202 FIGURE 203 158 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 204 PATIENT — POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: Probable gall-stones. OPERATIVE FINDINGS: Two small gall-stones. A Dense area in the region of the gall-bladder which was supposed to be material in the gall-bladder. This proved in the operation to be two small mulberry gall-stones adherent to one another. Figure 205 PATIENT — POSITION: Woman, age 50. Prone. ROENTGEN CONCLUSIONS: Pressure of large gall-bladder on first portion of the duodenum. OPERATIVE FINDINGS: Pathological gall-bladder. No gall-stones. Adhesions about the stomach, duo- denum and gall-bladder. A Pressure of gall-bladder on the bismuth mass in the duodenum. After repeated plates the opinion was passed that there was probably a pathological gall-bladder and no Roentgen evidence of gall-stones. Figure 206 PATIENT — POSITION: Man, age 48. Prone. ROENTGEN CONCLUSIONS: One gall-stone. OPERATIVE FINDINGS: One large soft gall-stone. A Outhne of one or more gall-stones. Figure 207 PATIENT — POSITION: Man, age 56. Prone. ROENTGEN CONCLUSIONS: One gall-stone. OPERATIVE FINDINGS: One gall-stone. A Very distinct gall-stone in individual weighing 200 pounds. THE ROEXTGEX DIAGX05IS OF SURGICAL LESIOXS 159 FIGURE 204 FIGURE 205 FIGURE 206 FIGURE 207 160 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 208 PATIENT — POSITION: Man, age 28. Prone. ROENTGEN CONCLUSIONS: Gall-stones. OPERATIVE FINDINGS: Gall-stones. A Outline of one gall-stone. This case was previously examined for renal calculus. There was a shadow found in the region of the right kidney. Patient was operated upon and no kidney stone found. After another Roentgen ex- amination the same shadow was found and proved to be a gall-stone. Figure 209 PATIENT — POSITION: Man, age 58. Prone. ROENTGEN CONCLUSIONS: Large number of small gall-stones. OPERATIVE FINDINGS: Sixty-seven small gall-stones. A Outhne of largest gall-stone. B — C Indistinct shadow of gall-stones. Figure 210 PATIENT — POSITION: Woman, age 36. Prone. ROENTGEN CONCLUSIONS: Gall-stones. OPERATIVE FINDINGS: Large number of gall-stones. A One of the largest gall-stones. B— C— D Other gall-stones. This patient weighed 214 pounds. Figure 211 PATIENT — POSITION: Woman, age 40. Prone. ROENTGEN CONCLUSIONS: Gall-stones. OPERATIVE FINDINGS: Several gall-stones. A Outhne of one gall-stone which made the diagnosis positive. B Outline of other gall-stones and gall-bladder. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 161 FIGURE 208 FIGURE 209 FIGURE 210 FIGURE 211 162 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 212 PATIENT — POSITION: Woman, age 70. Prone. ROENTGEN CONCLUSIONS: Group of small gall-stones. OPERATIVE FINDINGS: Gall-stones. A Group of eighteen small gall-stones the size of millet seeds. This case was examined for new growth of the large bowel and the gall-stones were found accidentally. There was no evidence of new growth. Figure 213 PATIENT — POSITION: Woman, age 43. Prone. ROENTGEN CONCLUSIONS: Pathological gall-bladder. OPERATIVE FINDINGS: Gall-bladder distended, thickened and full of very small crystals. A Increased density in the region of the gall-bladder which is constant throughout a series of plates. Figure 214 PATIENT — POSITION: Woman, age 6L Prone. ROENTGEN CONCLUSIONS: Large number of small gall-stones. OPERATIVE FINDINGS: Twelve gall-stones the size of beans removed from the gall-bladder. A — B Group of gall-stones which show faint peripheral shadows. Figure 215 PATIENT — POSITION: Man, age 58. Prone. ROENTGEN CONCLUSIONS: A large number of gall-stones. OPERATIVE FINDINGS: Over two thousand gall-stones found. A The upper limits of the gall-bladder. B Thirteen of the gall-stones. Arrows point to outline of gall-stones. Patient weighed 190 pounds. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 163 FIGURE 212 FIGURE 213 FIGURE 214 FIGURE 215 164 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 216 PATIENT — POSITION: Woman, age 40. Prone. ROENTGEN CONCLUSIONS: Adhesions holding the stomach to the subhepatic region due to gall-bladder involvement. OPERATIVE FINDINGS: Extensive adhesions from the liver and gall-bladder to the duodenum and stomach. Pathological gall-bladder. A — B Pressure of gall-bladder on the duodenum. Figure 217 Same case, upright position, showang fixation of the stomach to the subhepatic region. A Antrimi of stomach. B First portion of duodeniun. C Edge of liver. Figure 218 PATIENT — POSITION: Man, age 52. Prone ROENTGEN CONCLUSIONS: Two large dense gall-stones. OPERATIVE FINDINGS: No operation. A — B Outline of two gall-stones. Figure 219 PATIENT — POSITION: Man, age 56. Prone. ROENTGEN CONCLUSIONS: Three gall-stones. OPERATIVE FINDINGS: Operated upon for other conditions, but gall-stones not removed. A Three gall-stones. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 165 FIGURE 216 FIGURE 217 FIGURE 218 FIGURE 219 166 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS SECTION VI THE SMALL INTESTINE Jejunum — Ileum — Normal Roentgen Picture — Malposition — Functional and Organic Disturbances In the study of the small intestine our attention is given to the diseases of the jeju- num and ileum. The first portion of the duodenum, functionally and anatomically, is so closely related to the stomach that, for convenience, we have considered it a part of the stomach rather than a part of the small intestine. The passage of the bismuth through the normal small intestine is rapid. The speed depends upon the degree of intestinal activity. Frequently, within fifteen minutes after the bismuth meal, bismuth is seen in the caecum. On the other hand, at the end of four hours we have seen all the food still in the small intestine. There is almost continual mo- tion among the intestinal coils, so that our exposure must be less than half a second to obviate blurring. Throughout the jejunum we find the bismuth in finely divided particles producing a feathery or lacehke appearance. In a general way we can recognize the coils of intestine, but no information concerning the finer structure of the fining membrane can be learned. In the second and third portions of the duodenum, however, we are usually able to distinguish the individual valvulse. In the ileum we find the bismuth particles collecting together into small, discrete masses. In the terminal ileum, unless the emptying is too rapid, we find the coils com- pletely filled with a homogeneous dense bismuth mass. The important problems which one encounters in the study of the small bowel are first, malposition, which may be congenital or acquired; second, functional diseases; third, organic disease, which includes ulcer, new growth and adhesions. The small intestine may be subject to ptosis when a general visceroptosis is present. This condition is not common and has no particular clinical significance. The Roentgen plate simply shows coils of ileimi low down in the pelvis. Occasionally in hernial sacks, inguinal, umbilical or post-operative coils of intestine can be detected. This has some diagnostic value where surgical treatment is being con- sidered. Valuable evidence is given us in the characteristic displacement of the small intestine by intra-abdominal tumors. Enlarged spleen, hj^pernephroma and other kidney enlarge- ments, aneurism of the aorta, and tumors of the pelvic organs are some common causes of displacement. Pregnancy, with the enlargement of the uterus, and sometimes a dilated bladder in diabetic or prostatic cases will be easilj^ visualized. Large masses of mesenteric glands may displace various portions of the bowel. Functional disturbances of the small intestine show no characteristic Roentgen picture. The terminal ileum has been a great field for study during the past few years. One cannot be interested in this part of the alimentary tract without studjdng the results of the investigations of Lane, Jordan, Case, Bambridge and others. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 167 In considering the problems in this region, our opinions are based on our own actual experience. It is possible that we are more conservative in our opinions than is warranted by the progress made by others. In well-nourished individuals the ileum will be well emptied in six to eight hours. On the other hand, poorly nourished persons, past middle age, show a certain amount of ptosis and invariably stasis in the ileum. We believe this is physiological and in most cases not pathological. It has been frequently found that in the six-hour examination there may be a marked accumulation of bismuth in the ileum, with the colon entirely empty. This accumu- lation of ileal contents without evidence of any discharge through the ileocsecal valve is more suggestive of pathology in the small bowel than the picture of one loop that shows the so-called "Lane's kink." To be safely classified as stasis, bismuth should be present in the ileum from fifteen to twenty-four hours or more. In the presence of such a marked ileal stasis alone, we still cannot safely make a diagnosis of mechanical obstruction about the terminal ileum. The writers have found marked ileal stasis in a number of cases in which, at operation, no demonstrable lesion was found. At times we can show the terminal ileum kinked and adherent and associated with a definite ileal stasis. The fluoroscope is of value in demonstrating the presence of the ad- hesions. We cannot advise surgical treatment on this Roentgen picture alone, but only when accompanied b}^ a definite clinical picture. Ulcer of the jejunum has rarely been diagnosed by us from the Roentgen plate. How- ever, a series of cases have been studied at the Mayo Clinic and Carman claims that a definite percentage of these cases can be diagnosed by the Roentgen method. This in- volvement of the small bowel must be rare, for in our series of two thousand cases to date, not more than four such ulcers have been demonstrated. These ulcers occur usually after gastroenterostomies . The Roengten evidence of new growth is to be had only in the presence of obstruction. This obstruction must be nearly complete. The typical Roentgen plate of new growth of the small intestine shows a stasis proximal to some definite point in the intestine. This is associated with more or less dilatation of the proximal portion of the intestine. This dilatation may be so extensive that the shadow of the small intestine may be confused with that of the colon. In such a case, however, the differentiation depends on the char- acteristic shadow cast by the valvulse of the small intestine. Adhesions by obstructing the lumen may give an appearance identical with that of new growth. From the Roentgen point of view we know of no sure way of making a dif- ferentiation. The fact that obstruction from adhesions usually occurs in the right lower quadrant is sometimes of value in making a diagnosis, especially where there is a history of previous appendix operation or old pelvic inflammation. 168 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS THE SMALL INTESTINE Figure 220 PATIENT — POSITION: Woman, age 23. Prone. ROENTGEN CONCLUSIONS: Anatomical variation of the stomach and duodenum. OPERATIVE FINDINGS: General exploratory. Negative. Key plate. 1 Pyloric region, showing in the antrum the effect of pressure from the spine. 2 Poorly filled first portion of the duodenum. 3 Variation in the position of the descending duodenum. 4 Typical plate showing character of the jejunum. Figure 220A Key plate. This plate shows the character of the jejunum as differentiated from the ileum. A Jejunum. B Ileum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 169 FIGURE 220A 170 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 221 PATIENT — POSITION: Man, age 70. Prone. ROENTGEN CONCLUSIONS: Dilatation and obstruction of the jejunum due to fixation of jejunum in appendicial region, probably benign in character. OPERATIVE FINDINGS: Obstruction of the jejunum by dense fibrous adhesions in the right lower quad- rant. Patient died of pulmonary embolism four days after operation. A Normal stomach in state of spasm. Duodenum normal. B Dilated jejunum. C Jejunum fixed and obstructed in the right lower quadrant. Figure 222 PATIENT — POSITION: Woman, age 39. Prone. ROENTGEN CONCLUSIONS: Adhesions. Ileal stasis. OPERATIVE FINDINGS: Lane's kink. Dilatation of the ileum. Adhesions about the ascending colon. A Caecum. B Dilated ileum. C Dilated ileum. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIONS 171 FIGURE 221 FIGURE 222 172 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 223 PATIENT — POSITION: Woman, age 23. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Probable Lane's kink. OPERATIVE FINDINGS: Lane's kink. Dilatation of terminal ileum due to Lane's kink. A Proximal ileum. B Point of Idnking. C Distal ileum. D Caecum. Figure 224 PATIENT — POSITION: Man, age 41. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Marked dilatation of ileum in left lower quadrant with obstruction. OPERATIVE FINDINGS: Marked dilatation and obstruction of jejunum by a small annular carcinoma. A Arrow points to obstruction in jejunum. Patient weighed 280 pounds. Figure 225 PATIENT — POSITION: Man, age 26. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Twenty-four hour ileal stasis. Fixation of ileum to caecum and into pelvis by bands. OPERATIVE FINDINGS: Chronic appendix and adhesions with fixation of terminal ileum. A Site of fixation of ileum. Figure 226 PATIENT — POSITION: Man, age 19. Prone. (Eight-hour plate.) ROENTGEN CONCLUSIONS: Fixation of terminal ileum, Lane's kink. OPERATIVE FINDINGS: Lane's kink. Chronic appendix. A Point of fixation of ileum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 173 FIGURE 223 FIGURE 224 FIGURE 225 FIGURE 226 174 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 227 PATIENT — POSITION: Man, age 29. Prone. (Ten-hour plate.) ROENTGEN CONCLUSIONS: Adhesions about ascending colon with Lane's kink. OPERATIVE FINDINGS: Lane's kink. Chronic adherent appendix. A Point of fixation of ileum. B Effect of adhesions about ascending colon. C Coil of dilated ileum. Figure 228 PATIENT — POSITION: Man, age 26. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Marked obstruction of ileum. OPERATIVE FINDINGS: Marked obstruction of ileum due to pelvic band. A Site of obstruction of ileum. B Coil of ileum. Figure 229 PATIENT — POSITION: Man, age 46. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Marked obstruction of ileum due to general adhesions about caecum. OPERATIVE FINDINGS: Extensive adhesions about caecum and ileum, apparently following an old peritonitis. A Dilated and filled coils of ileum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 175 FIGURE 227 FIGURE 228 FIGURE 229 176 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 230 PATIENT — POSITION: Girl, age 16. Prone. ROENTGEN CONCLUSIONS: Marked dilatation of terminal ileum. Chronic appendix. Lung examina- tion; acute miliary tuberculosis. OPERATIVE FINDINGS: Marked dilatation of terminal ileum due to extensive tubercular peritonitis. A Dilated terminal ileum. B Chronic appendix. Figure 231 PATIENT — POSITION: Man, age 41. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Ileal stasis. OPERATIVE FINDINGS: Marked involvement in right lower quadrant by adhesions following per- forated appendix. A Marked dilatation of terminal ileum. Figure 232 Same case as Figure 231, twenty-four hours after bismuth meal. B Partly obliterated appendix. It is to be noted that the ileum is entirely empty at this time showing the appendix partly obliterated. It has been the writers' experience that the most marked obstruction gave the least stasis. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 177 FIGURE 230 FIGURE 231 FIGURE 232 178 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 233 PATIENT — POSITION: Man, age 2L Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Probable Lane's kink. OPERATIVE FINDINGS: Lane's kink. A Point of fixation of terminal ileum by pelvic band. Figure 234 PATIENT — POSITION: Man, age 49. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Obstruction of loop of ileum or jejunum. OPERATIVE FINDINGS: Small annular carcinoma of ileum. A Loop of ileum retaining bismuth after twenty-four hours. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 179 FIGURE 233 FIGURE 234 180 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 235 PATIENT — POSITION: Woman, age 35. Prone. ROENTGEN CONCLUSIONS: Diverticulum of the jejunum. OPERATIVE FINDINGS: Diverticulum not found. See finding of condition of lower bowel under Figure 237. A Diverticulum of the jejunum. Figure 236 Same case as Figure 235, twenty-four hours later, showdng diverticulum containing bismuth and air. Note marked filling defect in caecum. A Filling defect in caecum. Figure 237 Same case as Figures 235 and 236, by enema method, showing constant filhng defect in caecum. A Fining defect constant in caecum. OPERATIVE FINDINGS: Extensive involvement of caecum with tuberculosis. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 181 FIGURE 235 FIGURE 236 FIGURE 237 182 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 238 PATIENT — POSITION: Woman, age 30. Prone. ROENTGEN CONCLUSIONS: Probable diverticulum of jejunum. OPERATIVE FINDINGS: No operation. A From the Roentgen plate one would suppose that this diverticulum was bismuth in the ampulla of Vater but Roentgenoscopy proved this diverticulum to be part of the jejunum. Figure 239 PATIENT — POSITION: Man, age 31. Prone. ROENTGEN CONCLUSIONS: Marked twenty-four hour ileal stasis. OPERATIVE FINDINGS: Extensive adhesions about appendix involving transverse colon. A Marked ileal stasis: bismuth remaining in ileum from twenty to thirty-six hours. Figure 240 PATIENT — POSITION: Man, age 35. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Terminal ileum fixed probably to old appendix scar. OPERATIVE FINDINGS: Fixation of terminal ileum to old scar. A Loop of ileum fixed and adherent. Figure 241 PATIENT — POSITION: Man, age 21. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Ileal stasis of twenty-four hours. OPERATIVE FINDINGS: Adhesions about ileum. A Coils of ileum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 183 FIGURE 238 FIGURE 240 FIGURE 239 FIGURE 241 184 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 242 PATIENT — POSITION: Woman, age 41. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Ileal stasis and pericolic membrane. OPERATIVE FINDINGS: Extensive membrane formation and chronic appendix. A Ileum. B Fixed transverse colon. Figure 243 PATIENT — POSITION: Man, age 29. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Slight ileal stasis of twenty-four hours, cause not determined. OPERATIVE FINDINGS: Tuberculosis of caecum. A Portion of caecum found at operation to be tubercular. Figure 244 PATIENT — POSITION: Man, age 33. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Marked dilatation of terminal ileum. OPERATIVE FINDINGS: Lane's kink and adhesions. A Loops of dilated ileum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 185 FIGURE 242 FIGURE 243 FIGURE 244 186 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 245 PATIENT — POSITION: Woman, age 27. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Fixation of ileum and caecum into pelvic cavity. OPERATIVE FINDINGS: Extensive adhesions from pelvic organs. A Dilated ileum. B Csecum. Figure 246 PATIENT — POSITION: Man, age 50. Prone. ROENTGEN CONCLUSIONS: Displacement of terminal ileum to left of median line by dilated urinary bladder, due to tabes dorsalis. OPERATIVE FINDINGS: No operation. A Ileum displaced to left of median line. Figure 247 PATIENT — POSITION: Woman, age 35. Prone. ROENTGEN CONCLUSIONS: Displacement of ileum by a gravid uterus. OPERATIVE FINDINGS: No operation. Note: This plate demonstrates clearly the Roentgen appearance of jejunum and ileum. A Jejunum. B Ileum. C — D Space occupied by u terus. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 187 FIGURE 245 FIGURE 246 FIGURE 247 188 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS SECTION VII APPENDIX Meals — Technique — Pathological Appendices The Roentgen investigation of the appendix has been distinctly an American con- tribution. The faulty technique of the Continental school is acknowledged by European Roentgenologists. Schwartz, for his work on the gastro-intestinal tract, sent to Case for the use of several plates showing appendices. Their fundamental difficulty seems to lie in the character of the opaque meal. (The cereal mixtures, for one reason or another, do not readily enter the appendix.) We claim with our meal of buttermilk and barium that, in every instance, unless the lumen has been obliterated, the appendix will fill and it will remain so long enough to be demonstrated on the Roentgen plate or Roentgenoscope. To this statement we believe there is no exception. TECHNIQUE The technique is comparatively simple. The character of the opaque meal is the all- important factor. Ninety grammes of bismuth, or equivalent of barium, in a pint of butter- milk is the meal which will allow the appendix to be satisfactorily visuahzed. In a hospi- tal where a malted milk meal is used, the technique otherwise being identical with ours, out of three hundred routine bismuth examinations, the appendix was visualized in less than thirty. We are ignorant of the reason for this. It has been suggested that the fer- mented milk reaches the caecum in a more fluid state than the other media. Then again its acid reaction, or possibly even the presence of the lactic acid bacilli, may have some bearing on the matter. Whatever the mechanical or physiological reason, we know em- pirically from our experience covering four years that the buttermilk meal is of funda- mental importance for visualizing the appendix. The bismuth enema is of no great value in demonstrating the appendix. We have only occasionally seen the lumen of the appendix filled by the enema method. Secondly, let us call attention to the necessity of careful plate work. The Roentgeno- scope, to be sure, has a place in the study of the apperidix. But, as a matter of fact, the appendix shadow in not a few cases is threadhke and oftentimes but a series of three or four dots, so that its study becomes a matter of fine detail. For the visualization of detail, plates are essential. Case first emphasized the importance of the patient's position in his work, laying great stress on the advantage of the horizontal position. We, also, have found this position the most suitable. Plates are made both from the front and back. The upright position may occasionally bring the appendix to view when others fail. In a few cases a retrocsecal THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 189 appendix may be shown by means of what we call the lateral obhque view. In this posi- tion the posterior surface of the caecum is shown in profile. The patient lies with his right side on the plate. He then rotates on a longitudinal axis, so that the plane of the ab- dominal wall forms an angle of about sixtj^-seven degrees with the plate. The tube is per- pendicular to the plate and centered over the caecum. A retrocsecal appendix may also be shown by waiting until the caecum is partialh' evacuated, twenty-four to thirty-six hours after the meal, when the appendix can be seen through the shadow of the caecum. If one fails to locate the appendix thus, the screen may be of aid. jXIanipulation may be neces- sary to bring the appendix to view if hidden behind the caecum or coils of ileum. These can be held or pushed to one side with gloved hand or "wooden spoon." Once having located the appendix, then plates can be made. The screen, associated with palpation, furthermore can give evidence of appendicial adhesions and the possible relation of any tender-point to the appendix. The six and twenty-four hour plates are the ones most hkely to show the appendix. The appendix probably begins to fill shortly after the meal enters the caecum. However, the twentj^-four hour plate usually shows the appendix best, for in the earher plate coils of bismuth-filled ileum tend to cover it over. Later plates will be made if it be important to determine the length of time which the appendix retains the opaque salt. PATHOLOGICAL APPENDICES In order to recognize the pathological appendix we must first familiarize ourselves with its normal appearance. The appendix is made visible by the meal in its lumen or by fecal concretions which it may contain. The concretions may be mistaken for calculi in the iireter. The filled appendix appears on the Roentgenogram as a hnear shadow apparently projecting from the inner edge of the caecum. The distal end floats free in the abdominal cavity. It may he verticaUy behind the caecum, or horizontally along the pehdc brim, or hang over the pelvic brim into the pelvis. It may be high in the abdominal cavity, even above the ihac crest, or low in the pelvis, depending on the position of the caecum. It is freely movable under palpation. It varies in length from an inch or less, up to eight or nine inches. Its width ranges from a quarter of an inch to the diameter of a thread. It maj" be perfectly straight, curved, or obtusely angulated. The appendix usually shows as a dense homogeneous shadow. It may frequently appear segmented as a series of dots or dashes. This appearance may be produced by contrac- tions of circular muscle fibres in the appendix wall. It is to be remembered that the normal appendix may intermittently fill and empty. When the first plate is made the appendix may be empty, but another plate made five minutes later will find it fuU. This is particularly true in children. The writers have in mind a child of three years where this condition showed to a marked degree. The normal appendix does not retain barium or bismuth for any longer time than does the caecum. One source of error is to confuse a small residue in the terminal ileum for the appendix shadow. The pathological appendix may be acute or chronic. In acute appendicitis, the Roentgen ray is of httle diagnostic value and fortunately the clinical picture is usually definite enough. In some cases of acute, left-sided pain, transposed viscera may be shown by an opaque enema, or if there is time, the appendix itself can be shown by the usual meal. 190 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Chronic appendicitis may be shown by: 1. Absence of the appendix shadow. 2. Abnormal conditions of position, shape, and size of the lumen. 3. Concretions. 4. Tender-point. 5. Adhesions. To repeat, every normal appendix will show on the plate. Without history of appendec- tomy, an absence of the appendix shadow means either that its lumen has at least been partially obhterated by old inflammation, or is obstructed by a possible kink, or it may be so filled with mucus or concretions that the bismuth cannot enter. It is conceivable that an acute inflammation could so congest the walls that the lumen would be obhterated. In any case the appendix is pathological. This is all the more certain if, with the Roent- genoscope, tenderness is elicited over the appendix area. A retrocsecal appendix should be regarded with suspicion. However, we beheve that a normal appendix may occupy this position, but it will be freely movable. A retrocsecal appendix that is fixed is nine times out of ten pathological. The size of the appendix, we have found, is of no special pathological significance. Very rarely dilatation can be demonstrated, either of the whole appendix or of the tip. This means at some point there is obstruction which prevents emptying. This condition is more or less characteristic of acute appendicitis. Variations in shape may be caused by concretions, kinks and adhesions. Some of the curves seen at times give almost the appearance of knots. All these conditions we consider abnormal. The presence of concretions is certainly pathological. Concretions, because of their density, may show independently of the opaque meal. They may be mistaken for calcified tubercular glands, phlebohths or uretal calculi. In the filled appendix they cause definite defects. They appear as small circular vacuoles within the appendix shadow. Palpation with the Roentgenoscope may reveal tenderness over the appendix. When found, this phenomenon is quite pathognomonic of appendicitis. The writers remember one case where pressure on the tip of the appendix caused exquisite pain. The patient was operated upon the following day. The end of the appendix was dilated, filled with pus, and about ready to rupture. Stasis in the appendix at least suggests possible future trouble. One frequently sees bismuth retained in the appendix a week after the whole colon has been emptied. Case reports a case where the appendix still retained bismuth on the twentieth day. Pirie men- tions a case where the bismuth was present on the forty-third day. This condition of stasis means that the appendix drains itself poorly. This is a fertile field for the formation of fecaliths with sooner or later a definite appendicitis. Evidence of adhesions may be shown by the Roentgenoscope or by serial plates made with the patient in several positions. Adhesions involving the appendix itself tend to hold it fixed in a position. The demonstration of a permanent fixation between the appendix and some other organ or the abdominal wall is of pathological significance. Such a con- dition is best shown by palpation under the screen. The appendix may be retrocsecal and adherent to the csecum or bound down to the posterior wall. We have seen the tip of the appendix adherent to the gall-bladder and, on one occasion, adherent to a mass of adhesions about a duodenal ulcer. The appendix may be fixed about a loop of terminal ileum or even to a portion of a redundant sigmoid. Occasionally the appendix will be held in the pelvis by pelvic inflammation. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 191 Adhesions may deform the appendix itself, as will be shown by a condition of per- manent kinking. Frequently a kink will show better with the patient in the upright position. Adhesions about the csecum, ascending colon, and ileum, which probably bear a casual relation to appendicitis, are discussed in their respective chapters. 192 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS APPENDIX Figure 248 PATIENT — POSITION: Man, age 32. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Normal large bowel. OPERATIVE FINDINGS: One year after Roentgen examination for acute appendicitis. Key plate. 1 Caecum. 2 Ascending colon. 3 Hepatic flexure. 4 Transverse colon. 5 Splenic flexure.- 6 Descending colon. 7 Sigmoid. 8 Rectum. 9 Appendix This plate, with the exception of the condition of the appendix, is as like the classical text-book type as one will find in the average normal adult Roentgenographically. Figure 249 PATIENT — POSITION: Woman, age 22. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic obliterative appendix. OPERATIVE FINDINGS: Chronic appendix with obliteration of the distal portion. A Appendix. (Note the tapering of the visible distal portion.) B Caecum. C Transverse colon. D Splenic flexure. E Apparent fixation of the distal portion of the transverse colon. F Redundant sigmoid. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIONS 193 194 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 250 PATIENT — POSITION: Woman, age 28. Prone. ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Caecum. B Kinked appendix. Figure 251 PATIENT — POSITION: Woman, age 28. Prone. ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix with several concretions. A Ileal stasis. B Appendix with four concretions. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 195 FIGURE 251 196 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 252 PATIENT — POSITION: Woman, age 43. Prone. ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Caecum. B— C Kinks. D Obliteration of distal half of the appendix. E Marker (tender-point). Figure 253 PATIENT — POSITION: Woman, age 30. Prone. ROENTGEN CONCLUSIONS: Chronic appendix with adhesions about the hepatic flexure. OPERATIVE FINDINGS: Pericolic membrane. Chronic appendix. A Appendix with three concretions. B Csecum. C Point of fixation of proximal transverse colon to ascending colon. Figure 254 PATIENT — POSITION: Man, age 39. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Caecum. B Chronic appendix. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 197 FIGURE 252 FIGURE 253 FIGURE 254 198 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 255 PATIENT — POSITION: Man, age 43. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Fixed and retroceecal chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Retrocseca] appendix. B Distal portion of appendix. Figure 256 Same case as Figure 255. This plate was taken twentj'-four hours after the bismuth meal. Note the empty bowel, but bismuth still retained in the appendix. A Appendix. Figure 257 PATIENT — POSITION: Man, age 36. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. Distal half obliterated. A Note the kinking and obliteration of the distal portion of the appendix. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 199 FIGURK 255 FIGURE 256 FIGURE 257 200 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 258 PATIENT — POSITION: Man, age 19. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Kinked appendix. A Kinked appendix. B Empty caecum. Figure 259 PATIENT — POSITION: Man, age 38. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Kinked and retrocsecal appendix with concretions. OPERATIVE FINDINGS: Chronic appendix. A Appendix. Figure 260 PATIENT — POSITION: Man, age 23. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. PericoHc membrane. OPERATIVE FINDINGS: Chronic appendix. Adhesions about the ascending colon. A Chronic appendix. B Narrowing of bowel which was not as marked when only partly filled. The dilatation of the cajcum depends upon the amount of food passing. THE ROENTCxEN DIAGNOSIS OF SURGICAL LESIONS 201 FIGURE 258 FIGURE 259 202 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 261 PATIENT — POSITION: Man, age 29. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix, retrocaecal and adherent. OPERATIVE FINDINGS: Adherent and retrocecal appendix. A Proximal portion of the appendix. B Distal portion of the appendix. Figure 262 PATIENT — POSITION: Girl, age 13. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Kinked appendix. OPERATIVE FINDINGS: Appendix fixed and kinked in mid portion. A Note that the bismuth is precipitated distally and proximally from the mid portion. Figure 263 PATIENT — POSITION: Man, age 23. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix, obliterative type. OPERATIVE FINDINGS: Chronic appendix. A Chronic appendix. THE ROEXTGEX DIAGNOSIS OF SURGICAL LESIOXS 203 FIGURE 261 FIGURE 262 FIGURE 263 204 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 264 PATIENT — POSITION: Woman, age 40. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Fixation of appendix and cscum to left of the median line. OPERATIVE FINDINGS: Chronic appendix found beneath umbilicus. A Caecum well to left of median line. B Appendix. Figure 265 PATIENT — POSITION: Woman, age 24. Prone. (Twenty- four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Kinked portion of the appendix. Figure 266 PATIENT — POSITION: Woman, age 29. Prone. ROENTGEN CONCLUSIONS: Chronic appendix, retrocsecal and external. OPERATIVE FINDINGS: Chronic appendix. A Cfficum. B Appendix. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 205 FIGURE 264 FIGURE 255 FIGURE 266 206 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 267 PATIENT — POSITION: Woman, age 29. Prone. ROENTGEN CONCLUSIONS: Chronic appendix, kinked in mid portion. OPERATIVE FINDINGS: Chronic appendix. A Appendix. Figure 268 Artist's drawing of Figure 267. Figure 269 PATIENT — POSITION: Woman, age 33. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix with adhesions about the colon. OPERATIVE FINDINGS: Extensive adhesions about the ascending and transverse colon. Chronic appendix. A Appendix. B Colon fixed into right quadrant. C Caecum. Figure 270 PATIENT — POSITION: Man, age 28. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Stenosis and kinking in mid portion of the appendix. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 207 FIGURE 267 FIGURE 268 FIGURE 269 FIGURE 270 208 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 271 PATIENT — POSITION: Man, age 26. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix markedly kinked. OPERATIVE FINDINGS: Chronic appendix. A Appendix, retrocecal and external. B Marked kinking. Figure 272 PATIENT — POSITION: Man, age 26. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Kinked appendix. Figure 273 PATIENT — POSITION: Man, age 29. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Chronic kinked appendix. Figure 274 PATIENT — POSITION: Woman, age 29. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix adherent about caecum. A Note kinked and accidental outline of size of the lumen of the appendix. B Filling defect proved at operation to be due to adhesions. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 209 FIGURE 271 FIGURE 272 FIGURE 273 FIGURE 274 210 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 275 PATIENT — POSITION: Man, age 26. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix markedly kinked. OPERATIVE FINDINGS: Chronic appendix. A Appendix. Figure 276 PATIENT — POSITION: Man, age 23. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix which is kinked. Probable Lane's kink of ileum. OPERATIVE FINDINGS: Lane's kink. Adherent and kinked appendix. A Point of fixation of ileum by pelvic band. B Appendix adherent and fixed. Figure 277 PATIENT — POSITION: Woman, age 30. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Note while large bowel is practically free of bismuth, it is still retained in the appendix. Figure 278 PATIENT — POSITION: Woman, age 23. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Kinked appendix. OPERATIVE FINDINGS: Markedly dilated lumen with several points of fixation and kinking by adhesions. A Note size of liunen of the appendix. B Distal point. THE ROEXTGEX DL4GX0SIS OF SURGICAL LESIONS ^Yh 211 FIGURE 275 FIGURE 276 FIGURE 277 FIGURE 278 212 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 280 PATIENT — POSITION: Man, age 26. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Note irregular filling of the appendix and kinking at one portion. B Distal portion. Figure 281 PATIENT — POSITION: Man, age 48. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix fixed to gall-bladder region. OPERATIVE FINDINGS: Gall-stones. Chronic appendix fixed to base of gall-bladder. A Proximal portion of appendix. Arrow points to appendix passing up and behind csecum. (See Figure 202, Section, Gall-Bladder.) Figure 282 PATIENT — POSITION: Man, age 40. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Appendix. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 213 FIGURE 280 FIGURE 281 FIGURE 282 214 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 283 PATIENT — POSITION: Man, age 35. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix confirming Roentgenogram. A Marked kinking. (See artist's drawing.) Figure 284 Artist's drawing, same case as Figure 283. Figure 285 PATIENT — POSITION: Man, age 43. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Retrocsecal appendix. OPERATIVE FINDINGS: Appendix retrocsecal and fixed in subhepatic region. A Appendix. Figure 286 PATIENT — POSITION: Man, age 36. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Adhesions and chronic appendix with concretion. OPERATIVE FINDINGS: Chronic appendix with adhesions. A Kinked appendix. B Adhesions about ascending colon. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 215 ^oe^7f£/f £^./fi^:Cf-£^rt:^e FIGURE 283 FIGURE 284 FIGURE 285 FIGURE 286 216 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 287 PATIENT — POSITION: Man, age 39. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix, retrocaecal and adherent. OPERATIVE FINDINGS: Four days after examination an acute appendix developed which became gangrenous before removal. A Proximal portion. B Distal portion. Figure 288 PATIENT — POSITION: Man, age 46. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix with concretions. OPERATIVE FINDINGS: Chronic appendix with' several concretions. A Empty cxcum. B Appendix. Figure 289 Same case as Figure 288 forty-eight hours later, showing bismuth filled appendix. One week from this examination patient was operated upon and appendix still contained bismuth. Figure 290 PATIENT — POSITION: Man, age 61. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix with concretions. OPERATIVE FINDINGS: Chronic appendix. A Proximal portion. B Distal portion. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 217 FIGURE 287 FIGURE 288 FIGURE 289 FIGURE 290 218 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 291 PATIENT — POSITION: Man, age 30. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Adhesions about ascending colon, and chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Appendix. Figure 292 PATIENT ^POSITION: Man, age 53. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Very long appendix and kinked and fixed in mid portion. OPERATIVE FINDINGS: See Figure 293. Figure 293 Same case as Figure 292. (Twenty-four hour plate.) OPERATIVE FINDINGS: Chronic appendix with adhesions. THE ROEXTGEX DL\GXOSIS OF SURGICAL LESIONS 219 FIGURE 291 FIGURE 292 FIGURE 293 220 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 294 PATIENT — POSITION: Man, age 42. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix, retrocsecal and external to caecum. Ileum is abnor- mally external and fixed, probably by adhesions. OPERATIVE FINDINGS: Markedly kinked appendix. The whole caecum deformed by extensive adhesions. A Appendix. B Terminal ileum. C Caecum. Figure 295 PATIENT — POSITION: Boy, age 9. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Chronic appendix. OPERATIVE FINDINGS: Chronic appendix. A Appendix. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 221 FIGURE 294 FIGURE 295 222 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS SECTION VIII LARGE INTESTINE Method of Study — Opaque Meal and Enema — Normal Appearance — Chronic Constipation — New Growth — Malformation and Malposition — Adhesions — Colitis METHOD OF STUDY In the study of the colon we find the Roentgen ray to be of diagnostic value in the following conditions: First, abnormalities in motility; second, new growth; third, adhesions; fourth, congenital or acquired malformation or malposition; fifth, colitis; sixth, diverticulitis. In the usual routine the "six-hour" and "twenty-four hour" plates give us the best visualization of the colon. In the six-hour plate we normally find the head of the bismuth column at the splenic flexure, while the tail is at the lower end of the ileum. In the twenty- four hour plate the colon should be fairly well emptied, or at least only the transverse and the descending colon filled. To these limits there is a wide normal variation. For the diagnosis, particularly of new growth and other organic colon diseases, the best Roentgen evidence is obtained from the enema-filled colon. It may be added that no gastro-intestinal examination is complete without the opaque enema. OPAQUE MEAL AND ENEMA Just a word as to the medium which we employ for the enema and the manner in which it is given. It has been found that six ounces of the "prepared" barium sulphate in a pint of buttermilk, with the addition of enough warm water to make a quart, proves a very satisfactory medium. It is cheap, easily prepared and in no way disagreeable to the patient. The patient lies on the left side (unless a Roentgenoscopic examination is to be made at the same time) and a soft rectal tube is inserted about two inches. The mixture is allowed to flow in by gravity, the container never being more than three feet above the level of the patient. The enema is given very slowly and the flow interrupted frequently. This is important for the comfort of the patient. NORMAL APPEARANCE Let us briefly review the normal appearance of the large intestine. The caecum is that portion of the colon into which the ileum empties through the ileocsecal valve. It is almost surrounded by peritoneum and is, therefore, freely movable. It may be found in the pelvis or displaced upwards. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 223 The ascending colon extends upwards and backwards into the ihac fossa and reaches nearly to the liver, where it forms a more or less acute angle. The hepatic flexure, together \vith the proximal portion of the transverse colon, may frequently be ptosed, drawn forwards and downwards. This is a normal condition for many people. The transverse colon extends from the hepatic flexure to the splenic flexure. It varies greath' in position. Particularly in thin individuals it may hang as a loop reaching into the pelvis. In this position the distal portion may appear to overlie the descending colon. The Roentgenoscope or stereoscopic plates are useful for differentiation in such a condition. The close relation between the transverse colon and the greater curvature of the stomach should be borne in mind. The splenic flexure is firmly held to the diaphragm by a strong ileocohc ligament. This flexm-e normally occupies a position several inches higher than the hepatic flexure. The descending colon extends from the splenic flexure to the brim of the pelvis. This portion of the colon is practical!}^ retroperitoneal and is fixed. The sigmoid has a great normal variation in size and position, as it is attached by a mesentery which varies in length. The rectum extends from the external sphincter to the sigTnoid. It is the most dis- tensible portion of the colon and consequently has a great normal variation in size and shape. CHRONIC CONSTIPATION Chronic constipation is a condition which frequently requires a Roentgen investigation. In the cases which are not due to some definite obstruction we find two general classes: First, those showing atony of the colon, where we find the colon markedh' distended, usualh^ filled with gas, and a lack of any definite peristalsis; the second group presents a spastic condition in the colon. Here we find marked peristaltic contractions. The bismuth is seen divided into small masses, by spasm of the circular fibres. This is noted particularly in the descending colon. Both groups may or may not be associated with ptosis. Instead of the twenty-four hour plate showing the colon fairly weU emptied, a forty-eight hour or even ninety-six hour examination may stiU show the bismuth in the colon. NEW GROWTH New gro'Ri^h of the colon appears on the plate as a permanent fiUing defect in the colon shadow. The presence of a lesion may first be suspected during the course of the opaque meal and it is usually the twenty-four hour plate which gives the hint. Here we find the bariiun being held at some definite point in the colon. There may be proximal dilatation, depending on the severity of the lesion. Along with this stasis there may be a definite defect in the colon outline usuaUj^ of an annular or funnel shape. It is only in the last stages where there is obstruction that the bismuth meal gives us any e\adence. The early cases, without obstruction, are demonstrated best with the bismuth enema. Frequentlj' it has been observed that a growth will offer no obstruction to the meal, but does obstruct the passage of the enema. Schwartz has explained this by the theorj- that the tumor has adapted itself from the earliest stages to the pressm-e of the stools above, and that its funnel is shaped by the natural direction of the stools. On the other hand, the enema, which approaches suddenly from below, does not find the way prepared for this abnormal direction, and real obstruction is created. The mechanics is simply that of a valve. 224 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS The filling defect, as has been mentioned, is usually of an annular nature. However, it may have an irregular, bitten-out appearance; this is particularly true of new growth in the caecum or upper rectum. MALFORMATION AND MALPOSITION The Roentgenoscope has been found of great value in studying the colon. It is impor- tant to watch the enema as it flows in. It will be noted that the whole colon fills with bis- muth within a few minutes. The fluid is unirritating and flows easily and without hesitation clear to the ileocsecal valve. In cases of new growth there is a characteristic halting at the point of hindrance. This arrest may be complete or may be overcome in a longer or shorter time, according to the degree of stenosis. The hindrance to the movement of the bismuth stream may be out of all proportion to the degree of actual obstruction. The Roentgenoscope is valuable, for by it a palpable tumor may be detected coinciding with the fiUing defect. However, the tumor will not be a constant finding, particularly if we attempt to make an early diagnosis. We must guard against misinterpretation of fiUing defects in the colon as seen on the plate. Pressure from a normal spine may produce a suspicious appearance in the transverse colon. There ma^^ be a hiatus in the colon due to normal peristaltic movement. One of the frequent confusing appearances is due to multiple diverticula. This will be discussed later. ADHESIONS There is no characteristic picture of adhesions. We may have a band constricting some portion of the colon. This will produce a filling defect with proximal stasis if the obstruc- tion is severe enough. This picture may simulate new growth. The history may differen- tiate. With adhesions we may find more or less displacement of the viscera associated with the filling defect. This is not characteristic of the defects from new growth. The most frequent location for adhesions to occur is in the hepatic flexure area. Here we commonly find the ascending colon and the proximal transverse colon adherent, pro- ducing sharp angulation of the hepatic fiexure. This condition may be accompanied by more or less stasis in the csecum and ascending colon. The Roentgenoscope is valuable in determining the degree of fixation. This condition has been described as the "double-barrel shot-gun" appearance. These adhesions may be secondary to old gall-bladder trouble, or possibly a congenital condition, as a so-called "Jackson's membrane." The appendix region is also a favorite location for trouble from adhesions. This area is described more fully in another chapter. Post-operative adhesions from pelvic operations in women will frequently displace or distort the colon. The sigmoid is commonly found fixed, sometimes held over to the right and actually overlying the appendix. It is sometimes held down in the pelvis. The colon may be displaced by other organs. An enlarged spleen will displace the splenic flexure downwards. Likewise an enlarged liver or even gall-bladder will give the hepatic flexure in a low position. Various large tumors, such as hydronephrosis of the kidney, ovarian cysts or even large fibroids will cause an abnormal position of the colon. There are rare congenital conditions of the colon which the Roentgen ray may reveal. Transposition of the viscera is not as uncommon as has been supposed. Redundant sig- moid is sometimes found. These may be enormous, the coils of sigmoid almost equaUing in length the rest of the colon. Congenital dilatation of the colon, in infants called " Hirsch- brung's disease," shows a characteristic Roentgen picture. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 225 COLITIS We have noted in conditions of colitis that the Roentgenogram presents a more or less characteristic appearance. Following the passage of the bismuth meal the wall of the colon still appears to retain a coating of bismuth. It has been supposed that mucus adhering to the wall retains the bismuth. 226 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS LARGE INTESTINE ADHESIONS Figure 296 PATIENT — POSITION: Man, age 50. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Normal. OPERATIVE FINDINGS: No operation. Key plate. 1 Caecum. 2 Ascending colon. 3 Hepatic flexure. 4 Transverse colon. 5 Splenic flexure. 6 Descending colon. 7 Sigmoid. 8 Appendix. Figure 297 PATIENT — POSITION: Woman, age 38. Prone. ROENTGEN CONCLUSIONS: Incompetency of the ileocsecal valve due to adhesions about the ascending colon. These adhesions extend from the region of the caecum to the lesser curvature of the stomach, causing pressure on the duodenum and transverse colon. OPERATIVE FINDINGS: Exploration showed presence of a dilated duodenum due to adhesions which caused a narrowing of lumen. Appendix drawn up, although not grossly pathological, tied off and removed. Many adhesions separated in the right upper quadrant. Bismuth enema examination and bismuth meal. A — B — C — D — E Effect of pressure from adhesions. F Appendix and ileum. G Bismuth in ileum clue to incompetency of the ileocsecal valve. H Marked atony of the transverse colon. THE RijEXTGEX DiACxKOSIS OF SI-RGICAL LES LESIONS 228 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 298 PATIENT ^POSITION: Woman, age 38. Prone. Enema. ROENTGEN CONCLUSIONS: Marked incompetency of the ileocaecal valve due to adhesions about caecum. OPERATIVE FINDINGS: Tuberculosis of cacum and colon. A Point of obstruction in colon. B Note apparent atony of the colon due to infiltration of the whole bowel. C Bismuth having passed the ileocffical valve progresses readily almost to the stomach. Figure 299 PATIENT — POSITION: Woman, age 33. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Post-operative adhesions subsequent to an acute perforating appendix. OPERATIVE FINDINGS: Extensive adhesions about the hepatic flexure. The coils of ileum were external to ascending colon and fixed to parietal peritoneum. A Gas in small bowel due to partial olistruction. B Ascending colon. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 229 FIGURE 299 230 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 300 PATIENT — POSITION: Woman, age 38. Prone. Enema. ROENTGEN CONCLUSIONS: Extensive adhesions about caecum and ascending colon. OPERATIVE FINDINGS: Pericolitis. Chronic appendix. Dilatation of the caecum due to adhesions. A Transverse colon fixed and adherent to ascending colon. B Point of narro^vdng due to adhesions. C Dilated csecum. Figure 301 PATIENT — POSITION: Woman, age 19. Prone. Enema. ROENTGEN CONCLUSIONS: Pericolic membrane. Fixation of proximal transverse colon to ascending colon. OPERATIVE FINDINGS: Pericolic membrane and adhesions. A Cgecuni . B Fixed point of transverse cclon. Figure 302 Artist's drawing of Case 301. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 231 FIGURE 300 FIGURE 301 FIGURE 303 232 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 303 PATIENT — POSITION: Man, age 21. Prone. ROENTGEN CONCLUSIONS: Pericolitis with membrane. OPERATIVE FINDINGS: Jackson's membrane with retrocaecal appendix. A Fixation of transverse colon into right quadrant. B Caecum. Figure 304 PATIENT — POSITION: Woman, age 40. Prone. (Twelve-hour plate.) ROENTGEN CONCLUSIONS: Marked kinking and fixation of caecum and proximal portion of the transverse colon. OPERATIVE FINDINGS: Roentgen observations confirmed. A Fixation of colon. B Ileal stasis. Figure 305 PATIENT — POSITION: Woman, age 43. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Adhesions and fixation of proximal portion of the transverse colon. OPERATIVE FINDINGS: Extensive adhesion and membrane about ascending and transverse colon. A Filling defect due to adhesions. B Fixation of transverse colon. THE ROEXTGEX DIAGXOSIS OF SURGICAL LESIONS 233 FIGURE 303 FIGURE 304 FIGURE 305 234 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 306 PATIENT — POSITION: Woman, age 48. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Extensive adhesions about the ascending colon and hepatic flexure. Gall- stones. OPERATIVE FINDINGS: Adhesions. Partial obstruction of ascending colon due in part to gall-bladder adhesions. A — B Points of obstruction due to membrane. Figure 307 PATIENT — POSITION: Woman, age 47. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Adhesions about ascending colon and deformity of caecum due to post- operative adhesions from gall-bladder disease. Chronic appendix. OPERATIVE FINDINGS: Adhesion from gall-bladder causing partial obstruction of ascending colon, and chronic appendix. A Point of fixation of colon due to membrane and adhesions. B Deformity of caecum. C Chronic appendix. D Sigmoid fixed to base of CECcum. Figure 308 PATIENT — POSITION: Woman, age 5L Prone. Enema. ROENTGEN CONCLUSIONS: Post-operative condition of the ascending colon. OPERATIVE FINDINGS: Post-operative condition of the ascending colon due to adhesions. A Dilated terminal ileum. B Showing deformity of ca?cum. THE R(3EXTGEX DIAGXOSIS OF SURGICAL LESIONS 235 FIGURE 306 FIGURE 307 FIGURE 308 236 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 309 PATIENT — POSITION: Woman, age 36. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Marked pericolic membrane. Dilatation of caecum. OPERATIVE FINDINGS: Confirmed Roentgen plates. A Stenosis of ascending colon. B Dilatation of colon due to obstruction of ascending colon. Figure 309A PATIENT — POSITION: Woman, age 32. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Adhesions about ascending colon due possibly to a membrane. OPERATIVE FINDINGS: Pericolic membrane. Chronic appendix. A Point of narrowing in the bowel due to membrane. B Appendix. Figure 310 PATIENT — POSITION: Woman, age 42. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Pericolic membrane of ascending colon. Chronic appendix. OPERATIVE FINDINGS: Pericolic membrane. Chronic appendix. A Point of narrowing of bowel. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 237 FIGURE 309 FIGURE 309A FIGURE 310 238 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 311 PATIENT — POSITION: Man, age 36. Prone. Enema. ROENTGEN CONCLUSIONS: Marked incompetency of the ileocaecal valve. OPERATIVE FINDINGS: No operation. A Csecum and ascending colon. B Bismuth passing back into ileum. Figure 31 lA PATIENT — POSITION: Man, age 50. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Adhesions about ascending colon. OPERATIVE FINDINGS: Adhesions about bowel causing narrowing and partial obstruction. A Point of actual narrowing of bowel. Figure 312 PATIENT — POSITION: Boy, age 4. Prone. ROENTGEN CONCLUSIONS: Obstruction of transverse colon. Cause not determined. OPERATIVE FINDINGS: Obstruction of bowel due to abscess of liver, with subsequent adhesions which had completely invested the colon and caused obstruction. A — B Site of obstruction. Bowel almost completely obstructed at this point. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 239 FIGURE 311 FIGURE 311A FIGURE 312 240 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 313 PATIENT — POSITION: Baby, age 6 weeks. Prone. ROENTGEN CONCLUSIONS: Hirschbrung's disease or congenital dilatation of large intestine. OPERATIVE FINDINGS: Autopsy. Confirmed Roentgen observations. A — B Compare the size of this bowel with that of a child of four years. (See Figure 312.) Figure 314 PATIENT — POSITION: Man, age 20. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Adhesions about ascending colon and caecum. OPERATIVE FINDINGS: Confirmed Roentgen examination. A Dilated and obstructed terminal ileum. Figure 315 Artist's drawing of Case 314. THE ROEXTGEX DIAGXOSIS OF SURGICAL LESIONS 241 FIGURE 313 FIGURE 314 FIGURE 315 242 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 316 PATIENT — POSITION: Woman, age 23. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Extensive adhesions about the csecum. OPERATIVE FINDINGS: Obstruction of ascending colon due to old tubercular peritonitis. A Obstruction of ascending colon. B Shows only a small amount of bismuth passing through bowel. Figure 317 PATIENT — POSITION: Girl, age 14. Prone. ROENTGEN CONCLUSIONS: Pericolic membrane. OPERATIVE FINDINGS: Pericolic membrane. Chronic appendix. A Point of fixation of transverse colon to ascending colon. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 243 FIGURE 316 FIGURE 317 244 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 318 PATIENT — POSITION: Girl, age 13. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Fixation of transverse colon to old scar. OPERATIVE FINDINGS: Fixation of omentum to old appendix scar. A Site of fixation of transverse colon into pelvis. This deformity was due to the omentum being held by the scar from previous operation. Figure 319 PATIENT — POSITION: Man, age 21. Prone. Enema. ROENTGEN CONCLUSIONS: Extensive adhesions in upper right quadrant. OPERATIVE FINDINGS: Confirmed Roentgen observations. A Point of fixation of transverse colon to stomach and subhepatic region. THE ROEXTGEN DIAGNOSIS OF SURGICAL LESIONS 245 FIGURE 318 FIGURE 319 246 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 320 PATIENT — POSITION: Man, age 30. Prone. Enema. ROENTGEN CONCLUSIONS: Pericolic membrane of the ascending colon. OPERATIVE FINDINGS: Pericolic membrane. Chronic appendix. A Point of fixation. Figure 321 PATIENT — POSITION: Man, age 35. Prone. Enema. ROENTGEN CONCLUSIONS: Adhesions about proximal portion of the transverse colon. OPERATIVE FINDINGS: Confirmed Roentgen observations. A Narrowing of ascending colon due to a band of adhesions. Figure 322 PATIENT — POSITION: Man, age 38. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Adhesions about ascending and proximal portion of transverse colon. OPERATIVE FINDINGS: Extensive involvement of whole of right lower quadrant with adhesions, also membrane formations. A Point of fixation of transverse colon. B Csecum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 247 FIGURE 320 FIGURE 321 FIGURE 322 248 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 323 PATIENT — POSITION: Man, age 53. Prone. Enema. ROENTGEN CONCLUSIONS: Extensive adhesions about ascending colon probably causing incom- petency of ileocsecal valve. OPERATIVE FINDINGS: Adhesions, chronic appendix. Sigmoid attached to caecum. A Point of obstruction of ascending colon. B Coils of ileum. C Sigmoid. Figure 324 Same case as Figure 314. One year after operation. Though symptoms have all been relieved, yet bowel position remains about as in early plates. A Ctecum. B Transverse colon. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 249 FIGURE 323 250 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS INTESTINAL NE\A^ GROWTH Figure 325 Artist's drawing of Case 326. See colored Plate IV. Figure 326 PATIENT — POSITION: Woman, age 49. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Small intra-intestinal new growth at base of caecum. OPERATIVE FINDINGS: Small intra-intestinal tumor about the size of an egg. A Filling defect due to growth, outline of tumor. This tumor was dem.onstrated also without the bismuth meal. Arrows point to outline of growth. Figure 327 PATIENT — POSITION: Man, age 58. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Extensive new growth of the cscum. OPERATIVE FINDINGS: Extensive new growth of caecum. A Plate shows dilatation of the ileum and involvement of csecum. B Extent of new growth involving ascending colon. V^^f^-^Jf'tmtto n li^ PLATE IV — FIGURE 325 SMALL INTRA-INTESTINAL NEW GROWTH AT BASE OF CAECUM THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 251 FIGURE 327 252 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 328 PATIENT — POSITION: Man, age 23. Prone. ROENTGEN CONCLUSIONS: New growth at hepatic flexure. OPERATIVE FINDINGS: Small intra-intestinal tumor at hepatic flexure. Pathological report, adenocarcinoma. A Filling defect in bowel due to tumor mass. B Terminal dilatation of ileum due to partial obstruction in bowel. Figure 329 PATIENT — POSITION: Woman, age 69. Prone. (Six-hour plate.) ROENTGEN CONCLUSIONS: Obstruction of bowel at hepatic flexure due to probable new growth. OPERATIVE FINDINGS: Small annular new growth at hepatic flexure, involving liver and gall-bladder. Adenocarcinoma. A Obstruction at hepatic flexure due to small constricting annular groM'th. Figure 330 Same case as Figure 329. Artist's drawing showing very small constricting new growth. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 253 FIGURE 328 FIGURE 329 FIGURE 330 254 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 331 PATIENT — POSITION: Woman, age 36. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: New growth of proximal portion of transverse colon causing complete obstruction. OPERATIVE FINDINGS: Small annular new growth causing more or less obstruction. A Point of obstruction sho-n-ing how small an amount of bismuth is passing through the towel at this point. B Distended bowel due to obstruction. Note the dilatation of the terminal loops of ileum and ca?cum, due to the obstruction of the transverse colon. Figure 332 PATIENT — POSITION: Man, age 38. Prone. ROENTGEN CONCLUSIONS: A large intra-intestinal new growth at distal portion of the transverse colon. OPERATIVE FINDINGS: Large inoperable new growth of bowel. A Plate shows extent of the intra-intestinal growth. Note the size of the lumen of the bowel. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 255 FIGURE 331 FIGURK 332 256 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 333 PATIENT — POSITION: Man, age 34. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Intra-intestinal new growth at splenic flexure. OPERATIVE FINDINGS: Inoperable intra-intestinal new growth. A Extent of new growth in bowel. This filling defect was constant in the six, twenty-four and forty-eight hour plates. B Splenic flexure. Figure 334 Same case as Figure 333. Plates made forty-eight hours later with a bismuth enema. Note the fiUing defect. THE ROENTGEN DIACxNOSIS OF SURGICAL LESIONS 257 FIGURE 333 FIGURE 33.1 258 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 335 PATIENT — POSITION: Man, age 48. Prone. Enema method. ROENTGEN CONCLUSIONS: Intra-intestinal tumor at splenic flexure. Probable new growth. OPERATIVE FINDINGS: Autopsy. Extensive involvement of the transverse colon. Adenocarcinoma. A Complete obstruction of the distal portion of the transverse colon. B Splenic flexin-e. C Descending colon. D Sigmoid. Figure 336 PATIENT — POSITION: Man, age 53. Prone. Enema method. ROENTGEN CONCLUSIONS: Marked filling defect in the lower portion of the descending colon. OPERATIVE FINDINGS: Inoperable carcinoma involving the descending colon and sigmoid with perfora- tion into the bladder. A Defect due to growth. B Rectum. C Sigmoid. THE ROEXTGEX DIAGXOSIS OF SURGICAL LESIONS 259 f FIGURE 336 260 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 337 PATIENT — POSITION: Woman, age 36. Prone. ROENTGEN CONCLUSIONS: Small annular carcinoma of descending colon. OPERATIVE FINDINGS: Small annular carcinoma of descending colon. A Approximate size of the annular carcinoma. B Transverse colon. C Filling defect in caecum which at operation was found to be carcinoma. D Large normal appendix. Figure 338 PATIENT — POSITION: Woman, age 69. Prone. ROENTGEN CONCLUSIONS: Extensive carcinoma at descending colon with metastases of the caecum. OPERATIVE FINDINGS: Extensive involvement of the descending colon. Secondary involvement of other parts of the large bowel. A — B Extent of growth in descending colon. C Annular carcinoma of caecum. It is interesting to note the marked atony of the large bowel. Figure 339 Artist's drawing of Case 338. See colored Plate V, PLATE V — FIGURE 339 EXTENSIVE CARCINOMA OF DESCENDING COLON THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 261 FIGURE 337 FIGURE 338 262 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 341 PATIENT — POSITION: Man, age 33. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Small annular new growth of sigmoid. OPERATIVE FINDINGS: Small annular new growth of sigmoid. Pathological report, adenocarcinoma. A — B Extent of carcinoma. Figure 342 Artist's drawing of Figure 341 made of the resected portion. The sigmoid and descending colon show a small annular carcinoma. The Roentgen plate is even more striking than the resected portion of the colon. THE ROEXTGEX DIAGXOSIS OF SURGICAL LESIONS 263 FIGURE 341 FIGURE 342 264 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 343 PATIENT — POSITION: Woman, age 48. Prone. ROENTGEN CONCLUSIONS: New growth of the sigmoid and descending colon. OPERATIVE FINDINGS: Annular new growth of sigmoid. A Filling defect due to involvement of bowel at this point. Figure 344 PATIENT — POSITION: Man, age 31. Prone. ROENTGEN CONCLUSIONS: Extensive involvement of the sigmoid. OPERATIVE FINDINGS: Extensive involvement of the entire sigmoid. Probable carcinoma. A Lower boundary of bowel. B Extension of growth in sigmoid. C Point of marked obstruction about the descending colon. This is a forty-eight hour plate and shows the obstruction at point C. An enema given showed the obstruction as in A and B. The surgeon also considered the possibihty of the growth being sarcoma but its character could not be definitely proven as no specimen was removed. Patient died within six months. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 265 FIGURE 343 FIGURE 344 266 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 345 PATIENT — POSITION: Man, age 61. Prone. Enema. ROENTGEN CONCLUSIONS: Extensive new growth of descending colon, sigmoid and rectum. OPERATIVE FINDINGS: Complete involvement of whole pelvic cavity. Carcinoma. A Descending colon. B Rectum. C Sigmoid. The only portion of the lower bowel that is normal. Figure 346 PATIENT — POSITION: Woman, age 28. Prone. Enema. ROENTGEN CONCLUSIONS: Obstruction of lower bowel. OPERATIVE FINDINGS: Small annular carcinoma of descending bowel. A Point of obstruction. B Dilated sigmoid. C Rectum. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 267 FIGURE 345 FIGURE 346 268 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 347 PATIENT POSITION: Man, age 58. Prone. Enema. ROENTGEN CONCLUSIONS: Diverticulitis of sigmoid and descending colon, with possible early car- cinoma of sigmoid. OPERATIVE FINDINGS: Small annular carcinoma. Diverticulitis. A Small filling defect of lower bowel due as it proved to annular carcinoma. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 269 FIGURE 347 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 271 SECTION IX DIVERTICULITIS OF THE COLON ^Multiple diverticula of tlie colon are not so uncommon as has been thought. Their recognition has become more frequent through the aid of the Roentgen ray. In our ex- perience the number of cases of diverticulitis compared with the cases of colonic new growth is about one to three. The Roentgen picture of multiple diverticula is rather characteristic. After the passage of the bismuth meal we may find, in the region of the sigmoid or lower descending colon, numerous discrete, round shadows about the size of a pea. These shadows are due to portions of the bismuth meal remaining in small sacculations in the gut. Under the Roentgenoscopic screen, these shadows are seen to occur in groups and to bear a constant relation to each other. jNIanipulation may show the relation of these shadows to the wall of the colon. In some cases there will be found a definite palpable mass on the left lower quadrant, due to a peridiverticulitis with its mass of inflammatory tissue. This picture may be confused with new growth of the colon, and it may be suggested that there is a casual relation between this condition and new growth. The important diagnostic factor is the prolonged retention of the bismuth in the di- verticula. It is not uncommon to find these shadows persisting for four or five days after the bismuth meal. Case reports one case where the diverticula retained bismuth on the sixteenth day. The diagnosis may sometimes be made -ndth the bismuth enema. The patient should be encouraged to retain the enema as long as possible. It is also advisable to have a higher percentage of barium in the solution. The patient should be examined just previous to expelling the solution and thirty to sixty minutes afterwards. This usually insures proper filling of the diverticula. It will frequently be noted that these patients will not be able to empty the whole colon, usually only the rectum and lower sigmoid. A careful series of plates must be made in suspected cases of colonic new growth even though miiltiple diverticula be present. In the writers' experience early carcinoma may have its beginning in these areas and unless extreme care is exercised, one may overlook early new growth. The problem is parallel to the recognition of early gastric cancer beginning on chronic ulcer. A very good rule to observe, in the presence of diverticula of the bowel, is to consider new growth if there is found a narrowing of the lumen of the bowel at any point. DiverticuUtis will not cause a localized stenosis as in Figure 347, 272 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS DIVERTICULITIS Figure 348 PATIENT — POSITION: Woman, age 48. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Diverticulitis. OPERATIVE FINDINGS: No operation. A Sigmoid. B Splenic flexure. Figure 349 PATIENT — POSITION: Man, age 46. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Diverticulitis. OPERATIVE FINDINGS: Diverticulitis. A — B Multiple diverticula. Figure 350 PATIENT — POSITION: Woman, age 44. Prone. ROENTGEN CONCLUSIONS: Diverticulitis. OPERATIVE FINDINGS: Diverticulitis. A — B Multiple diverticula. Figure 351 PATIENT — POSITION: Man, age 52. Prone. ROENTGEN CONCLUSIONS: Diverticulitis. OPERATIVE FINDINGS: No operation. A — B Multiple diverticula. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 273 FIGURE 348 FIGURE 349 FIGURE 350 FIGURE 351 274 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 352 PATIENT — POSITION: Woman, age 46. Prone. ROENTGEN CONCLUSIONS: Diverticulitis of sigmoid and descending colon. OPERATIVE FINDINGS: Several diverticula removed from the lower bowel. A — B Large diverticula. Figure 353 Artist's drawing of Case 352. See colored insert, Plate VI. Figure 354 PATIENT — POSITION: Woman, age 48. Prone. Enema. ROENTGEN CONCLUSIONS: Diverticulitis of the lower colon. OPERATIVE FINDINGS: Several large diverticula removed. A Several large diverticula. Figure 355 PATIENT — POSITION: Man, age 63. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Diverticulitis of the entire colon. OPERATIVE FINDINGS: No operation. A — B Area of diverticula of lower bowel. >. y PLATE VI — FIGURE 353 DIVERTICULITIS OF DESCENDING COLON THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 275 FIGURE 354 FK3URE 355 276 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS Figure 356 PATIENT — POSITION: Woman, age 63. Prone. (Twenty-four hour plate.) ROENTGEN CONCLUSIONS: Diverticulitis of the whole colon. OPERATIVE FINDINGS: No operation. A — B Multiple diverticula. C Appendix. D Diverticula in transverse colon. Figure 357 PATIENT — POSITION: Man, age 58. Prone. Enema method. ROENTGEN CONCLUSIONS: Diverticulitis. OPERATIVE FINDINGS: No operation. A — B Diverticulitis of sigmoid and descending colon. C A small diverticulum. D Gall-stones. THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS 277 FIGURE 357 278 THE ROENTGEN DIAGNOSIS OF SURGICAL LESIONS ROENTGEN TERMS At a meeting of the American Roentgen Ray Society, October 1, 1913, on the recom- mendation of the Committee on Nomenclature, the Society adopted the following terms: Roentgen: To be pronounced rent-gen. Roentgen ray: A ray discovered and described by Wilhelm Komad Roentgen. Roentgenology: The study and practice of the Roentgen ray as apphed to medical science. Roentgenologist: One skilled in Roentgenology. Roentgenogram: The shadow picture produced by the Roentgen ray on a sensitive plate or film. Roentgenograph (verb): To make a Roentgenogram. Roentgenoscope : An apparatus for examination with the fluorescent screen excited by the Roentgen ray. Roentgenoscopy: Examination by means of the Roentgenoscope. Roentgenography: The art of making Roentgenograms. Roentgenize: To apply the Roentgen ray. RoENTGENizATiON : Apphcation of the Roentgen ray. Roentgenism: Untoward effect of the Roentgen ray. Roentgen diagnosis, Roentgen therapy, Roentgen dermatitis: These terms are self-explanatory. INDEX Adhesions, intestinal, pp. 226-249, Figs. 296-324. See also under appendix, colon, duodenum, gall-bladder, ileum, intestine (large and small), stomach. Adhesions, multiple, Figs. 163, 168, 170, 171, 205, 216, 297, 319. Pelvic, Fig. 245. Apparatus, p. 3. Appendix, pp. 188-220, Figs. 248-295. Acute, p. 189. Adhesions, Figs. 253, 255, 261, 262, 264, 269, 278, 281, 285, 286, 293. Adhesions, diagnosis of, p. 190. Chronic, p. 190, Figs. 23, 28, 31, 225-227, 230, 231, 239, 240, 249-295, 300, 309A, 310, 317, 320, 323. Concretions in, p. 190, Figs. 251, 259, 286, 288, 290. Diagnosis, p. 189. Kinked, Figs. 250, 257-259, 262, 265, 267, 270, 271, 273-276, 278, 280, 283, 292, 294. Long, Fig. 292. Obliterated, Figs. 249, 252, 257, 263. Retrocecal, Figs. 255, 259, 261, 266, 285, 287, 294, 303. Stasis in, p. 190. Technique, p. 188. Test meal for, p. 188. Bile in cystic duct. Fig. 184. Bladder, dilated, Fig. 246. Cajcum, adhesions. Figs. 298, 300, 314. Deformity caused by adhesions. Figs. 294, 307. Dilatation, Figs. 300, 309, 331. Kinking, Fig. 304. Tuberculosis of. Figs. 237, 243, 298. Tumors of, Figs. 326, 327. Calculi, biliary. See gall-stones. Renal, p. 143. Cancer, pp. 35, 68. See also under colon, duodenimi, gall-bladder, ileum, intestines, jejimum, liver, oesophagus, rectum, sig- moid, stomach. Early, diagnosis of, p. 68. Cardia, ulcer at. Fig. 165. Cardio-spasm, Fig. 36. Cholecystitis, p. 143, Figs. 21, 25, 27, 199, 200, 213. Cholesterine gall-stones, p. 142, Figs. 187, 193. Colitis, p. 225, Fig. 300. Colon, adhesions, p. 224, Figs. 222, 227, 239, 253, 260, 269, 291, 297-301, 304-312, 314, 318, 319, 321-323. Cancer, Figs. 328, 329, 335, 337, 338, 340, 345. Diverticuhtis of, pp. 271-277, Figs. 347-357. Enema for examination of, p. 222. Malformation and malposition, p. 224. Obstruction and stenosis, Figs. 311A, 312, 316, 321, 331. Ptosis, Fig. 11. Tuberculosis, Fig. 298. Tumors, p. 223, Figs. 328-340, 345. Constipation, chi-onic, p. 223. Cystic duct, bile in. Fig. 184. Diagnosis between gastric lesion and pressure of large intestine. Fig. 33. Direct, p. 2. Indirect, p. 1. Diverticulitis, p. 271, Figs. 347-357. Diverticulum, p. 95, Figs. 235, 236, 238, 348-357. Duodenal cap, p. 96. Duodenum, pp. 92-139. Adhesions, Figs. 168-171, 182. See also under ulcer, duo- denal and adhesions. Anatomical variation. Figs. 2, 220. Cancer, Fig. 181. Dilatation, Figs. 68, 168, 297. Diverticulum, p. 95. Gall-bladder perforating into. Fig. 141. Normal, p. 93, Fig. 122. Obhteration due to ulcer. Figs. 138, 140, 145, 146, 148, 155, 157, 166, 167. Obstruction caused by tumor. Figs. 177-180. Technique, p. 93. Ulcer, p. 92. See ulcer, duodenal. Enema for intestinal examination, p. 222. GaU-bladder, pp. 140-165, Figs. 182-219. Adhesions, Figs. 139, 168, 172, 174, 182, 216, 281, 307. Cancer, Fig. 329. Disease of, p. 143, Figs. 21,25, 27, 199,200, 205,213, 216, 307. Identification of, p. 142. Perforating into duodenum. Fig. 141. Pressing on duodenum. Fig. 205. GaU-stones, pp. 140-165, Figs. 141, 182-219, 306. Composition of, p. 142. Diagnosis of, p. 142. Differentiating from other conditions, p. 141. In common duct, Fig. 199. In cystic duct. Fig. 189A. Interpretation of plates, p. 142. Mistaken for appendicitis. Fig. 189A. Mistaken for stone in the kidney, Fig. 208. Multiple, Figs. 184, 186, 189A, 195, 200, 201, 209, 210, 212, 213, 215. Percentage shown bj' Roentgen rays, p. 140. Technique, p. 140. Gastro-intestinal diagnosis, p. 1. Haudek's niche, p. 95. Hepatic flexure, tumors at, Figs. 328, 329. Hernia, p. 166. Hirschprung's disease. Fig. 313. Hour-glass stomach, pp. 34, 70, Figs. 39, 41, 42, 44, 45, 53, 54-56, 60, 61, 63, 83, 165. Double, Fig. 166. Due to cancer, p. 70, Fig. 110. HypermotiUty of stomach, p. 96. Hypernephroma, Figs. 34, 35. Hyperperistalsis, p. 95. Ileal stasis, p. 167, Figs. 222, 223, 225, 227, 231, 239, 241-243. IleocEecal valve, incompetency of. Figs. 297, 298, 311, 323. Ileum, adhesions. Figs. 240, 241, 245. Cancer, Fig. 234. Dilatation, Figs. 222, 223, 230, 231, 244, 327, 331. Displacement, Figs. 245, 246, 247. Normal, p. 166, Fig. 220A. Obstruction of. Figs. 228, 229, 234, 314. 279 280 INDEX Intestine, large, pp. 222-277, Figs. 296-357. Adhesions, pp. 224, 226-249, Figs. 222, 227, 239, 253, 260, 269, 291, 294, 296-324. Congenital dilatation. Fig. 313. Enema for, p. 222. Malformation and malposition, p. 224. Method of study, p. 222. Normal appearance, p. 222, Figs. 226, 248. Obstruction due to liver abscess, Fig. 312. Tuberculosis of. Figs. 237, 243, 298. Tumors, pp. 223, 250-269, Figs. 325-347. Intestine, small, pp. 166-186, Figs. 220-247. Adhesions, p. 167, Figs. 221, 222, 225, 229, 231, 240, 241, 244, 245. See also under duodenun, adhesions. Cancer, Figs. 224, 234. Diagnosis, p. 166. Diverticulum of. Figs. 235, 236, 238. Passage of bismuth through, p. 166. Tumors, p. 167, Figs. 177-180. See also under ileum, cancer and jejunum, cancer. Intestines, cancer. Figs. 181, 224, 234, 326, 328, 329, 335, 336-338, 340, 341, 344-347. Tuberculosis, Figs. 237, 243, 298. Jackson's membrane. Fig. 303. Jejunum, cancer, Fig. 224. Dilatation and obstruction of. Figs. 221, 224. Diverticulum of. Figs. 235, 236, 238. Normal, p. 166, Fig. 220A. Ulcer, p. 167. Kidney, stone in the, p. 143. Tumors, Figs. 34, 35. Lane's kink, p. 167, Figs. 28, 222, 223, 226, 227, 233, 244, 276. Liver, abscess, causing intestinal obstruction, Fig. 312. Adhesions, Figs. 168, 216. Cancer, Fig. 329. Meal, bismuth-buttermilk, p. 2. Bismuth-cereal, p. 2. Opaque enema, p. 222. Membranes. Mucosal defect of duodenum, p. 94. ffisophagus, cancer. Fig. 95. Dilatation in an infant. Figs. 177-180. Obstruction of. Fig. 36. Omentum, adhesions. Fig. 318. Pancreas and gastric ulcer. Fig. 50. Pericohc membrane. Figs. 242, 253, 260, 301, 305, 309, 310, 317, 320, 322. Pericolitis, Figs. 300, 303. Peritonitis, old. Fig. 229. Tubercular, Figs. 230, 316. Prognathion dilatation. Fig. 76. Ptosis, Figs. 9, 11, 14, 15, 16, 19, 22, 33. Pylorus, cancer, p. 35, Figs. 92-96. Contraction, normal. Fig. 27. Obstruction of. Fig. 34. Spasm, p. 35. Ulcer at, Figs. 69, 71, 73, 74, 76, 77, 79, 83A. Rectum, cancer. Figs. 345, 346. Reider test meal, p. 2. Retroperitoneal tumors. Fig. 35. Roentgenoscopy, pp. 1, 32, 96. Sigmoid, adhesions. Fig. 323. Cancer, Figs. 336, 340, 341, 344-347. DiverticuHtis of. Figs. 347, 352, 357. Tumors of. Figs. 343, 344. Sphincter, pyloric. Fig. 27. Spine, pressure on stomach, Fig. 7. Stereoscopy in gall-stone work, p. 141. Stomach, pp. 1-91. Adhesions, Figs. 45, 55-57, 65. Anatomical variation. Figs. 2, 220. Cancer, pp. 35, 68, Figs. 86-121. Dilatation of. Figs. 9, 14, 15, 16, 19, 21, 29, 30, 33. Dilatation in an infant. Figs. 177-180. Hour-glass, p. 34. See hour-glass stomach. Hypermotility in duodenal ulcer, p. 96. Normal, pp. 1-31, Figs. 1-33. Ptosis of. Figs. 9, 14-16, 19, 22, 33. Redundancy of mucous membrane. Fig. 48. Resection, Fig. 75. Shape of, p. 4. Spasm of, p. 35. Tumors of, pp. 34, 68-91, Figs. 67, 84-121. Tumors of, diagnosis, p. 68. Ulcer of, p. 32. See ulcer, gastric. Technique, general, p. 3. Tuberculosis. See caecum, colon, intestines, peritonitis. Tumors. See cancer, intestines, kidney, stomach. Intra-abdominal, p. 166. Ulcer, duodenal, pp. 92-139, Figs. 53, 56, 58, 62, 71, 125-174. And adhesions, p. 94, Figs. 136, 139, 141, 145, 147, 148, 155, 157, 166-172. And gastric hyperperistalsis, p. 95. Diagnosis of, p. 92. Hypermotility of stomach in, p. 96. Obstructive type, Figs. 138, 140, 145, 146, 148, 155, 157, 166, 167. Perforating, Figs. 143, 162. Pinpoint defect of mucosa, p. 94, Figs. 144, 147, 153, 160, 173. Ulcer, gastric, pp. 32-67, Figs. 36-83A, 165, 182. Acute, Fig. 79. Diagnosis of, pp. 33, 35. Disproved by Roentgen rays. Fig. 159. Induration in, p. 34. Mahgnant, Figs. 87-91, 93, 104, 114, 115. Malignant degeneration of, p. 69. Perforating, p. 33, Figs. 39, 41, 43, 44, 49, 50, 71. Technique, p. 32. Ulcer, jejunal, p. 167. Uterus, gravid. Fig. 247. Valvulie conniventes, Fig. 1. COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RD 540 G29 Q C.2 The Roi'"iij"i: i; .^q-.o'y, u' -.umical lesio "ERSITY TTPRAPTES ■ indicF DATE DUE Demco, Inc. 38-293