^C6 ■O -^-^c- Columbia ®nibemt|Co inthttitp of Mtb)govk COLLEGE OF PHYSICIANS AND SURGEONS ?^^ Reference Library Given by DR. H. E. HALE THE ROENTGEN DIAGNOSIS OF DISEASES OF THE ALIMENTARY CANAL ■-■ '■■' . f.iu;n ■■ NEW YOR;: BY RUSSELL D. CARMAN, M. D. Head of Section on Roentgenology, Division of Medicine, Mayo Clinic; Professor of Roentgenology (Mayo Foundation), Graduate School of Medicine, University of Minnesota AND ALBERT MILLER, M. D. First Assistant in Section on Roentgenology, Division of Medicine, Mayo Clinic; Fellow in Roentgenology (Mayo Foundation), Graduate School of Medicine, University of Minnesota WITH 504 ORIGINAL ILLUSTRATIONS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1917 Copyright, 1917, by W. B. Saunders Company Printed in America PREFACE Within a very few years the roentgenologic examination of the digestive tract has become an extraordinarily efficient and practicable aid to gastro-intestinal diagnosis. The literatm-e on the subject, though extensive, has been widely scattered through periodicals, and, at the time the preparation 'of this book was begun, no effort had been made in America to collect the well- established facts into a single volume. Our intent has been to select and arrange in a systematic manner those things which seem not only to be true but worth while, and especially those which we have verified by experience with a large amount of material. We have purposely avoided extensive descriptions of appara- tus since this subject has been rather full}^ dealt with in several comprehensive pubhcations. On the other hand, we have given detailed protocols of the findings in a considerable number of cases which have come under our observation. Thus our hope is that the book will be of some practical service to our co-workers in the field of roentgenology. For the sake of brevity, many citations of authority have been omitted, but there is no pretense that the bulk of the facts related are from observations original with us. In the occasional instances in which we have dissented from the opinions of others, we have endeavored to quote oppos- ing views with fairness and without conscious implication that our own word should be considered final. Because of the lessons they may teach, our mistakes have been recorded unsparingly, but these errors should not be regarded as reflecting on the general efficiency of roentgen diagnosis. To the distinguished brothers whose name designates the clinic in which the work has been done and who have given us exceptional opportunities for the comparison of roentgenologic and operative findings, to our fellow members of the surgical, clinical and pathological staffs, who have heartily cooperated with us, to Mrs. ]M. H. Mellish of the EcUtorial Department, whose aid has been unflagging, and to our intimate associates in the roentgen laboratory, who have given us generous help, our obligations are gratefully acknowledged. The Authors. Mayo Clinic, Maij, 1917. 11 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/roentgendiagnosiOOcarm CONTENTS CHAPTER I Page Apparatus 17 Transformer, 18 — Vertical Screen Apparatus, 18 — Foot-switch, 19— Tube-stand, 20— Table, 20— Tubes, 21— Intensifying Screens, 22— Plates and Developers, 22. CHAPTER II General Technic 24 Preparation of the Patient, 24 — Opaque Salts, 25 — Vehicles, 26 — Opaque Enema, 27 — Quantities of Opaque Salts, 28 — Six-hour Meal, 28 — Screen-examination, 29 — Plates, 31 — Case Records, 32. CHAPTER III Interpretation 34 CHAPTER IV The Esophagus 39 Technic of Examination, 39 — Anatomical Memoranda, 4G — Nor- mal Esophagus as Shown by Roentgen Ray, 47 — Pathologic Esopha- gus as Shown by Roentgen Ray, 48 — Cardiospasm, 50 — Carcinoma, 57 — Diverticulum, 62 — Cicatricial Strictures, 65 — Spasm, 70 — Foreign Bodies, 71 — Miscellaneous Esophageal Lesions, 71. CHAPTER V The Stomach 75 Technic of Examinaticjn, 75 — Roentgen Anatomy, 77. CHAPTER VI The Normal Stomach 82 Habitus, 82— The Abdominal Wall, 86— Gastric Tonus, 86— Form, 87— Tone, 92— Position, 95— Size, 96— Contour, 97— Mobility, 97— Flexibility, 99— Gas-bubble, 99— Secretion, 99— Peristalsis, 100 — Motility, 106 — Roentgenologic Tests of Motility, 110. CHAPTER VII The Abnormal Stomach 121 Form Variations, 121 — Hour-glass Stomach, 121 — Changes of Contour, 124 — Alterations of Tone, 129 — Altered Position, 131 — 13 14 CONTENTS Page Alteration of Size, 132— Altered Mobility, 132— Lessened Flexi- bility, 133 — Gas-bubble, 133 — Secretion, 134 — Abnormal Peristal- sis, 134 — Disordered Motilitj^, 139 — Zones of Motility Based on Six-hour Meal, 146. CHAPTER VIII Gastbospasm 153 Etiology, 162— Differentiation, 162. CHAPTER IX Gastric Cancer 171 Filling-defects, 173 — Filling-defects from Causes other than Can- cer, 179 — Alteration of Pyloric Function, 186 — Peristalsis, 189 — Altered Motihty, 189— Lessened Mobility, 190— Lessened Flexi- bility, 190 — Persistent Local Spasm, 191 — Altered Size and Capac- ity, 191 — Displacement, 191 — Pathologj^, 192 — Roentgen Char- acteristics of Fungous Cancer, 194 — Roentgen Characteristics of Scirrhous Cancer, 194 — Mucoid Cancer, 196 — Carcinomatous Ulcer, 196— Operability, 198— Early Cancer, 202. CHAPTER X Fibromatosis of the Stomach 214 CHAPTER XI Syphilis op the Stomach 219 CHAPTER XII Various Benign Tumor-producing Lesions of the Stomach. . . 241 CHAPTER XIII Gastric Ulcer 2.50 Roentgenologic Signs of Gastric Ulcer, 252 — The Niche, 252 — Accessory Pocket, 256 — Contributorj'- Signs of Ulcer, 257 — Spas- modic Manifestations: the Incisura, 257 — Spasmodic Hour-glass, 261 — Other Forms of Spasm, 261 — Organic Hour-glass, 263 — Residue, 264 — Gastric Hypotonus, 264 — Acute Fish-hook, 266 — Abnormalities of Peristalsis, 266 — Tender Point, 267 — ^Lessened Mobility, 267 — Value of Sign-groups, 268 — Association of Gas- tric with Duodenal Ulcer, 268 — Carcinomatous Ulcer, 268. CHAPTER XIV Miscellaneous Gastric Conditions 292 Hair-ball, 292— Other Foreign Bodies, 297— Diverticula, 297— Diaphragmatic Hernia-and Elevation of Diaphragm (Eventi-ation), 301— Gastroptosis, 307. CONTENTS 15 CHAPTER XV Page The Stomach of Infants and Children 313 Congenital Pyloric Stenosis, 315 — -Aerophagy in Infants, 317. CHAPTER XVI The Stomach after Operation 319 Jejunal and Gastro jejunal Ulcers, 326 — Regurgitant Vomiting and Vicious Circle, 336 — Recurrence and New Development of Lesions after Operation, 341. CHAPTER XVII Gall-stones and Disease of the Gall-bladder and Liver . . . 349 Gall-stones, 349 — Diseases of the Gall-bladder, 363 — The Liver, 370. CHAPTER XVIII The Small Intestine 374 The Normal Small Intestine, 374 — The Abnormal Small Intestine, 380. CHAPTER XIX Duodenal Ulcer 386 Symptoms, 386 — Pathology, 387 — Technic of Examination, 390 — Roentgenologic Signs, 392 — Concurrence of Diiodenal and Gastric Ulcer, 412. CHAPTER XX Miscellaneous Lesions of the Small Intestine 429 CHAPTER XXI The Large Intestine 434 Technic of Examination, 434 — The Normal Colon, 436 — The Abnormal Colon, 443. CHAPTER XXII Cancer of the Colon 450 CHAPTER XXIII Dwerticulitis. 467 CHAPTER XXIV Tuberculosis of the Colon 481 16 CONTENTS CHAPTER XXV Page Chronic Colitis 486 CHAPTER XXVI Chronic Intestinal Stasis and Constipation 493 CHAPTER XXVII Chronic Appendicitis 508 CHAPTER XXVIII Miscellaneous Lesions and Conditions of the Colon 520 Polyposis, 520 — Anomalies of Migration and Rotation, 521 — Cecum Mobile, 524 — Jackson's ]Membrane, 526 — Transposition, 527 — Intussusception, 528 — Hirschsprung's Disease (Megacolon) and Megasigmoid, 529 — Incompetence of the Ileocecal Valve, 530 — Enteroliths, 533 — Foreign Bodies, 534 — Fistulse, 534 — Rectum, 537— The Colon after Operation, 537. Bibliographic Index 543 Index or Subjects 547 THE ROENTGEN DIAGNOSIS OF DISEASES OF THE ALIMENTARY CANAL CHAPTER I APPARATUS An adequate equipment of roentgen apparatus simplifies and facilitates the examination of the digestive tract and for such purposes can hardly be dispensed with. It is true that in this, as in many other things, the man counts for more than the machine, and the bulk of roentgenologic knowledge has been gained by those who had to content themselves with crude appliances. Yet, modern apparatus saves time and labor, invites thoroughness and lessens the chance of error. The coil, which superseded the static machine, is still used by many for roentgenography and to some extent for roentgeno- scopy. It gives an excellent screen image, but the interrupter, whether of the mechanical, electrolytic or mercury-turbine type, is a frequent source of trouble when subjected to hard usage. In recent years, the coil has generally yielded place to the interrupterless transformer, the development of which has been due largely to American ingenuity. Of interrupterless ma- chines, a number of excellent makes are on the market, and the differences between them are not of great consequence. They are adaptable both to roentgenoscopy and to roentgenography and are dependable and economical in operation. A varied assortment of vertical and horizontal screen- apparatus, tube-stands, automatic plate-changers for stereo- scopic plates, and minor accessory ^apparatus is obtainable. 2 17 18 APPARATUS These accessories are constantly undergoing modification and improvement, so that the operator can easily satisfy his personal preferences and requirements. Extensive and detailed de- scription of apparatus would be superfluous here, but a few remarks concerning equipment may be of practical aid. TRANSFORMER The transformer for the excitation of the roentgen tube does not necessitate the use of a current-interrupter on the primary or low-tension side, as does that of the coil; hence it is com- monly termed an ''interrupterless transformer." Nevertheless, interruptions of the current are made, though on the secondary or high-tension side, by a commutating switch, for the purpose of utilizing a selected portion of the sine- wave, and thus obtain- ing a pulsating unidirectional current. These machines vary in capacity. It is advisable, however, to avoid extremes, as those of medium capacity are best adapted to general roent- genologic work. At present, we are using machines rated at 6 or 8 kilowatts. Transformers are simple, practical, durable and efficient, and obviate the need of a coil and interrupter with their annoyances. They are made to operate on either direct or alternating currents, preferably the latter. The three- wire alternating-current sys- tem makes possible the use of 110 volts through the transformer for screening, and 220 volts for making plates. Operating control-boards and protection screens are supplied with the machines. If Coolidge tubes are to be used, the transformer should be constructed so as to back up a spark of 10 inches or more. This requires a commutating disk of greater diameter than those used in the past, and necessitates an oil-immersed transformer. The rheostat should have ample capacity to pre- vent overheating. VERTICAL SCREEN APPARATUS For a number of years no one piece of apparatus has con- cerne droentgen work miore than a suitable appliance for making FOOT-SWITCH 19 fluoroscopic examinations. Opinions regarding such instru- ments have been diversified, hinging chiefly on the question of protection, and there have been extremists pro and con. The development of such apparatus has been a matter of evolution, with regard to adequate protection, ease of manipulation, ac- cessibility of parts, durability, and avoidance of an awesome appearance. Most of these qualities are embodied in each of the various makes of vertical screen apparatus. In general, such an appara- tus consists of a counterweighted tube-box which can be freely moved laterally and vertically on the frame upon which it is mounted. The box is covered with heavy sheet lead and is provided with a door at the side through which an interchange- able tube-holding board can be taken in or out. A small window in the front of the box, opposite the target of the tube, is covered inside with a thin aluminum filter. Over the outside of the window is placed an adjustable diaphragm, usually of lead rein- forced with brass. The diaphragm may give either a circular (iris type) or rectangular field, the latter being the most gen- erally used. Its operation is controlled by an ingenious mechanism with a handle convenient to the operator's left hand. In front of the tube-box is a high, wide shield, against which the patient stands during the examination. The shield may be of thick, heavy metal with an aluminum or celluloid window, or made wholly of celluloid in a metal frame. The fluoroscopic screen is supported from the tube-box either by cords or by a crossarm with rigid suspension rods. The latter device makes it possible to move the tube and screen in unison, and keep the fluoroscopic field in constant view. A small turntable, upon which the patient stands while being examined, is added to the equipment of some machines, and facilitates rotation for different angles of view. FOOT-SWITCH All screen work is done with current ranging from 1 to 3 milliamperes controlled by a graduated foot-switch. 20 APPARATUS To operate, the main rheostat on the machine is set to the maximum desired for screen work, and this maximum is ad- mitted to the screen tube by the third pedal of the foot-switch. There are two other pedals which admit respectively one-third and two-thirds of the maximum current, the regulation being effected through an auxiliary rheostat to which they are con- nected. We are accustomed to using approximately 3 milli- amperes as the maximum, 2 milliamperes for the intermediate, and 1 milliampere as the minimum. These readings, however, will fluctuate somewhat according to the resistance of the tube. The graduation by the foot-switch permits the operator unassisted to proportion the current to the thickness of the patient and thus to give the intensity of illumination desired. This arrangement diminishes the likelihood of overheating an ordinary tube, and its convenience is obvious. In addition to the current-control a light-circuit is led into the foot-switch and attached to a make-and-break switch which controls the subdued illumination of the room between examinations. This light is also turned on and off by the operator's foot. TUBE-STAND For making plates of the stomach a stationary tube-stand is convenient. A fixed, horizontal, tubular, iron frame carries a vertical stand, which rides on ball-bearings and can be locked at any point. The tube-holder and carriage are counter- weighted and can be raised, low^ered and rotated as necessary. Near the end of the stationary frame a light wooden table is hinged on a w^all-bracket so that it can be folded up. It is fitted with an adjustable wooden plaque for holding the cassette when plating patients in the standing position. By lowering the table and adjusting the tube-carrier, plates can be made with the patient recumbent. TABLE Trochoscopes and combined tables for roentgenoscopic and roentgenographic work are obtainable in various designs. One TUBES 21 of these tables, designed for routine service, suits our own work admirably. The table-top is of standard-make, tunnel type, with cellu- loid window and standard stereoscopic plate-shifting mechan- ism. The top is supported by an iron frame, largely of tubular construction. A vertical tube-stand is carried upon horizontal rods attached to the back of the table, and is fitted with ball-bearings so that it can be easily shifted. By means of a lock it can be fixed in any position. The tube-holder is of the usual type with a lead- glass, bowl-shaped container secured to a metal base-frame, and can be raised, lowered, tilted to any angle or rotated upon its horizontal axis. The table has been further amplified by placing a movable tube-box beneath it for horizontal screen-examinatioDs. The tube-box and adjustable diaphragm are similar to those used on vertical screen-apparatus. The box shifts laterally on a frame, and the frame and box can be moved lengthwise on a tubular track, with ball-bearings for all moving parts. The arrangement thus permits the use of two x-rs^j tubes; one on the vertical tube-stand for making roentgenograms, the other in the tube-box for screen work, the tubes being main- tained at vacua appropriate for their respective purposes. By a device the tube-box carriage and the vertical tube-stand can be linked together and moved in unison, so that the screen-field can be plated quickly by swinging the upper tube into place. TUBES For plate-making various types of ordinary gas tubes, both American and foreign, can be employed. Greater differences as to quality and durability are observed between individual tubes than between types. Preferably they should have a 7- inch bulb and a heavy copper anode faced with tungsten. For screening, we have used water-cooled tubes with entire satis- faction. The reservoirs of these tubes are of extra size, and hold about a pint of water, so that heating is avoided even with 22 APPARATUS prolonged use. They withstand hard service and with reason- able care will last for a considerable time. Recently Coolidge has brought out a tube of extraordinary efficiency. It is exhausted to a much higher degree than the ordinary tube. The cathode is a tungsten filament in the shape of a flat, closely wound spiral, and is heated by current either from a storage battery or a small transformer, with rheostat control. The storage battery can be used whether the main current supply is either direct or alternating, but in the latter case, some form of rectifier is necessary for recharging the battery. The small transformer is of use only with alternating current. Electrons are liberated from the cathode in propor- tion to the degree of heat, and the tube-penetration can thus be controlled with precision. The tube is coming into common use for screening, plating and therapeutic purposes. It is very durable and seems to be ideal. Our own experience with it has been highly satisfactory. INTENSIFYING SCREENS Intensifj^dng screens are distinctly advantageous because they shorten the time of exposure. Fortunately, there are American screens quite as good as the foreign screens, if not better. In using the screen, cleanliness and careful loading, with firm contact, must be observed. The cassette should be of light weight, thin, durable, light-proof and easily loaded. Cassettes made of aluminum are preferable to those of wood. PLATES AND DEVELOPERS The best plates are those which have unvarying uniformity, fair latitude, moderate speed and good keeping qualities and are free from blemishes. Reasonable latitude is desirable in order that slight variation in the time of exposure will not impair the roentgenogram. The greater the speed, the less is this latitude; hence it is better to choose a plate that is neither extremely fast nor extremely slow. Manufacturers recommend PLATES AND DEVELOPERS 23 developers which are best suited for their plates, and their advice should be followed. Questions are frequently asked as to the length of exposure necessary to produce a satisfactory roentgenogram. This depends, as the operator will soon learn, upon the capacity of his machine, the voltage, the milliamperage passing through the tube, the speed of the plate, the tube distance, the density of the part and whether or not an intensifying screen is used. Therefore, the beginner should not hastily blame his equipment nor be surprised at his early failures, for they can be overcome only by experience. CHAPTER II GENERAL TECHNIC In order that comparisons may be made on a uniform basis, the roentgenologist should have a customary routine. While it would be desii'able for all roentgenologists to employ identical methods, efforts in this direction have thus far been fruitless. However, the individual examiner will find it advantageous to choose and follow as faithfully as possible the method which to him seems best. His routine should, of course, be flexible enough to vary in exceptional circumstances. Indeed, some degree of inventiveness and ingenuity is requisite in deahng with extraordinary circumstances, but in forming opinions allowance should be made for am^ departure from the accus- tomed procedure. It should he kej)t constantly in mind that many of the conclu- sions herein stated are based on the routine descrihed. Those who attempt to folloiv this hook should adhere with reasonable fidelity to the technic as related. Otherwise there may he annoying dis- crepancies in the results. On the other hand, it should also be emphasized that rigid adherence to any routine will not alone make diagnoses; that interpretation of findings, which can be learned only by experience, is quite as important as technical methods; and that the beginner must expect at least a few disappointments at first. Preparation of the Patient. — One of the most important roentgenologic signs of a lesion in the digestive tract is deformity of contour, and such deformity may be imitated by the presence of food or fecal material. The stomach, when examined, should be empty; ample time should be allowed for evacuation of the last meal taken prior to the examination, and the patient should abstain from food until the examination is finished. The ma- 24 OPAQUE SALTS 25 jority of our patients come to us directly from the gastroenter- ologist after tubing and lavage, and while as a rule, these latter procedures are not a necessary prelude, they insure a more thorough evacuation of food-bits and secretion in obstructive cases, and clear out mucus and hemorrhagic detritus from the craters of gastric ulcers. If the colon is to be examined by the opaque clysma, the patient should be previously purged with oil or a saline, preferably oil, and should flush out the bowel with a cleansing enema shortly prior to the examination. In exceptional instances where motility is especially con- cerned, as in cases of suspected stasis, a separate examination under the patient's accustomed conditions and without purga- tion, enemas or fasting, may be conducted. Such findings should be compared with each other, and not with those ob- tained after preparatory measures. Opaque Salts. — In the early attempts at visualization of the human digestive tract, bismuth subnitrate was tried. Its occasional toxicity led to some fatalities and it was soon aban- doned. Since then bismuth subcarbonate has been extensively employed. It has been claimed (and disputed) that its alka- linity somewhat depresses peristaltic activity. The oxychloride of bismuth, which is sometimes used, is a trifle lighter than the subcarbonate, and hence a little more easily held in suspension. Peristalsis, as seen with the oxychloride, is perhaps a trifle more active than that seen with the subcarbonate. Both the subcarbonate and oxychloride are harmless even in much larger quantities than ordinarily administered. The oxides of zir- conium (kontriastin) and thorium, and the magnetic oxide of iron have been used to a limited extent. Chemically pure barium sulphate at less than a tenth the cost of bismuth salts is equally satisfactory and is now generally employed. We have adopted it for both the opaque meal and the enema. It must be free from any soluble salts of barium which are toxic; it should be in a finely divided state, and can be obtained in this condition from manufacturers. It is harm- less, tasteless, and does not inhibit or unduly stimulate peris- 26 GENERAL TECHNIC talsis, but is passed through the digestive tract more rapidly than bismuth salts. Attempts have often been made to visualize the digestive canal after inflation with air or gas. Notwithstanding the fact that pronounced lesions have occasionally been demonstrated in this manner, the. method is far less certain than the use of opaque meals and enemata, and hardly deserves serious consideration. Vehicles. — In selecting a medium for the administration of opaque salts, a wide latitude of choice is offered. Any of the commonly used vehicles may be employed with satisfaction, but it is desirable that the mixture shall have the following qualities : 1. It should be palatable. 2. It should be sufficiently viscid to hold the opaque salt in good suspension. 3. It should not be too thick to fill small recesses. 4. It should not unduly stimulate gastric secretion. 5. It should neither accelerate nor retard motility. The vehicles commonly used include water, milk (plain, condensed or fermented), mucilage of acacia, potato-starch, bread-and-milk, corn-starch-pap, gruels and various cereals. Each of these has its advantages and disadvantages, depending on the purpose in view. For the six-hour opaque meal, a cereal, such as one of the wheat breakfast foods, is desirable. At the beginning of the screen-examination, a little plain water and barium (or bismuth) can be given to advantage. By palpation it can easily be shifted into all parts of the stomach, thus out- lining its borders. Being of thin consistency it will enter small niches and ulcer-pockets, and as it does not excite the pyloric reflex can be expressed into the duodenum, thus establishing the site of the pylorus and outlining the duodenal bulb. For complete filling of the stomach to finish the screen-examination and for roentgenography, fermented milk, which may be ob- tained either in bottled proprietary form or can be made by adding culture-tablets to whole milk, is admirable. This is THE ENEMA 27 relished by most patients, holds the opaque salt in good suspen- sion, and does not affect the motor functions. Mucilage of acacia, freshly made from the powdered gum, is effective. It is especially useful in examining the esophagus. Condensed milk holds up barium fairly well and is palatable, but owing to its fat, markedly diminishes motor activity. Thick gruels of wheatmeal or oatmeal are often used in esophageal work. A pap made up either with potato-starch or corn-starch is an excellent vehicle. We have used both extensively, but have of late given preference to the corn-starch because of its more pleasant taste. The starch is obtainable everywhere in pound cartons. To prepare the pap in quantity the following recipe may be used: Nine ounces of corn-starch dissolved in 14 ounces of cold water is poured into 6 quarts of boiling water. Forty-five ounces of barium sulphate is stirred into a thin paste with 20 ounces of hot water; allowed to boil for three or four minutes, and is then added to the starch-pap. The whole mixture is stirred well and allowed to boil for five minutes slowly. After cooling, 3^^ ounce of vanilla extract is added. Syrup of rasp- berry in larger quantity, or other flavoring, can be used as desired. The mixture will keep well on ice for two or three days. On standing a scum may collect; this should be removed. The customary portion for each patient is 12 ounces of the mixture, which amount contains approximately 3 ounces of barium. The Enema. — The essentials of an opaque enema are: 1. That the mixture shall not be irritating to the bowel. 2. That it shall be sufficiently large to fill the entire colon. 3. That it shall be sufficiently ffuid to flow freely, yet thick enough to keep the barium (or bismuth) well distributed. Any of the opaque salts may be used as a base but the inex- pensive barium sulphate is employed most generally. In some instances bolus alba (kaolin) is added, 500 gm. to 3 pints. For mediums, mucilage of acacia, fermented milk, condensed milk, mucilage of tragacanth, starch and other vehicles are employed. Any of these or combinations of them can be used 28 GENERAL TECHNIC satisfactorily. The starch solution has the occasional disadvan- tage of becoming lumpy on standing and thus obstructing the enema tube. A combination of mucilage of acacia, condensed milk and barium (described in the chapter on The Large Intes- tine) makes an excellent enema. Quantities. — The quantity of opaque salts used for the meal by different roentgenologists varies markedly, ranging from 1 to 6 ounces at a single administration, and the total amount of ingesta may be from 6 to 30 ounces. The proportion by weight of opaque salt to medium varies from 10 to 25 per cent. As a general rule, it will be found that mixtures containing less than 10 per cent of the opaque salt, especially barium, are not reliable for visualizing lesions on the screen or plate. There are wide differences among various examiners in the manner and time of observation. One routine frequently em- ployed consists in the administration of a single opaque meal, the phenomena of its progress through the digestive canal being noted at successive intervals by screening and plating. By the double-meal method as used by Haudek,^ which we have preferred to follow, one meal is given chiefly for the purpose of testing motility, and this is followed by another six hours later, at which time the roentgenologic examination is made. The Six -hour Meal. — As employed by Haudek, the six-hour meal was made up originallj' T\-ith bismuth subcarbonate. Haudek' s wide experience convinced him that a distinct residue from this meal in the stomach after six hours was usually of pathologic significance, although, in some instances, he beheved it might result from gastric atony. For four years or more we have used barium sulphate in the meal, and as barium leaves the stomach earlier than bismuth, a residue from the former has even greater import. The various causes of such a residue are hereinafter enumerated. In our habitual routine, the meal consists of 2 ounces of barium sulphate in 4 ounces of cooked cereal, to which a httle skimmed roilk and sugar are added. Objection has been made that in those cases in which the six- hotu- meal has advanced into the transverse colon or splenic THE SCREEN-EXAMINATION 29 flexures it may interfere with the screen and plate examination of the stomach. This seldom happens, and when it does, re- examination can be made after the colon is empty. Personally, we would rather risk the necessity of a second examination than do without the six-hour meal. The principal advantage of the six-hour meal is the saving of time to the examiner and of annoyance to the patient entailed by repeated screening or plating. It not only shows whether the stomach is able to clear itself within the given time, but also by its position and distribution in the intestine gives gross information as to intestinal motility. Its use is based on the theory that the exact emptying-time of the stomach is less im- portant than the fact that a liberal time-limit for evacuation is or is not exceeded. It is quite possible that a more refined study of the gastric clearance-time will be of greater diagnostic aid. In estimating the significance of slighter variations in the time of emptying, however, the numerous physiologic and pathologic factors affecting motility will need to be carefully weighed. The Screen-examination. — We believe that the advantages of the screen in the examination of the digestive tract can hardly be too strongly emphasized. Only by its use can exact informa- tion be obtained as to mobility and flexibility, the phenomena of peristalsis and antiperistalsis, the nature and permanence of irregularities of contour, and the effects of palpation, respiratory movement and varying positions. All changes can be seen at every instant, in the order of their succession, at any desired angle, and in these respects a few minutes of screening is equiva- lent to hundreds of plates. The screen also affords convenient opportunity for inspecting the chest and abdomen for numerous lesions which may affect the digestive tract reflexly. A very necessary part of roentgenoscopic technic is the proper preparation of the observer's eyes. To secure a maximum of dark-accommodation and retinal perception the examiner should be in the darkened screen-room for ten or fifteen minutes before beginning his work. The maintenance of this accommo- dation is furthered by the use of subdued illumination whenever 30 GENEEAL TECHNIC light is required at intervals, and the use of smoked glasses during these periods. For the room-light a color in the red portion of the spectrum is preferred,^ and is best secured indirectly by reflection from a tinted ceiling. The walls may be finished in the same color. Male patients should be stripped to the hips. Women may be allowed to wear a kimona of thin material, but this should be devoid of buttons or ornaments, and the underskirts should be dropped below the abdomen. Palpatory manipulation is a very essential part of the roent- genoscopic procedure and should never be omitted. Not infrequently the patient, made apprehensive by his somber surroundings, tenses his abdominal muscles so that palpation is ineffective. This difficulty can usually be overcome by quiet- ing the patient's fears. He should also be required to bend his head forward, drop his shoulders, allow his arms to hang hmply, and breathe deeply with open mouth. Mindful of the numerous disasters which have befallen the pioneers in roentgenology, many have a lively sense of possible danger to the operator from the use of the screen. We can say only that after several thousand examinations with the appa- ratus heretofore described, we have experienced thus far no evil effects. Haudek also states that he has made 12,000 screen-examinations without sustaining injury. The tendency of the rays to produce sterility is well known, and perhaps may not be overcome by the usual protective measures if exposures are long or frequently repeated. Certain blood-changes also have been noted by Portis and others. But workers with the ray who take the customary precautions are not likely to develop roentgen dermatitis or carcinoma. The operator should endeavor to secure the greatest amount of protection consistent with efficiency. He should wear gloves of leaded rubber or other opaque material, and should protect the genitalia with an apron of leaded fabric. If, with all these measures, he is still dubious of his safety, he should test for leakage with radiographic films, plates or pastilles. Case No. A Sex - Age.-. [ Total Acidity Free Hel. Comb. Acids [ Lactic Acid Food remnants Oppler-Boas Yeasts Sarcines HabituB N. E. Residue 0. 1. 2. 3. 4. Head I. C. H. F. T. C. S. F. D. Peristalsis Nor. Active Vigorous Not Seen Bulb Seen Size 1 2 3 Reg. Irreg. Duod. Visualized Immediately Delayed Not Seen Antrum Seen Regular Irregular Not Seen Mobility Free Slightly Fixed Fixed Filling Defects Card Media. Pylorica GO. Incisura Card. Media. Pylorica Transient Hour-Glasa Stomach Organic Intermittent Tender Point L. C. Duod. G. B. McB. Niche Diverticulum . Epig. Increased Severity... — radiates-.. Trouble— Esopliagus, Stomach, Bowels, Duration _ Pain— Slight, severe, dull, gnawing, fullness, distress, where - continuous „,_ intennittent - — frequency... after meals _ ....- „ „ ™ night, time aggravated by food, quantity, solid, acid, fats, fibrous; relieved by food, soda, belching, vomiting. Stomach feels better full, formerly, now; empty, formerly, now. ,. duration — .- any time.- Vomito— Rarely, occasionally, often.... blood, Sour Stomach -Gas Jaundice, si., distinct Cramps Morph. B. M.— Regular, constipation, diarrhoea, black, clay, blood, mucus. Typhoid „ Weight— Increasing, stationary, off _....-,Ibs. in....-^™^ — Reduced diet - - - General Condition— Good, fair, poor, weakness, emaciation, pallor, appetite. — ■ Operations: mucus, bile, forced, delayed, tube- — Fig. 1. — Scratch sheet for fluoroscopic findings and clinical data. p bo > 5^'! MS (u 2 •as >• 2 o < z H w w H s <: Id .2 ^ Q3.S' cat. 2c |3^ >, tjJ 9 H ^" fe -" PL, O z 1 u > c 1 2 o 1 35 2 >■ > ^ u H o < H u u H s < O f/) & a. u > d ^ N ri m M M « s J X t^J M> Q 2" OJ z ^S 6:^ a r^^ w> a. S< J -<< Z o Z T c 00 u ^ S a) V t« a S z 01 C firt tn a SI O 1 H 4) > 3 1 < Z o i_ o < 11 < 1 cJ 5 o o t. «*-! < u a; oa 5 J3 3 cu 0. o u U 2 en D 9 > H fi H u u <: u Z a. q: a, f- < tn a. OO « M M M DIGESTIVE TRACT SHEET, X-RAY. (l)AbsceBs (2)AdheBion OjAnomaly (4)Atony (B)Cnnccr (6)D)latation (7) Dia placement (8)1 (9)Enteroptosis (lO)Fistula (Il)PoreignBody {l2)Hcmi(idiBphr. (ia)Hira<:!isprung's Dis. (14 (ISjlMompBlencG (16) Indc terra inale (ITjJnckaon'fl M. (l8)Kink (l9)Negativo (^9)^ (21)Nonnal (M)Oba true Hon (23)Ptosia (24) Redundancy (£6)Spaflin (26)Spaatid^ (28)Stcnosis (29)StrEcturo (aO)SyphiN3 (3l)Transpoaition (32) Tuberculosis (33)Tumor (35) Cardiospasm (3S) Gall -a tones (37)FiJlingQefccC (A)E3ophnEU3 (B)SWmacl. (C)Cardia (D)Medii (E)PaR pylor. (DPylor (G) Greater cur V. (H) Leaser curv. (I)Duodonum (J)Je]unum (K)neam (L)Ileo-cecal Val (M)Colo.i (N)Cocam (O)AscendirB Colon (P)Hepatk Flexure (QjTransverae Goli (B)Splcnic Fiexuro (S) Descending Colon (DSiemold Floxure (U)RcctDm -hHyperlonic oOrtbotonic yllypoton DEFECTS -cCard. mMed. ppyl. gGre d. raMed. ppyl. nNnrrow bBroad dD (c)Completenflor six hra. ntncomplet rRapid sSloiv TFrcqucn 1 PHOTOGRAPHS.-yYf? Fio. 2. — Perm anon I PLATES 31 As for the patient, his safety is fairly assured by the protect- ive features of the apparatus and by the brevity of the exami- nation. With reasonable care as to the character of the tube (say one backing up 4 to 6 inches on the parallel spark-gap at 3 milliamperes, 110 volts), no patient will be harmed. Two or three milliamperes on the tube-circuit will usually suffice, but for thick patients 4 or even 5 milliamperes may be required. The time necessary for roentgenoscopic investigation will not usually exceed ten minutes. Occasionally, however, when peristalsis especially is to be studied, a little more time will be required. By judicious use of the foot-switch, turning on the rays only as needed, the aggregate of exposure can be consider- ably lessened. Plates. — After the examiner has acquired some proficiency with the screen, he will occasionally be inclined to dispense with plates, especially in the apparently normal cases when the patient is thin, the screen image sharp, and the clinical history negligible. But it is never wholly safe to do this, and at least two or more plates should be made in every case. Plates show minute deformities which cannot be detected on the screen, may be studied at leisure, and may be filed for future reference. When the result of an examination is indecisive, an increased number of plates may give further assistance. They can be made either in rapid succession or at longer intervals. Multiple plates are especially useful in studying the stomach, the pyloric region and the duodenum, when a lesion is strongly suspected but cannot be determined in the ordinary way. Lewis Gregory Cole,^ has elaborated the multiple-plate method and applied to it the term "serial radiography." He employs a table equipped with a plate-changing device beneath the table-top which permits the making of multiple plates with- out disturbing the patient. In published discussions of gastric roentgenology it is occa- sionally intimated that the screen and plate are rivals. This is a misapprehension. Rather should they be Considered as indis- pensable complements to each other in every complete exami- 32 GENEEAL TECHNIC nation. Personally, we have always used both methods, and would fear to discard either. Cases are frequently met with in which sometimes one, sometimes the other, alone elicits the information sought. The positions employed for particular purposes, suitable sizes of plates, and other details are described elsewhere. We find some advantage in the intensifying screen and use it regu- larly. But as to this and many other technical refinements, such as the tube-distance, the milliamperage, length of exposure, etc., no hard and fast rules can be laid down, and every roent- genologist determines these things according to his^ own judg- ment and the character of his equipment. I Stereoscopic plates are striking in their appearance and are somewhat more informative than single roentgenograms, but they are rather superfluous if a careful screen examination is made. Roentgen kinematography has been tried in a few instances with fairly satisfactory results. It is not practicable as a routine and does not possess any extraordinary advantages over roent- genoscopy. Records. — The benefits derived from a systematic record of case observations more than compensate the examiner for the time required to register his findings, no matter whether he sees 1 or 20 cases a day. Such a system not only keeps the material in shape for ready comparison, but promotes orderly thoroughness of observation, thus preventing the errors often consequent on haphazard investigation. Besides the usual series of card indices, our own records con- sist of a fluoroscopic sheet, a permanent record sheet and a recapitulation sheet. The sheet which is used in the screen- room (Fig. 1) has a brief form for the sahent facts of the chnical history and the gastric analysis, besides blanks for entry of the screen findings. Most entries can be made simply by checking or underscoring the item. In the blank square the examiner notes his diagnostic opin- ion or the most significant facts. Subsequently, the notations SiiEET A. Page DIGESTIVE TRACT, X-RAY — ^ — — ESS T — ! 2 s 1 S 1 1 1 1 1 1 3 14 15 ii. Ill ■ — J f T If J 1 1 I 1 III 1 ' ^ 3 4 5 6 7 e 9 10 II 12 13 14 15 16 17 17 IB 19 -. 19 20 . ^21 22^ --JL 23 24 24 25 25 Fig. 3. — Recapitulation sheet, DIGESTIVE TRACT. X-KAV Sheet B. Page... "fflSf r ~ ■7^ 5 % " "ESS ^ T? ■b; s? = 3 OPERATIVE P,»D,»OS ."'"•««' 7 [ 1 i i I 1 1 1 . ! t 1 1 J 1 i 1 ! 1 1 1 ] 1 2 3 4 5 5 6 7 7 8 8 9 9 10 10 II II 12 12 13 13 14 14 15 13 16 16 17 17 18 18 19 19 20 20 21 21 22 1 22 23 23 24 24 25 ~ - 25 Fia. 3.— Recapitulation sheet contiaued. REFEEENCES 33 on this sheet are compared with the plate findings, and a final report is entered on the permanent record sheet. The permanent record sheet may seem rather elaborate and cumbersome, but it can easily be filled out, nearly all the data being entered by underscoring (Fig. 2). Some of the items are seldom used, but have been included in order that the record may cover a wide range of possibilities. The diagnostic division provides for an abbreviated cipher of the diagnostic opinion. Pathologic conditions are denoted by numbers and the parts involved by capital letters. By combining a number and a letter the diagnosis can be condensed within small space. Before each item in the body of the sheet is a small letter. If the item is underscored, this letter is entered in the corre- sponding column of the recapitulation sheet. This is a device of H. S. Plummer's and is applied to many of the records in the Mayo Clinic. The recapitulation sheet facilitates a rapid summary of case findings (Fig. 3). By tracing a single column on this sheet the percentage of occurrence of a given observation can readily be found; thus also the incidence of various combinations can be determined quickly. REFERENCES 1. Haudek, M.: "Die Technik und Bedeutung der rad. Motilitats Prufung." Ver. xxix Deutsch. Kong. f. Int. Med. J. F. Bergmann, Wiesbaden, 1912, 143-148. 2. Petit, H.: "Extraction rapide des projectiles de guerre par le chir- urgien seul a I'aide de la lumiere rouge et des reperages suc- cessifs sur I'ecran radioscopique." Paris Medical, 1916, vi, 76. Abst. Jour. A.M. A., 1916, Ixvii, 707. 3. Haudek, M.: Personal communication, May, 1913. 4. PoRTis, M. M. : "Blood Changes in Workers with the Roentgen Ray and Apparatus for Protection." Jour. A.M. A., 1915, Ixv, 20-21. 5. Cole, L. G.: "Serial Radiography in the Differential Diagnosis of Carcinoma of the Stomach, Gall-bladder Infection, and Gastric or Duodenal Ulcer." Arch. Roentgen Ray, 1912-13, xvii, 172-181. 3 CHAPTER III INTERPRETATION The roentgenologic examination of the digestive tract is not a mysterious art requiring extraordinary talents. Neither is it a simple diagnostic method which can be learned in a day. Its successful employment demands industry, experience, judgment and care, just as any other procedure in medicine — no more, but no less. The roentgenologist has to deal with shadows and shadow defects as signs of normal, reflex and pathologic conditions. These signs vary in their frankness and degree. Some of them are more or less direct, showing as definite and permanent additions to or subtractions from the normal contour. Others are rather indirect, revealing only perversion of function, and the seat and nature of the pathologic change can only be inferred. Indirect signs have different values at different times, singly and in combination. It is impossible to put into words the exact worth of these signs in their fluctuating grades. That can be learned only by actual experience with adequate material and by following cases to the operating room and the post- mortem table. The most painstaking description of a lesion is not equivalent to seeing it oneself in the opened belly, and only by this sort of vision can one obtain a proper understanding of roentgen diagnosis or confidence in the method. Familiarity with reflex conditions and the protean forms of spasm is abso- lutely essential. The maintenance of a conservative attitude in this work is especially necessary, and, at the same time, especially difficult. The veteran roentgenologist, as well as the novice, is tempted to see too much rather than too little. Once the observer has acquired some familiarity with his work he will find that direct 34 INTERPRETATION 35 signs of lesions will be manifest quickly or not at all. He should, of course, take sufficient time to examine his patient in all the routine particulars, but unduly prolonged examinations dull the sense of proportion, and a perfectly innocent stomach may seem guilty to ungenerous scrutiny. Failure to discover a lesion by the roentgen-ray is often pardonable, but the subjection of a patient to needless operation upon trivial roentgen evidence alone, is not readily forgiven by those concerned. Common sense has been defined as the ability to distinguish the important from the unimportant, and in this meaning every diagnostician has an abiding need of common sense. There are two very practical checks against error which the examiner may employ, namely, reexamination and the giving of antispasmodics in cases in which spasm is suspected. In all doubtful cases one or both of these tests should be applied. By any means of diagnosis, exceptional cases are found which are quite at variance with the common rule. Naturally, these are tremendously impressive, so impressive that it is difficult thereafter to avoid being unduly alert for them. The only safe way is to hold fast to the rule and regard exceptions with doubt. The statement of W. J. Mayo, that only about one person in ten with gastric symptoms has a gastric lesion, is w^orth remem- bering. The beginner is likely to be disappointed by the multi- tude of cases in which he is unable to find any roentgenologic evidence of a gastro-intestinal lesion, and will often feel that he is at fault. But besides a percentage of patients with such lesions which no one is as yet able to discover, there will be a much larger number of patients whose symptoms are produced by conditions outside the digestive tract. Extrinsic conditions giving rise to abdominal symptoms are sometimes discoverable during an examination of the digestive tract. The observer should keep in mind the possibility of aneurysm, pleural, pul- monary, mediastinal and cardiac disease, diaphragmatic hernia and eventration, subdiaphragmatic abscess, gall-stones, renal, 36 INTERPRETATION ureteral and vesical stones, enlargements and tumors of the kidney, spleen, liver and pancreas. He should watch, at least casually, for vertebral disease, for fractures and deformities, in short, for every abnormality, and report it whether it may or may not have any relation to the patient's complaints. To be sure, gall-stones and stones in the urinary tract are likely to be overshadowed by the barium and discovery of them will be only fortuitous, but if their presence is suspected they should be looked for at a separate examination. The hazard attending diagnosis based exclusively on plate findings, especially when the plates are few in number, deserves particular stress. Plates show but a single phase and a single angle of view. Artefacts which may be produced in countless ways, the appearances which are physiologic and the signs which are pathologic cannot be distinguished from each other with any degreee of certainty if only one or two plates are made. Yet, when used as a complement to the screen, the plate may give substantial aid, and it should be employed in that manner only. How shall the examiner report his findings? How far shall he go in translating them into terms of diagnosis? This depends on his relations to the clinician, the acquaintance which each has with the other's province, and whether the work is done in an organized institution or independently. An ultra- conservative method would be simply to report the bare facts of the observation — a shadow here, a filling-defect there, a residue, or whatever is seen — and leave all diagnostic interpre- tation to the clinician. To be wholly satisfactory this would necessitate an extent of organization which has not yet been reached, and few clinicians understand the precise significance of roentgenologic indications. For this reason verbose reports of all the roentgen phenomena observed in a given case are worse than useless because they may mislead the clinician, and a simple statement of the conclusions formed would be far better. Another way would be for the roentgen examiner to restrict his diagnoses to those cases in which the roentgen signs alone are pathognomonic, or practically so, such as the niche of gastric INTERPEETATION 37 ulcer or the filling-defect of advanced carcinoma. Certainly he can perform valuable service in this manner, but what of the cases in which the roentgen signs, though definitely abnormal, are not definitely diagnostic, and yet may corroborate a clinical picture? As a concrete illustration may be cited the occurrence of a six-hour gastric residue with apparent cutting-off of the prepyloric region, phenomena w^hich are definitely abnormal but which are alone not sufficient to maintain a diagnosis either of cancer or ulcer. The roentgenologist from his observations alone can say only that a pathologic condition exists. Yet these signs when combined with the clinical facts, may point rather directly to the nature of the lesion. Extreme limitations of diagnostic latitude are not truly con- servative, but are reactionary. They would seem to rest on the assumption that a diagnosis is a statement of fact, not an expression of opinion. Yet every diagnosis implies the exercise of opinion and the rendition of judgment, and even the patholo- gist, who has the last word in this respect, is not infallible. It is less important that we be solicitous regarding artificial rules which we may impose on ourselves — as though a game were being played — than that we remember the rights of the patient. It is his just due that all features of his condition shall be properly weighed, not only separately but also in their relations to each other and as a whole. Many roentgen mani- festations are as yet intelligible only in the light of clinical and other facts. It follows, then, that somewhere and somehow the roentgeno- logic findings should be correlated with the clinical as well as all other data. How shall this be done? 1. It may be done by the clinician. This implies a broad knowledge on his part of roentgen diagnostics, which can be acquired only after years of experience. Reduced to practical terms it means that it would be better for the clinician to make his own roentgenologic examinations. Possibly th s is the ultimate solution. 2. The clinician and the roentgenologist may make a 38 INTERPRETATION joint examination, or go over their respective findings at a personal conference. Active co5peration would certainly be preferable to the customary passive combination of their work. 3. The roentgenologist himself may correlate his findings with the clinical and other data. Under present conditions this is perhaps the most practical and efficient method. As a medical man he should have little difficulty in refreshing his knowledge of symptoms, laboratory reports, and, at least gross, physical signs. By so doing, his work will rest on broader foundations, and not only will his interpretations be tempered by the clinical data, but he will also acquire a more exact sense of purely clinical values. The clinical data may be used: 1. In combination with the roentgen observations to form a general complex on which the diagnosis is based. 2. As an index of the possibilities and probabilities in the case at hand and thus direct the examiner's particular atteiition to them. 3. To prevent too hasty judgment, as in those cases in which the roentgen signs do not harmonize with the clinical facts, and in which a more careful review of these signs or a reexami- nation may show them to have been mistaken. [Fear has been expressed in some quarters that clinical data may unduly prejudice the roentgenologist and give bias to his verdicts. This could occur only on condition that his experi- ence has not been sufficient to teach him the relative value of signs, either roentgenologic or clinical. To sum up, the essentials for satisfactory roentgen diagno- sis are faithfulness to an orderly routine, careful observation, reexamination in doubtful cases, cautious and correlated inter- pretation, and last, but not least, a willingness to admit when- ever it is true, that the findings are inconclusive. CHAPTER IV THE ESOPHAGUS Technic. — While in most cases no special preparation of the patient is necessary for an examination of the esophagus, there are cases of obstruction in which retained food or secretion may interfere with the examination or impair the accuracy of its k\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\;;\\\\\\\V\\\V'.\'- Dorsjl ^,rrT-_ Fig, 4. -Cross-section diagram showing position of the esophagus relative to other organs in the oblique view. results. Whenever such conditions are suspected it is advisable to have the gullet cleared out either by the voluntary efforts of the patient or by tubing and lavage. Standing with his back to the tube and with the screen against his chest, the patient should first be given a general survey in the anterior position. With the diaphragm widely extended, the entire chest should be inspected, attention 39 40 THE ESOPHAGUS being given to the supraclavicular regions, the lungs during forced respiration, the excursions of the diaphragm, and the size and position of the heart and aorta. Fig. 5. -Screen examination of the esophagus. Patient in right anterior oblique position. ^The patient is then turned to an angle of about forty-five degrees so that his left scapula is directed toward the tube, while the screen hangs over his right chest. In this position, the right anterior oblique, the rays pass through the patient obliquely, as shown in the cross-section diagram (Fig. 4), and TECHNIC 41 the photograph (Fig. 5). The exact angle desired can rarely be obtained beforehand, but, looking on the screen, the observer can rotate the patient slightly in either direction until the greatest space is attained between the shadow of the vertebral column behind and that of the heart and aorta in front. The horizontal leaves of the diaphragm are extended to their limit, while the vertical leaves are approximated until only the esoph- ageal region is in the visible field. Screens of average size :.>r-^ I- - TD'- .^ i^-'.. q; •> '(■■■' 1 ■"■■ -^:. ,1 T , ■4. ■■■■■ ■■ -Q ■-A- a:\ ■v^.: Fig. 6- — Diagrammatic view, right anterior oblique position. space. A, A, retrocardiac will not accommodate the whole extent of the esophagus, and hence require raising and lowering to cover the entire course. Besides, for clear vision and to avoid distortion, it is better to have a small field with the tube and screen in the plane of any point which is to be closely scrutinized. After the patient is satisfactorily posed he is given a barium- acacia mixture, a teaspoonful at a time. This is prepared by mixing four parts of barium sulphate with one part of fresh mucilage of acacia, as described by Hirsch,^ who, however, prefers bismuth instead of barium. When first mixed it is 42 THE ESOPHAGUS rather dry and granular, but by continued stirring becomes smooth and homogenous. A total of 2 to 4 spoonfuls is all that is necessary. The resulting mass is exceedingly viscid. It descends the esophagus slowly and tends to coat its walls .'Fig. 7.— Patient in right anterior oblique position for roentgenography of the esophagus. throughout. Each bolus is followed in its progress down- ward. For additional observation the patient drinks a cupful of bariumized gruel (2 ounces of barium sulphate in 3 or 4 ounces of a thin gruel of any breakfast cereal). This can be TECHNIC 43 swallowed in larger quantities than the acacia mixture and shows the distensibility of the esophagus somewhat better. If the esophagus is markedly dilated above an obstruction, greater amounts of bariumized gruel or corn-starch-pap are given to show the extent of dilatation. / Fig. 8. — ^Position of patient for roentgenography of the epicardia. A small cone should be used to secure good definition. In the right anterior oblique position, the esophagus, with the exception only of its short subdiaphragmatic portion, can be studied to best advantage. Particular attention should 44 THE ESOPHAGUS be paid to the retro-cardiac space, the clear area lying between the spine and the heart and large vessels. Encroachment upon this space should suggest the possibility of an aneurysm or mediastinal tumor. The drawing illustrates (Fig. 6) the nor- mal relations. The anterior position, the patient facing the observer squarely (or at a very slight angle) is desirable for inspection of the subdiaphragmatic portion of the esophagus and also for determining the position of lateral diverticula. In making roentgenograms it is better to select that position which during the screen examination showed the conditions to best advantage. For the oblique view the plate, taking the place of the screen, should have the same degree of obliquity (Fig. 7). Plating in the anteroposterior view (Fig. 8), with the patient's back against the cassette, is advantageous for show- ing lesions of the epicardia. Plates 11 by 14 inches, or 14 by 17 inches, should be used with the intensifying screen, and the tube at a distance of 20 to 30 inches. By using a small cone and small plate, lesions which have been located exactly can be shown with better definition. Many prefer to make plates with the patient recumbent, and we often make them in this way. Variations of technic, both in screening and plating, can be improvised to suit the circumstances of the case. The left posterior oblique position, which is the reverse of the right anterior oblique, and the posterior position, the patient facing the tube, are occasionally employed. Lateral positions, either right or left, are sometimes satisfactory if the patient be not too broad-chested. Different media may be used, such as fermented milk, bread- and-milk, or any sort of porridge. The use of barium or bis- muth in capsules for determining obstruction is not advised. Capsules, whether large or small, behave as foreign bodies in the esophagus, are swallowed wdth difficulty as a rule, and may lead to an erroneous diagnosis of obstruction. In 1912 Myer and Carman- demonstrated the persistence of dilatation years after symptomatic cure of cardiospasm. TECHNIC 45 They employed for the demonstration a thin rubber bag tied over the end of a rubber tube. The bag-tipped tube was passed down to the cardia and then filled with a bismuth mixture injected through the tube by a syringe. By this means the dilatation could still be observed, both on screen and plate, though obstruction had ceased. Later, Bassler^ made use of the bag-tipped tube, which was passed into the stomach, filled with water, and pulled up into the cardia, thus blocking it. The esophagus above it and outside the tube was filled with a bismuth suspension in order to de- termine the presence of irregularities and lesions in esophagi which were not sufficiently stenosed to show signs with the ordinary technic. The method occasioned considerable dis- comfort to the patient and caused retching and regurgitation. The bulkiness of the bag and tube made it difficult to pass through small strictures and, on the whole, the procedure was unsatisfactory. Crump^ employs sausage-skins, as cleaned and prepared for packing houses, which he keeps in a solution of 1 per cent, liquor formaldehyd and 10 per cent, glycerin. The distal end is tied with a piece of silk floss so as to make a bag. The proximal end is slipped over a rubber tube and tied. The empty bag is practically only a string, and, with the aid of a little water, is swallowed by the patient, after cocainizing the pharynx if necessary. It is then ffiled through the tube from an irrigator with a bismuth emulsion and the roentgenographic examination made. The skins are easily obtained and it is claimed that by this method the exact extent of involvement can be seen, and early as well as late lesions can be outlined. It is stated also that it is especially applicable to non-stenotic conditions. In many instances it is advisable to supplement the esoph- ageal examination with an examination of the stomach to elucidate the symptoms complained of. In this event the patient should have the usual preliminary preparation for gastric examination and should be examined in the horizontal 46 THE ESOPHAGUS position, either supine or prone, or even in the Trendelenburg position, for lesions high in the cardiac portion of the stomach. The roentgenologist must expect frequent negative results, even in patients whose history is fairly emphatic. Some of these are perhaps merely neurotic; in others the trouble is spasmodic and intermittent, and in these an examination is usually negative unless made during an attack. Repeated examinations are often necessary to show intermittent stenotic conditions and to differentiate them from organic and permanent obstructions. Interpretation of esophageal findings, unless they are extra- ordinarily typical, should be cautious. If the examiner is not thoroughly acquainted with the clinical facts in the case, he had better report simply what he sees without atlbempting to translate his observations into a diagnosis. He may say, for example, that obstruction of a certain degree was noted, with or without irregularity of contour at a certain point, or report whether or not there is evidence of a lesion outside the esophagus. The information may be associated by the clinician with his own data and a conclusion formed. This caution is necessary because of the frequent roentgenologic similarity of various esophageal lesions. ANATOMICAL MEMORANDA Directly after its beginning (the introitus) at the cricoid cartilage, the esophagus swerves to the left so that it projects slightly beyond the left border of the trachea. Above the bifur- cation of the trachea it is pushed to the right and somewhat posteriorly by the aorta. Passing behind the beginning of the left bronchus it descends with the aorta which it half entwines so as to lie in front of the aorta just above the diaphragm. Running obliquely to the left, it passes through the diaphragm at the hiatus esophagi, which is about at the level of the tenth dorsal vertebra, and thence continues very obliquely to the left into the stomach. The average total length of the esophagus is about 25 cm., of which 3 to 5 cm., the epicardia, lies below the THE NORMAL ESOPHAGUS 47 diaphragm. The caliber is somewhat irregular, one investi- gator having noted thirteen shght constrictions in its course. The anatomical points of narrowing that are of chief importance are as follows: 1. At the introitus. 2. At the aortic arch. 3. At the crossing of the left bronchus. 4. At the hiatus esophagi. 5. At the cardiac opening. The entire epicardia is distinctly narrower than the rest of the esophagus. THE NORMAL ESOPHAGUS AS SHOWN BY THE ROENTGEN-RAY Movements. — The act of swallowing, as seen with the x- ray, may be divided into two phases, a pharyngeal and an esophageal. In the first phase the bolus is passed back into the pharynx by the tongue, the intrapharyngeal pressure is increased by contraction of the muscles of the pharynx until the introitus relaxes, and the food is forced into the esophagus. In the second phase the bolus passes rapidly down the esoph- agus to the cardia, is held there momentarily, and then enters the stomach. The rate and manner of descent vary consider- ably with the consistence of the bolus, its size, form, taste and temperature. The time required to complete the act of deglu- tition varies all the way from two seconds to eight or ten. Fluids descend quickly, while solids travel slowest. Thin fluids go down in an almost continuous stream; thick fluids and semi- solids are broken up into detached finger-sized masses. The latter, as a rule, hesitate at the narrowings mentioned, espe- cially at the introitus, the crossing of the left bronchus and the cardia. According to some observers, the delay at the cardia consumes about half of the total time required in a single act of swallowing. Peristalsis. — The fluidity of the media customarily em- ployed, the rapidity of the act of deglutition and the numerous 48 THE ESOPHAGUS anatomic irregularities of the esophagus combine to make the detection of peristalsis difficult. The propulsive effect of pharyngeal constriction at the commencement of deglutition and the influence of gravity, especially as shown by the behavior of fluids in the esophagus of a standing patient, add to the com- plexity of this function and the difficulty of its analysis. How- ever, esophageal peristalsis is frequently observed under both normal and abnormal conditions. According to Holzknecht,^ the peristaltic wave occurs as a constriction ring about 1 cm. broad, driving the ingesta before it. Its speed has been stated as 1 inch per second. Like that of the stomach, peristalsis of the esophagus is subject to numerous normal and abnormal variations in force and frequency, but aside from the exaggera- tion of peristaltic activity seen in stenotic conditions, cardio- spasm, for example, and reverse peristalsis as noted in obstruct- ive cases, these variations are seldom seen or regarded. THE PATHOLOGIC ESOPHAGUS AS SEEN WITH THE ROENTGEN-RAY Displacem,ent. — Displacement of the esophagus in its course may occur as a result of aneurysm, pleural, pulmonary or medi- astinal inflammations, mediastinal tumor, substernal thyroid, vertebral diseases or deformity, or cardiac enlargement. Dis- placement by an intrinsic lesion is relatively rare, although a filled diverticular sac may push the esophagus aside. Deformity of Contour. — Irregularities of contour may be produced either by extrinsic or intrinsic conditions. Localized filling defects may result from the pressure of an aneurysm or mediastinal tumor. Retained food-bits in obstructive cases may produce irregularities resembling those of a new growth. The principal intrinsic lesions which alter the esophageal out- line are carcinoma, benign stricture, cardiospasm and diverti- culum. Unless there be rather marked stenosis, minor inden- tations of the esophageal wall wdll hardly be visualized during the brief transit of opaque media. In any event, the numerous slight normal irregularities must be borne in mind. The deform- OBSTRUCTION 49 ity of contour produced by a diverticulum, showing as a pouch- like addition to the esophageal lumen, can hardly escape notice. Obstruction. — Stenosis is evidenced by retardation of the opaque medium in its passage through the esophagus, by visible narrowing of the lumen, sometimes by evident dilatation above the strictured area and occasionally by exaggerated or reverse peristalsis. The degree of retardation will depend somewhat upon the fluidity of the medium employed as well as the tight- ness of the constriction. Opaque capsules should not be used, for reasons previously mentioned. In seeking for evidences of obstruction, regard must be had for the slight delay often noted normally at the introitus, the left bronchial crossing and the cardia and for physiologic factors affecting the rapidity of de- scent. With high-seated stenosis, regurgitation of the medium may hinder visualization. The commonest extra-esophageal causes of obstruction are aneurysm and mediastinal inflammation or tumor. Other extrinsic conditions sometimes causing compression are sub- sternal goiter, vertebral lesions, aortic dilatation, tuberculous glands and enlargement of the heart. Compression stenoses almost always affect the mid-portion of the esophagus. When viewed in the oblique position the encroachment of an aneurysm or aortic dilatation upon the retrocardiac space and its expansile pulsation make the diagnosis possible. Vertebral deformity, substernal goiter and cardiac enlargement show roentgenologic- ally. The roentgenologic evidences of mediastinitis, mediastinal tumor and tuberculous glands are less obvious, but the increased density without expansile pulsation is suggestive. Compression stenoses are apt to be associated with displacement of the esoph- agus, and this fact is important in differentiating them from lesions of the esophagus itself. Obstruction due to outside pressure, as by an aneurysm, is less marked than obstruction from an intrinsic lesion. Some of the intrinsic causes of obstruction are cardiospasm, carcinoma, diverticulum, benign cicatricial strictures, foreign bodies, polypi and reflex spasm. To these might be added the 50 THE ESOPHAGUS rare cases of abscess (as from a foreign body), syphilis, tuber- culosis and actinomycosis. A large diverticular sac when filled may exert sufficient pressure to obstruct the esophagus considerably. It is noteworthy that the patient's dysphagia is often out of proportion to the roentgenologic signs of obstruction. With fluids or even with porridge there is often seen onl}^ shght delay or none at all. Barclay^ sometimes gives such patients dry bread crumbs or crusts in order to excite spasm, and then follows with the barium mixture to show its seat. Dilatation. — More or less dilatation is a common sequel of an obstruction. The most extreme dilatation is seen in cases of cardiospasm, where the esophagus may attain a breadth of three fingers or more. Dilatation above carcinomatous steno- sis is commonly less marked than above benign obstruction. A small, contracted, carcinomatous, syphiUtic or high hour-glass stomach may cause dilatation of the lower esophagus by the backing up of the gastric contents. The dilated esophagus consequent upon obstruction, espe- cially that due to cardiospasm, often contains a quantity of fluid secretion through which the barium falls slowly, often in a winding manner, at first suggesting the irregular lumen of an esophageal carcinoma. Continued filling will indicate the condition. In such cases, evacuation with the stomach-tube and reexamination is advisable. CARDIOSPASM The chief roentgenologic characteristics of typical cardio- spasm are the blunt or regularly conical obstruction at or near the cardia, and the secondary dilatation of the esophagus above it. The smooth, symmetrical termination of the shadow, usu- ally at the hiatus esophagi, less frequently at the cardia, is rarely seen in any other condition. The dilatation is often extreme, involving almost the entire esophagus. It may thus attain a capacity of a pint, or even more. In some cases, the CARDIOSPASM 51 dilated, sac-like esophagus may contain much fluid through which the opaque meal falls in blobs. The dilated fluid-filled esophagus is occasionally visible at the side of the spine, on the screen before giving the barium. The upper esophageal con- tour is fairly regular, but is sometimes indented here and there by sharp, moving contraction-waves or, occasionally, by a stationary spasmodic constriction. Because of the dilatation, peristalsis is not effective in its effort to propel the esophageal contents into the stomach, and the patient depends upon increasing the intra-esophageal pressure by adding to its con- tents and by energetic contraction of the pharynx. Thus by drinking a glass of water after taking food, he is often able to overcome the obstruction at the cardia and drive the food into the stomach. In cases of long standing the esophagus may be more or less elongated and somewhat kinked, or S-shaped. Antiperistalsis has been noted and is a natural sequence of obstruction anywhere in the digestive tube. Cardiospasm is to be differentiated chiefly from carcinoma and from benign organic stricture. Carcinoma of the lower esophagus rarely produces stenosis limited to the hiatus esoph- agi, but nearly always extends above the diaphragmatic opening and, as a rule, the lower end of the barium shadow tails out irregularly. Post-traumatic strictures sometimes occur in the lower esophagus, but here again one may expect irregu- larity instead of the symmetrical cone of cardiospasm. However, warning must be given that irregularity does not invariably signify organic obstruction, nor does smooth regularity invariably indicate cardiospasm. Exceptionally a cardiospasm may show a slightly devious tailing out, and exceptionally an organic stricture may not give rise to an irregular shadow. Case 114,572, female, aged 27. During the past four years this patient has had intermittent attacks of discomfort behind the ster- num while eating. The food seemed to lodge before entering the stomach. Upon drinking hot water the food seemed to pass suddenly into the stomach. Unless she remained quiet for a time after eating, the meal came up just as swallowed without nausea. During the past 52 THE ESOPHAGUS two years she seldom took a meal without this trouble. She drinks large quantities of liquid with her food. Cold water causes distress and is regurgitated immediately after swallowing. The patient is constantly losing weight. Roentgenoscopy and the roentgenogram (Fig. 9) show marked obstruction at the cardia, where the esophageal lumen has a smooth, conical termination. Above the obstruction the esophagus is con- siderably dilated. Fig. 9. — Cardiospasm, (a) Constriction. Note dilatation above. Dilatation with the hydrostatic bag effected a clinical cure. Case 111,736, female, aged 30. Fourteen years ago she began to have occasional, sudden, sharp pain just behind the center of the sternum, intense for a few moments, with no food relation and relieved by belching. Two years ago she had a severe attack of vomiting and soon afterward began to have a choking sensation on swallowing solid foods. She frequently resorted to drinking water to force food down and became unable to eat a meal without taking considerable liquid. Later she began to vomit while at meals, and often was obliged to leave the table though hungry. There never was marked nausea. One year ago she began having her stomach washed out, and learned to use the tube herself, employing it once a week for the past eight months. She discovered on one occasion that the tube could CARDIOSPASM 53 Fig. lOx. — Cardiospasm. Spasmodic constriction, a. Filling-defect due to food remnants, h. Fig. IQy. — Cardiospasm; same case shown in Fig. lOx, after washing out esophagus. Constriction at a. Note absence of filling-defect. 54 THE ESOPHAGUS not be passed into the stomach and called a physician who made a diagnosis of diverticulum. At present she vomits two or three times at each meal, and often cannot get sufficient food into her stomach to satisfy her hunger. No pain is experienced. Appetite good. Weight and strength slightly below normal. Two roentgenograms are shown (Figs. 10a; and lOy). Figure 10a:, made at the first examination, shows obstruction at the cardia with an irregularity of its lower left border resembling the filling-defect of a neoplasm. In order to exclude food remnants as the cause of this appearance, the patient's esophagus was washed out with the tube and a second roentgenogram made (Fig. lOy). In this the filling-defect Fig. 11. — Cardiospasm. Hiatus esophagi, a. Constriction at cardia, 6. Some dilata- tion of epicardia, a to b. Marked dilatation above a. Direct anterior view. has disappeared. Doubtless, therefore, it was due as was suspected to food-bits. Both roentgenograms show the characteristic obstruc- tion at the cardia with diffuse dilatation of the esophagus above. Forcible dilatation was followed by clinical cm-e. Case 105,770, male, aged 49. When a child the patient's esophagus was burned with hot mush, after which he spat up bloody mucus for a time. His chief complaint was difficulty in swallowing. He has had his present trouble since the age of 14 years; first noticed that in eating an apple, he had to drink water to force it down. This is true also with CAEDIOSPASM 55 other solid foods. The patient states that he can feel the lower end of the esophagus loosen up and let food go through. Usually water alone will not go through and comes up sooner or later. He often awakens at night and has to rid himself of collected saliva. On a few occasions he has had to empty his esophagus of food after eating too heartily. The roentgenogram (Fig. 11) shows marked obstruction at the cardia. The subdiaphragmatic portion of the esophagus is dilated, but above the hiatus the esophageal dilatation is extreme and ex- tends to the upper border of the sterum, the esophagus having a' di- ameter of approximately 3}4 inches. The cardiospasm'was relieved Fig. 12. — Cardiospasm. Spasmodic constriction at a. by forcible dilatation with the hydrostatic bag. It is of interest to note, as a possible etiologic factor, that for some years the patient had also had symptoms suggestive of duodenal ulcer. About two years after the esophageal stretching, the presence of a duodenal ulcer was confirmed by roentgen examination, and verified at operation. Case 136,926, male, aged 37. In a letter this patient related a typical history of cardiospasm, as follows: "I have had all manner of treatment but it seems to do no good. Twelve years ago I had a bougie passed down my throat and into my stomach once a day for thirty days. Then I took all kinds of vibration and electrical treat- 56 THE ESOPHAGUS Fig. 13. Fig. 14. Fig. 15. Fig. 16. Fig. 17. Fig. 18. Figs. 13, 14, 15, 16, 17 and IS. — Roentgenograms illustrating cardiospasm. CARCINOMA 57 merits without benefit. Whenever I eat anything I have to drink a lot of water to push it througli into the stomach. Sometimes it will not go through but comes back up again. Otherwise, I am apparently well." In the roentgenogram (Fig. 12), is seen the characteristic obstruc- tion with dilatation of the esophagus above. The spasm was so pro- nounced in this patient that half the motor meal was retained after six hours. Following dilatation of the constriction bj'- the hydrostatic bag, recovery was complete. CARCINOMA The situation in order of frequency of esophageal carci- nomata has been variously stated. On the whole, it appears that they are exceedingly rare from the introitus to the tracheal bifurcation, are more common below the tracheal bifurcation and most common in the cardiac portion. The facility with, -which esophageal cancer can be shown by the x-ray depends largely upon the degree of obstruction. Those w^hich are decidedly obstructive are characterized, as a rule, by tortuous irregularity of the stenosed lumen. Above the stenosis there may be some dilatation, but this is usually less marked than in benign obstruction. Antiperistalsis has been noted above the point of obstruction. In some cases of cancer of the esophagus not involving the cardiac opening, the latter remains gaping, wdthout producing the usual physio- logic retardation of the material s^vallow-ed. The detection of early, non-obstructive cancers is more difficult. The esophageal contour, outlined by the barium- acacia mixture, wdll show filling-defects proportionate to the growth, but these must be carefully differentiated from the numerous normal irregularities. In a few^ instances, observers have noted reflex esophageal spasm accompanying early cancers. Obstructive carcinomata must be differentiated from benign organic and spasmodic strictures and from pressure stenoses. In any of these there may be irregularity of the esophageal lumen, though less constantly than in carcinoma. Rarely, a diverticulum may somewhat resemble the roentgenologic as- 58 THE ESOPHAGUS pects of esophageal cancer, and diverticula may result from obstructive cancer. In many cases of carcinoma the only roentgen sign found will be some degree of obstruction and a complete diagnosis can be made only by taking the clinical features into account. Case 113,484, male, aged 64. For three months he has had a per- sistent dysphagia, increasing in severity. At present he can swallow no solid food and takes semi-solids and liquids with difficulty. He ^ Fig. 19. — Carcinoma of the esophagus. Filling defect and obstruction a. regurgitates stringy mucus. Attempts at swallowing cause some pain under sternum radiating to back. He has lost 45 pounds in nine months, mostly in the last three months, and has grown weaker. The roentgenogram (Fig. 19) shows obstruction and irregular filling-defects in the mid-portion of the esophagus. The denser shad- ows are produced by a retention of the six-hour meal, while the thin- ner shadow above is the barium gruel taken at the time of examina- tion. Esophagoscopy showed a cauliflower carcinomatous growth in the middle third of the esophagus. Case 120,943, female, aged 34, Patient states that when a child three years old she swallowed some acid used by tinners in soldering. She does not remember any subsequent trouble in swallowing until CARCINOMA 59 Fig. 20. — Carcinoma of the esophagus. Stenosis with irregular filling defect, a. Fig. 21. — Carcinoma of the esophagus. Irregular obstruction at a. 60 THE ESOPHAGUS one year ago when attempts to swallow large bits of meat caused chok- ing. Eight months ago the dysphagia began to be constant and mouthfuls of food were regurgitated. She is now able to take liquids only. She has lost about 30 pounds during the last eight months. The roentgenogram (Fig. 20) indicates irregular obstruction in the middle third of the esophagus, without marked dilatation above. Fig. 22. — Carcinoma of the esophagus. Infiltration and obstruction, a. Pulsion sac, h. Bismuth in left bronchial tree inhaled while swallowing, c. Esophagoscopic examination: Growth in the middle third of esophagus, thought to be carcinoma. Case 133,217, male, aged 67. Six months ago began to hiccough at meal time. Nothing further was noticed until three months ago when he began to have dysphagia, the pain being referred to the upper sternal region. Later, attacks of vomiting commenced, and these CARCINOMA 61 Fig. 27. Fig. 28. Figs, 23, 24, 25, 26, 27 and 28. Illustrative cases of cancer of the esophagus. 62 THE ESOPHAGUS have continued, much mucus and unsoured food being ejected with the vomit. Weight loss, 20 to 30 pounds. Roentgenogram (Fig. 21). Obstruction at the lower third is well marked. The irregularity of contour was clearly seen on the screen. Case 44,345, female, aged 46. Ten months ago she had difficulty in swallowing which diminished for a month, then increased until for the past three months she has been unable to take solid food. The food seems to stick at about the upper border of the sternum, and is quickly regurgitated. Weight loss, 25 to 30 pounds. The roentgenogram (Fig. 22) shows : (a) Irregular obstruction high in the esophagus, (6) pulsion sac, (c) bismuth in right bronchial tree, inhaled during attempts to swallow. DIVERTICULUM The classification of diverticula into ''pulsion" or "pressure" sacs and "traction" sacs is generally accepted. The pulsion sacs, which are by far the most numerous, are produced by internal pressure and occur nearly always at the pharyngo- esophageal juncture (the introitus) where there is a tendency to deficient musculature, and where anomalies in closure of the lower branchial clefts may play a part. Traction sacs result usually, it is claimed, from gland infection about the left bronchus, are rare, have few symptoms, and are generally found at autopsy only. Pulsion diverticula commonly have a lateral or posterior situation. In size, diverticula vary from that of a pea to that of a very large pear. When filled with the opaque mixture, a pulsion diverticulum commonly shows on the screen or plate as a symmetrical sac with a smooth, rounded base. In exceptional instances, the sac may appear to be some- what irregularly shaped and retained food bits may give rise to such irregularity. Its fluid contents have a level upper surface. Its position with reference to the esophagus can be determined usually by the course of the barium through the latter, but the introduction of an opaque bougie into the eso- phageal lumen will show the relations better on the screen or in the roentgenogram. The sac or its major portion lies below its opening into the esophagus, at which point the overflow drainage into the esophagus can sometimes be observed. DIVERTICULUM 63 Dilatation above a high-seated carcinoma or benign stric- ture may somewhat resemble a diverticulum, and this resem- blance is heightened if the dilatation has become pendant so that it no longer drains from its lowest point. In carcinoma the strictured lumen below the dilatation is commonly irregular. It is noteworthy that diverticula rarely become carcinomatous. Case 116,535, male, aged 55. Seven years ago he began to have occasional attacks of choking with food, and at times when lying down Fig. 29. — Diverticulum of the esophagus, a. felt as if an object were rising in his throat with a bubbling sound then falling back again. The choking increased in severity until two years ago. Since then it has diminished, but the amount of food he is able to take has also diminished. When the pocket fills, its contents are often regurgitated through his mouth and nose two to five times during a meal. At night food in the sac causes distress. During the past year he has formed the habit of taking a swallow of water and then expressing the contents of the sac by massage with the finger, which enables him to sleep with comfort. He is obliged to chew his food well and swallow slowly. To him it seems that no food goes into his stomach until the pocket is filled, and then there is a choking sensation. 64 THE ESOPHAGUS There has been an increasing change in the tone of his voice since the trouble set in. During the screen examination, the pocket shown in the roentgeno- gram (Fig. 29) was seen to fill with the barium gruel after which the gruel trickled down the esophagus, showing that the sac was a diver- ticulum. Note the characteristic situation and contour. Finding at operation: Diverticulum, size of lemon, coming off the left side near cricoid. Excision of sac. Case 2492, male, aged 55. For eleven j^ears the patient at times has had regurgitation of food immediately after eating. The trouble Fig. 30. — Diverticulum of the esophagus, a. has grown worse during the past two years, and although he has a good appetite he cannot eat with satisfaction. Food regm'gitates through the nose occasionally. He has kept to his bed for the past ninetj" days, has lost strength and his normal weight of 135 pounds has de- clined to 90 pounds. The roentgenogram (Fig. 30) shows a very large, kidnej-shaped, diverticular sac coming off to the right and extending upw^ard, because of less resistance in that direction. It gives the impression that the esophageal opening is lower than the highest portion of the sac, but this is due to the fact that the neck of the sac and the esophageal open- ing, which is higher up, are not visualized. Operative findings: Diverticulum, right side of esophagus, Ij'ing under sternum. CICATRICIAL STRICTURES 65 Case 99,346, male, aged 66. Dysphagia with regurgitation began six years ago. This has continued, but by eating slowly he gets along fairly well. To him the seat of obstruction seems to be just below the cricoid. Liquids give more difficulty than solids. Roentgenogram (Fig. 31), oblique view. Small diverticular sac coming off opposite the cricoid. EiG. 31. — Oblique view of small esophageal diverticulum, a. CICATRICIAL STRICTURES Cicatricial stenoses may be the result of a healed ulcer, either simple, tuberculous or syphilitic, or of a trauma, such as results from drinking caustic liquids. In traumatic cases the stricture may not cause dysphagia until many years after ^the receipt of the injury. Such strictures may occur at any point in the esophagus. Often the esophageal lumen above the stenosis is slightly dilated and shows a rounded, smooth, sym- metrical termination, from which a thin stream of barium trickles through the stenosis. Thus, if seated high up, the condition may be mistaken for a diverticulum, but in the latter 66 THE ESOPHAGUS Fig. 32. Fig. 33. Fig. 34. Fig. 35. Fig. 36. Fig. 37. Figs. 32, 33, 34, 35, 36 and 37. — Illustrative cases of diverticulum of the esophagus. DIVERTICULA 67 \ ^'^ Fig. 38. Fig. 40. Fig. 39. Fig. 41. Fig. 42. Fig. 43. Figs. 38, 39, 40, 41, 42 and 43. — Illustrative cases of diverticulum of the esophagus. 68 THE ESOPHAGUS instance the drainage is from the upper part of the sac and not from the bottom as in stenosis. Other than the finding of obstruction with dilatation above it, both of which of course, vary in degree, the roentgenologic appearance of benign organic stenoses is not especially character- istic, and differentiation from other obstructive conditions will 1 Fig. 44. — Indention due to aortic arch, a. Benign stricture of the esophagus with barium trickling through, h. depend upon the history and upon data elicited by other means. Case 118,020, female, aged 50. When five years old this patient swallowed lye. During childhood she had some difficulty in swallow- ing, but gradually grew better, although she has always had to mas- ticate food well or it would stick. Seven years ago she thought some- thing lodged in the stricture, as she was obliged to take liquids only CICATRICIAL STRICTURES 69 for several weeks. A similar attack came on rather sudclenlj^ about three weeks ago. The roentgenogram (Fig. 44) shows marked constriction of the esophagus opposite the aortic arch, with barium trickling through the stricture. The indentation caused by the arch can be noted. The esophagus is somewhat dilated above the stenosis. Case 117,800, male, aged 2li years. Eight months ago he drank a strong solution of lye. Since then he has been unable to retain any- FiG. 45. — Benign obstruction of esophagus. Stricture at a. thing but milk. Solid food is vomited in from a few seconds to one hour after eating. The roentgenogram (Fig. 45) shows obstruction in the middle third of the esophagus, with dilatation above. Case 122,779, female, aged 38. Two weeks after gastroenterostomy for a duodenal ulcer the patient developed marked dysphagia. A stricture was found by the esophagoscope. Later, a gastrostomy was 70 THE ESOPHAGUS performed. At this time no evidence of malignancy was found, but the cause of the stricture was never determined. Roentgenogram, Fig. 46. Stricture in lower third of esophagus, smoothly regular, and evidently not malignant. SPASM Aside from spasm at the cardia, spasm may occur also any- where along the course of the esophagus, with more or less consequent obstruction. Such spasm has been seen as a reflex Fig. 46. — Benign obstruction; barium trickling through stricture at a. from early carcinoma. By analogy one would expect spasm of the esophagus as an occasional reflex from gastric irritations, just as gastric spasm is sometimes seen in duodenal irritation. Barclay'' holds that a small esophageal abrasion or ulcer may set up a spasm of such severity and persistence that complete obstruction may result, and he mentions a case of this character in his experience. He believes that simple or peptic ulceration of the esophagus is of more frequent occurrence than is com- monly taught. Transitory reflex spasms are not likely to be demonstrated, unless the examiner is unusually fortunate. FOREIGN BODIES 71 FOREIGN BODIES The foreign bodies which are now and then found lodged in the esophagus include coins, dental plates, bones, pins, buttons, rings and the innumerable things which most children and some adults put into their mouths. The point of lodge- ment may be anywhere in the esophageal course, though more often at the anatomic narrowings, such as those at the aortic arch and the introitus. Arrest of a foreign body may be due to an organic stenosis. Demonstration of a foreign body by the roentgen-rays depends upon its size and density. Small bones, bone buttons and cartilage are not easy to detect even on the plate. Roentgenoscopic localization of non-opaque bodies may sometimes be aided by giving the barium mixture and discover- ing the point where the stream is obstructed or turned aside. An illustration of this is seen in Fig. 47. Case 101,410, male, aged 23-^ years. Eleven days previously he had swallowed a coin which caused vomiting and some bleeding from the nose. Since then he has been unable to swallow anything except liquids. The roentgenogram (Fig. 47a) shows foreign body (coin) high in the esophagus. This was definitely determined by screening the patient in the oblique position. MISCELLANEOUS ESOPHAGEAL LESIONS Although they have no diagnostic roentgenologic signs, there are conditions, other than those mentioned above, the possibility of which the roentgenographer must bear in mind in drawing conclusions. Cases have been seen of paralysis of the gullet in which the patient, while unable to swallow solids, could take liquids readily. Fistulous communications between the esophagus and the trachea or bronchus exist occasionally, occurring as a result of wall-destruction by carcinoma (Fig. 48), tuberculosis, abscess or foreign body. In such cases, the fistula may be traced by the course of the opaque mixture, but this method of examination, because of its obvious possibilities for evil, is hardly to be recommended when the history is 72 THE ESOPHAGUS Fig. 47. — Complete obstruction in lower third of esophagus by a portion of beef steak. Note peristalsis above the obstruction. Fig. 47a. — Coin in the esophagus, a. REFERENCES 73 indicative of the condition. Esophageal piles may give symp- toms of obstruction, but no cases with roentgenologic signs have been reported. The authors have seen one case of bulbar palsy in which the barium lagged both at the introitus and at the cardia. Although infrequently met with, esophageal polyps sometimes exist. Stewart^ describes them as having their situation high in the esophagus, being usually pedunculated and sometimes of considerable size. Roentgenologicallyjthey simply give signs of obstruction. Fig. 48. — The irregular stenosis due to the cancer is seen at a. Below this is seen the fistulous tract through which barium has passed into the main trunk of the left bronchus, h, and its lower branches c. Verification by autopsy. REFERENCES 1. HiRSCH, I. S.: ''The Roentgen-Ray Study of the Esophagus." Interstate Med. Jour., 1916, xxiii, 42-67. 2. Myer, J. S. and Carman, R. D.: "Cardiospasm with Saccula- tion of the Esophagus, with Special Reference to the Persist- ence of the Sac." Jour. A. M. A., 1912, lix, 1278-1281. 3. Bassler, a.: "Early Diagnosis of Cancer of the Esophagus." Jour. A. M. A., 1913, Ix, 1283-1284. 4. Crump, A. C: "A New Aid for the Diagnosis of Stricture of the Esophagus." Jour. A. M. A., 1914, Ixii, 1471-1473. 74 THE ESOPHAGUS 5. HoLZKNECHT, G. : ''Die normale Peristaltik des Kolon." Muen- chener Med. Wchnschr., 1909, ii, 2401-2403. 6. Barclay, A. E.: "The Stomach and Esophagus." Macmillan Co., New York, 1915, 20. 7. Barclay, A. E.: "The Stomach and Esophagus." Macmillan Co., New York, 1915, 29-30. 8. Stewart, W. H.: "The Value of the Rontgen Examination in Obstructions of the Esophagus." Arch, of Diagn., 1913, vi, 309-314. CHAPTER V THE STOMACH TECHNIC The examination of the stomach comprises four steps, as follows: (1) preparation of the patient; (2) administration of a six-hour meal; (3) roentgenoscopic examination; and (4) roentgenography. Preparation. — On the evening previous to the day of exami- nation, the patient is permitted to eat his evening meal as usual, or the special meal prescribed by the gastroenterologist if the gastric contents are also to be examined. He is instructed to omit breakfast the next morning, and either go first to the gastroenterologist for examination or come directly to the roentgen laboratory. The Six -hour Meal. — At the laboratory the patient is given 4 ounces of well-cooked wheat breakfast food in which has been stirred 2 ounces of barium sulphate. To this he may add milk (not cream), and a little sugar according to his taste. He is directed to abstain from other food or drink, except water, until the examination is completed. Roentgenoscopy. — Six hours later he returns and is taken to the screen room. If the patient be a man he is stripped to his hips; if a woman, she is permitted to wear a thin garment. The patient takes his position in front of the vertical screen apparatus, with his back against the celluloid panel. The operator sits on a stool in front of the patient and screen. By means of the foot-switch, the room-illumination is turned off and the rays turned on. First, the chest is briefly inspected. Next, the position and distribution of the six-hour meal are noted. Then, 75 76 THE STOMACH the patient takes a mixture of 8 ounces of water and 2 ounces of barium sulphate, freshly stirred. While he is drinking this the canalization, that is to say, the manner in which the ingested stream descends to the lower portion of the stomach, is observed. If there is doubt that a given shadow from the six-hour meal represents a gastric retention, the observer notes whether or not the barium-water merges directly with the suspected shadow. When the patient has finished drinking, the contents of the stomach are first driven by the pressure of the operator's hand toward the fundus to outline its contour. Then the con- tents are pressed toward the pylorus. Some of the barium- water usually is forced out into the duodenum and in this way the location of the pyloric ring can be determined. The patient is next given a second mug containing 12 ounces of corn-starch-pap with barium (see page 27). When this has been drunk, the filled stomach is inspected and its general form, contour, size, position, mobility, flexibility and peristalsis noted, the patient being rotated for different angles of view, and palpatory manipulation being employed as necessary. The oblique \dew is never omitted, since by this means lesions on the anterior or posterior wall are sometimes discovered when they would fail to show in the postero-anterior view. The tube-box diaphragm is used freely, narrowing the aperture for close study of particular regions. During the screen-examina- tion, special attention is directed to the pyloric portion of the stomach because it is not always well outlined on the plate. If the barium tends to settle away from the pylorus, the ingesta are driven toward the pyloric end by manual pressure. Note is taken of the volume and character of the flow through the pylorus, whether scant or copious, intermittent or continuous. The ob- server follows peristaltic waves from their commencement to their termination, noting whether they continue without interruption to the pyloric ring, and observing their depth on each curvature. Antiperistalsis is watched for, since its presence is almost always associated with a pathologic condition either of the stomach or duodenum. It is seen most often in the obstructive lesions at or ROENTGEN ANATOMY 77 near the pylorus. If peristalsis is apparently absent, the observer waits a bit for its appearance. Likewise, when duodenal ulcer is suspected, the study is continued intermittently for several minutes, if necessary, in order that sufficient time may elapse for hyperperistalsis to appear. If pathologic conditions involv- ing the upper gastric pole are surmised, the patient is examined also on the fluoroscopic table. Here the dorsal position offers the better opportunity for palpation, but the patient is examined prone and at various angles in addition. When the screen- examination is concluded, the findings are entered on the blank previously mentioned (Fig. 1). Plates. — Plates are made immediately after the screen- examination is completed. The patient lies prone upon the cassette, the tube at his back and 18 or 20 inches distant from the plate. He is instructed to remain perfectly still and refrain from breathing during the exposure. Eleven by 14-inch plates are used as a rule, but by careful posing 10 by 12-inch plates will often suffice. The 8 by 10-inch size is used generally for serial or multiple plates of the pyloric and duodenal regions. In making plates of the patient lying prone, he is supported by cushions under his chest and thighs if his abdomen is promi- nent, in order to prevent undue abdominal pressure and con- sequent distortion. Lesions high in the cardia are sometimes better shown by plates made with the patient on his back or even in the Trendelenburg position. Plates are easily made with the patient standing, and this is done often, though the upper portion of the stomach is not usually well outlined. The plates are compared with the screen-observations as noted on the fluoroscopic sheet, and the net findings are entered on the permanent record sheet (Fig. 2). ROENTGEN ANATOMY The barium-filled normal stomach as seen on the screen or plate differs in many respects from the stomach described in most textbooks of anatomy. However, this does not warrant 78 THE STOMACH the conclusion that the textbooks are wrong and that the roent- genologic stomach is an absolute standard. Indeed it has been urged, and with reason, that the roentgen stomach is to some extent an artefact, that the differing stomachs shown at autopsy, in the opened belly of the living, and by the x-ray, represent nothing else than different conditions of the organ according to the degree of filling, the character of the filling material, whether food, fluid, air or barium, the contraction of the gas- tric musculature, the degree of rigor mortis, the changes caused by opening the abdomen and, finally, the conformation of the neighboring organs. But the roentgenologist need not concern himself with absolute standards; he is interested rather in roentgenologic bases of comparison. The stomach described and illustrated in textbooks of anatomy is characterized by the extreme breadth of its cardiac end, the fundus, and the convergence of its walls to form a narrow pyloric portion. The majority of stomachs as observed by the aid of the roentgen ray and with the patient standing do not show this wide difference between the diameters of the car- diac and pyloric segments. On the contrary, the usual roent- genologic hook-form stomach is tubular rather than bulbous, and its pyloric portion, except, of course, immediately at the pylorus, is almost as broad as its cardiac portion. Further, it occupies a position which is largely vertical, instead of largely transverse, as customarily shown in anatomical drawings. A relatively infrequent form of roentgenologic stomach, the steer- horn, does lie rather crosswise, but it bears little resemblance otherwise to conventional illustrations of this organ. Anatomists customarily divide the stomach into two parts — a cardiac portion (fundus) and a pyloric portion — some roent- genologists follow this division. Others prefer to speak of a vertical (cardiac) portion and a horizontal (pyloric) portion. This is applicable to certain types of stomach. Most divisions are based on the hook-form of stomach, and one of these dis- tinguishes descending, transverse and ascending portions. A convenient division is that used by many roentgenologists, by ROENTGEN ANATOMY 79 which the stomach is divided into pars cardiaca, pars media and pars pylorica. The accompanying drawings illustrate these divisions in both the common forms of stomach (Figs. 49 and 49a). The pars cardiaca (fundus; fornix; antrum cardiacum) may be regarded practically as the upper third of the stomach. According to some, its lower limit is marked by the incisura _,Gas "butble (MagenbUse) — -Pars mei^i PyloAs CO. Fig. 49. — Steer-horn stomach. cardiaca, the angle above the junction of the esophagus with the stomach. However, the incisura cardiaca is frequently confounded with a shallow indrawing sometimes seen at a considerably lower level on the greater curvature. The pars cardiaca fits snugly under the left arch of the diaphragm. It contains the gas-bubble (magenblase) within its upper convexity. B'u.Xb'u.s 3ii-tod.eni, \ Pylo .Gas "biibUe (KagenUase) j-PaTS cardiaca pi|lorvca' Fig. 49a. — Fish-hook stomach. When the stomach is filled, the base of the gas-bubble is marked by the horizontal plane at the upper surface of the gastric contents. Near the level of this plane, on the lesser curvature, is the esophageal opening. The pars media (body; corpus; pars intermedia) extends from the pars cardiaca to the incisura angularis. The incisura 80 THE STOMACH angularis is well marked in the fish-hook stomach, in which it is constituted practically by the most dependent portion of the lesser curvatm-e. With the institution of peristalsis the incisura angularis is deepened by the peristaltic wave, which passes on and is succeeded by another wave that renews and deepens the incisura. But it is inaccurate to conceive of the incisura angu- laris as a permanent, non-moving indentation due to muscular contraction. This notion is doubtless related to the idea of an ^'antral sphincter," which is open to question, as will be seen hereafter. The pars media of the fish-hook stomach descends vertically, or a little obliquely to the right, from the pars cardiaca. Its walls are largely parallel. The pars media of the steer-horn stomach courses obliquely or transversely to the right from the pars cardiaca, and its walls tend to approach each other progressively, to its junction with the pars pylorica. The third segment, the pars pylorica, is the smallest of the three divisions. It narrows somewhat from its beginning at the incisura angularis to its termination at the pyloric ring. In the fish-hook stomach it occupies a rather vertical position, while in the steer-horn it lies either transversely or obliquely downward. The term antrum (antrum pylori; antrum pyloricum) is often applied to the bulbous expansion of the pars pylorica in front of a peristaltic constriction. Thus its size is variable. In its largest extent it includes the whole pars pylorica, with which the term is sometimes used more or less synonymously. The pyloric ring shows as a hiatus in the barium shadow, approximately from an eighth to a quarter of an inch in breadth, between the pars pylorica and the duodenal bulb. When the pyloric sphincter relaxes, the barium flowing through it shows the pyloric canal, centrally placed, and of varying width accord- ing to the degree of sphincteric relaxation. While usually the pyloric hiatus can be demonstrated, it may not be observed because of an overhanging bulb, failure of the barium to pass the sphincter, or an unfavorable angle of view. The pars cardiaca and pars media of a fish-hook stomach are sometimes spoken of as the descending arm, and the pars ROENTGEN ANATOMY 81 pylorica as the ascending arm. The length of the ascending arm, and hence the height of the pyloric opening above the lowest point on the greater curvature, is the hubhohe of Haudek. The upper pole of the stomach is the dome of the pars cardiaca, while the lower pole is the most dependent arc of the greater curvature. CHAPTER VI THE NORMAL STOMACH It is rather trite to say that a knowledge of normal condi- tions as revealed by the roentgen-ray is essential to a proper understanding of abnormal conditions. Yet this general truth applies so accurately and specifically to the roentgenology of the stomach that its reiteration is never amiss. The ironical aphorism is sometimes ventured that there is no normal stomach. By this is meant, of course, that there is no standard normal roentgenologic stomach. Stomachs which are markedly dissimilar in their roentgenologic characteristics may each be appropriate for its possessor and functionate in a normal manner. Nevertheless, while the appearances of the stomach as seen in the roentgenogram are almost protean, these variations have limits, even though wide, which can be determined in a general way. In determining whether or not a given stomach is normal, account must be taken of its length, breadth, capacity, contour, position, form, tonus, mobility, peristalsis and motility. Now these numerous and varying factors not only mutually affect each other, but they are also modified markedly by the general body-form — the habitus — of the individual. Whoever has examined a large number of stomachs and noted their relation to frame-structure must certainly feel that the stomach nor- mally corresponds to the type of body, just as facial character- istics distinguish races. The general "build" of the individual thus becomes a matter of prime importance. Habitus. — Stiller^ has emphasized the enteroptotic habitus (asthenic or atonic habitus, asthenia universalis congenita), and its relation to disorders of the abdominal and thoracic viscera. Extreme mobility of the tenth rib is a stigma of the enteroptotic 82 HABITUS 83 habitus, which is further characterized grossly by a sUght skeleton, a long narrow, shallow, sunken thorax, steeply falling ribs, wide intercostal spaces, an acute epigastric angle, a thin, weak musculature, a poor panniculus, and pallor of the skin. This habitus is prone to visceral ptoses and ''vegetative neuras- thenia." The stomach of an enteroptotic person is usually a long, capacious, vertically lying, relaxed, pendulous sac. Contrasting strongly with the enteroptotic, is the broad, or apoplectic habitus, with its robust frame and musculature, its short, elevated, broad and deep thorax, ribs running almost horizontally to the sides, narrow intercostal spaces, and obtuse epigastric angle. In the broad habitus the stomach is main- tained at a high level in the abdomen, is relatively short and small, and tends to lie obliquely or transversely. Between these extremes is the normal habitus, neither broad nor enteroptotic, varying within these limits, and hardly capable of exact definition. In the normal habitus the stomach is of medium length and capacity, and lies vertically or a trifle obliquely in the abdomen. Taking the epigastric angle — the angle between the costal margins, Avith the ensiform at the apex — as a measure, Stiller classifies an angle of twenty-five degrees or less as enteroptotic, fifty to eighty degrees as normal, and one hundred and twenty to one hundred and forty degrees as broad. The photographs herewith show the three types of habitus with their accompanying types of stomach. During the screen examination the outline of the stomach was drawn on a glass plate with soft crayon, marking also the epigastric angle, the umbilicus and the anterior superior iliac spines. The drawing was then transferred to paper by contact with pressure, and this in turn was applied to the patient's abdomen. The outline was then filled in with lamp-black to indicate the barium-filled portion of the stomach, and the patient was photographed. Figures 50 and 51 illustrate two examples of the normal habitus. The man, in Fig. 50, has a typically normal build. His stomach is of moderate size, and the lower pole is exactly 84 THE NOEMAL STOMACH at the umbilicus. The woman, in Fig. 51, may also be rated as of the normal habitus, though there is an inclination to the Fig. 50. — Normal habitus. Fig. 51. — Normal habitus, inclining to the broad. Fig. 52. — Broad habitus. broad type. Her stomach is of medium size. The pylorus is not much above the level of the lowest sweep of the lesser curva- ture. The lower gastric pole is at the umbilicus. The man H.JlBITUS 85 shown in Fig. 52 is a definite example of the broad habitus. His musculature is well developed, his chest broad, and his trunk short. His stomach is quite in keeping with his body Fig. 53. — Enteroptotic habitus. Fig. 54. — Enteroptotic habitus of moderate degree. Fig. 55. — ^Lo-n- stomach, the result of abdominal relaxation rather than an enteroptotic habitus. form, and sweeps in a broad curve across the upper abdomen. The woman in Fig. 53 has the typical enteroptotic habitus. Her musculature is poorly developed, and her trunk is long and 86 THE NORMAL STOMACH narrow. Her stomach is likewise long and its lower pole is well down in the pelvic basin. The man in Fig. 54 also is enterop- totic though of less pronounced degree. His stomach is quite long and broad, and its lower pole is a handsbreadth below the' umbilicus. The Abdominal Wall. — A second factor which modifies the form and position of the stomach is the tension of the abdominal wall. With a wall of good tone, other things being equal, the stomach and abdominal viscera will be held up at a higher level than if the wall be lax. The markedly flaccid belly, fre- quently seen in multiparas, or after the removal of large tumors or ascitic fluid, is often accompanied by extensive ptoses. In Stiller's- opinion, the flaccid abdomen has been confounded by some roentgenologists, Holzknecht, for example, with the habitus enteroptoticus, which latter Stiller limits to a congenital form of body with a flat, rather than pendulous belly. Fig. 55 illustrates the effect of relaxation of the abdominal wall. The woman can ha.rdly be described as of the enteroptotic habitus. She is beyond middle age and has borne children. Her abdomen is lax and pendulous, and her stomach is corre- spondingly long and low-placed. The tension of the abdominal wall varies not only with its general tone but also with its degree of active contraction as determined consciously or unconsciously by the patient himself. During examination a phlegmatic person is likely to show his natural and accustomed abdominal tension, while a nervous or apprehensive individual is apt to contract his abdominal muscles strongly. Gastric Tonus. — A third factor affecting the form, position and size of the stomach is the tone of the gastric musculature — its capacity of contracting upon and adapting itself to its con- tents. However, gastric tonus is judged, from the roentgeno- logic standpoint, largely by the gastric form, position and size, all of which are widely influenced by the habitus, the abdominal tension and other elements. The subject of tone will presently be considered further. FORM 87 Finally, the form and position of the stomach are influenced to some extent by the conformation of adjacent organs, by the character of the filling material and by its amount. Thus, the attributes and appearances of the roentgenographic stomach are so closely interrelated that a roentgenologic esti- mate of any single quality is comparative rather than absolute, and only valid in proportion to the carefulness with which all Fig. 56. — Normal steer-horn stomach. contributing elements are considered. Nevertheless, by usage, certain arbitrary bases of comparison have become established, which are convenient, and which will not mislead if they are considered in association with each other. Form. — As a rule, the normal adult stomach takes one of two general forms, the steer-horn or the fish-hook. The steer-horn stomach, so-called because of its resemblance to the horn of a steer, occurs much less frequently than the fish- hook. The steer-horn is seen normally in association with the broad habitus, whether in man or w^oman, although this type 88 THE NORMAL STOMACH of body is seen most commonly in males. Relatively small, as a rule, it is broadest at the fundus and narrows progressively to the pylorus which is its most dependent portion. It occupies an oblique, sometimes almost transverse, position and lies well above the umbilicus (Fig. 56). Fig. Fig. 58. Fig. 59. Fig. 60. Figs. 57, 58, 59, and 60. — Normal stomachs of steer-horn form. The fish-hook is by far the most common form of stomach met with. It resembles a hook or the letter J. It descends more or less vertically from the diaphragm, curves across the spine, FORM 89 and ascends to the pylorus, which latter lies above the level of the lowest point on the lesser curvature. It is the usual associate of the slender and the normal habitus, but may occur also with the broad habitus (Fig. 61). Fig. 61. — Xormal stomach of fish-hook form. Between the typical steer-horn and typical fish-hook, forms are sometimes seen which are difficult to classify, as they possess some of the characteristics of both (Fig. 70). Further, what seems to be a steer-horn with a small amount of ingesta, may assume a fish-hook form if its contents be increased, either 90 THE NORMAL STOMACH because of the sagging produced by the additional weight, or its lengthening to accommodate a greater volume. Holzknecht'^ has defined the normal stomach as one which in the upright position and a fihed condition has the pylorus for its lowest point, which is above the umbilicus. It is of steer-horn form with a Fig. 62. Fig. 63. Fig. 64. Fig. 65. Figs. 62, 6-3, 64 and 65. — Normal stomachs of fish-hook form. broad, vertical, cardiac portion and a narrow, horizontal pyloric seg- ment. Holzknecht states repeatedly that the pylorus should be the lowest point, on the ground that this is the optimum for its function. His observations were made in 1906 and are not necessarily represen- FORM 91 tative of his present views. However, this may be, Cannon* points out that this conception of the normal stomach rests upon the assump- tion that the stomach is emptied by gravity drainage. Cannon holds that the contents of the alimentary canal are in exact equilibrium, even in the standing position, that '^ drainage" in the common usage of that term is impossible, and that muscular contraction is necessary to move food onward through the alimentary canal. Fig. 66. Fig. 67. \ Fig. 68. Figs. 66, 67, 68 and 69. Fig. 69. -Normal stomachs of fish-hook form. Certainly the steer-horn form of stomach is so rare that if this be the only normal stomach then more than 90 per cent, of all stomachs must be abnormal. We find it difficult to believe this, since hundreds of fish-hook stomachs which we have examined were found to be ana- tomically normal at exploration during the course of an abdominal operation for other conditions. In short, we feel that, barring ex- 92 THE NORMAL STOMACH treme exaggerations, the general form of the stomach has far less significance than the manner in which it performs its functions. Tone. — According to Schlesinger's'' classification, which has received rather general acceptance, four varieties of tonus are distinguished — the orthotoiiic, hypertonic, hypotonic and atonic (Fig. 71). He regards the orthotonic, or normal-toned, stomach as one which contracts upon its contents with sufficient force to main- [FiG. 70. — Normal stomach of type between the steer-horn and fish-hook form. tain a tubular form, even with a moderate amount of ingesta.. The orthotonic stomach is assumed by Schlesinger to be normal because most frequently seen and because it performs its func- tions in a normal manner. It is of fish-hook form and of uni- form diameter, its walls being parallel nearly to the pylorus where they converge bluntly, and its lower border is at or near the umbilicus. Schlesinger's hypertonic stomach, as the term indicates, shows an excess of tonicity. It is short, has a small, flattened gas-bubble, is broadest at the cardia, and its walls narrow TONE 93 steadily to the pylorus, giving it a steer-horn form and an ob- lique or transverse position. Its lower border is well above the umbilicus. The hypertonic stomach, though relatively infre- n IE nz CO. Fig. 71. -Schlesinger's classification of stomachs according to tone. I, Hypertonic; II, orthotonic; III, hypotonic; IV, atonic. quent, is not pathologic. Schlesinger regards it as the primary type from which other types have developed by the stretching and sagging of its walls. His conception of a hypotonic stomach is one which evi- 94 THE NOEMAL STOMACH dences relaxation of its longitudinal muscle-fibers by an increase of length, and consequent, sagging downward. The circular fibers are also relaxed and, with the patient standing, the barium meal broadens the diameter of the lower pole, which sinks below the umbiHcus. The upper pars media is somewhat narrowed by the tendency to approximation of its vertical walls. Schlesinger's atonic stomach shows relaxation to an extreme degree. Ingesta which would completely fill an orthotonic stomach now merely fill the expanded, basin-like lower pole. The vertical walls of the pars media approach each other, closely enough in some instances to retard momentarily the descent of barium. The lower border of the stomach is well down in the pelvis. The gas-bubble, without support below to give it a semilunar shape, appears fusiform. Though not normal, the atonic, as Barclay^ pertinently remarks, should be discussed in connection with the normal stomach, for it is a ''defective physiological action rather than a pathologic condition." While Schlesinger's classification is more or less diagram- matic, it serves as a satisfactory scale for comparisons. In its practical appHcation it is subject to the following quahfications : 1. The ''atonic stomach" of clinicians is not represented solely by the atonic stomach of Schlesinger, for the frequency with which "atony" is used in a clinical sense justifies the as- sumption that it is applied to all degrees of hypotonus. 2. Schlesinger limits the hypertonic stomach to the stomach of steer-horn shape. But fish-hook stomachs are often seen which are undoubtedly hypertonic as shown by their extremely narrow diameter, shortness, and high position, although the hook-form is retained. 3. He regards only the hypertonic and orthotonic types as normal. In a narrow sense this is perhaps true, but hypotonic stomachs are often seen which are in keeping with the entero- ptotic habitus of their possessors, and which perform their functions in a normal manner. Thus w^e feel that the chief test by which the stomach is to be POSITION 95 adjudged of normal tone is its correspondence to the habitus of the individual, and not its form, size and position alone. With the broad habitus the tone may vary from orthotonus to hyper- tonus. With the normal habitus it may be expected to vary from orthotonus to at least slight degrees of hypotonus. With the enteroptotic habitus, hypotonus is the rule, not only of the stomach, as Stiller has pointed out, but of other organs as well, and the gastric hypotonus should not be given undue or exclu- sive stress. Again, strictly speaking, tonus is an intrinsic quality of the gastric musculature, but the position, form and size of the stomach are modified not only by varying degrees of gastric tone but also by the intra-abdominal pressure and the amount of ingesta. Increased intra-abdominal tension tends to lift up and shorten the stomach; diminished tension tends to lower and lengthen the. stomach. Hence the tonicity of the abdom- inal wall as well as conditions within the belly, such as ascites, pregnancy, new growths, etc., must be considered in estimating the actual tonus. Further, gastric tonus may vary to some extent at different times in the same individual, and at different stages of digestion. Position. — It should be sufficiently clear from the foregoing that the position of the lower gastric pole has a wide range within normal limits, and it may lie well above or well below the umbilicus, the level of which grossly corresponds to a line joining the iliac crests. The position of the lower pole is affected also by respiration, being lowered slightly in inspiration and raised slightly in expiration. The position of the pylorus varies rather widely with the form of the stomach, the habitus of the individual and the posi- tion of neighboring organs. Thus the pylorus of the steer-horn stomach often lies far above the umbilical level, high up in the right hypochondrium. The pylorus of the fish-hook stomach is usually slightly to the right of the median- line and somewhat above the umbilicus. But a low-lying stomach may have its pylorus even below the umbilical level and in the median line. 96 THE NORMAL STOMACH The pylorus of an acute fish-hook stomach is often to the left of the median line. The cardiac end of the stomach does not vary its position normally. Noteworthy is the fact that the stomach descends from the upper pole with a slight obliquity forward so that its lower pole is closer to the abdominal wall than is its upper pole. For this reason the roentgen shadow of the lower gastric segment is sharper in the anterior view than that of the cardiac segment (Fig. 72). r Fig. 72. — Lateral view, diagrammatic, sliowing the more anterior situation of the lower gastric pole. When the patient lies on his back on the screen-table, the stomach shows a wide, oval pars cardiaca and pars media, while the pyloric portion seems narrowed, or may not be seen at all, thus giving a greater resemblance to the traditional sac-form of the anatomists. In the prone position also, the stomach lies higher than when the patient is standing; the cardiac end is broader and the pyloric end narrower. Size. — The normal stomach is a potential cavity. Its apparent size depends therefore on the volume of its contents. The stomach accommodates itself to an increasing volume of MOBILITY 97 contents chiefly by an increase of width, but partly also by an increase of length. The expansibility in all directions with an increase of the gastric contents is a noteworthy feature of the normal gastric wall. An orthotonic adult stomach will ordi- narily accommodate 24 fluid ounces of a barium mixture with- out discomfort to the patient, and by this amount the gastric periphery will be effectively visualized. A hypertonic stomach may hold this quantity but with rather evident distention. Capacity is increased proportionately to loss of tone. A 24- ounce barium meal does not completely fill a hypotonic stomach, but abdominal palpation or the institution of peristalsis may increase the gastric tone until the barium is forced well up to the gas-bubble. In megalogastria the stomach may be of enormous size and yet functionate properly. Ewald^ mentions one with a capacity of 1680 c.c. (56 ounces). On the other hand, the smallest normal stomach he noted could accommodate only 250 c.c. (8 ounces). Contour.^ — The otherwise smooth and regular contour of the normal stomach is broken by the incisura cardiaca, the incisura angularis and by peristaltic waves. As stated before, the incisura cardiaca is the upper angle at the junction of the esophagus with the stomach. The incisura angularis is the deep depression on the lesser curvature at the junction of the pars media and pars pylorica. On the greater curvature, about where the left costal arch crosses the stomach, a broad, shallow, incurvation is frequently seen, especially if the abdomen be rigid or retracted, and is probably due to the pressure of the abdominal muscles, although some observers have attributed it to the spleen. Hypotonic stomachs also sometimes have a long sweeping incurvation of the greater curvature of the pars media. The contour of the pyloric end varies with the peristalsis of the antrum, but is always normally symmetrical at any stage of contraction. Mobility. — The principal fixing supports^ of the stomach are the esophagus and gastro-phrenic ligament at its cardiac 98 THE NORMAL STOMACH end, and the hepato-duodenal ligament, about an inch beyond the pylorus. Between these points, the dependent body of the fish-hook stomach has a considerable range of passive move- ment, and by palpatory maneuvers can be lifted up or shifted to either side. By drawing in or relaxing the abdominal wall most patients can raise or lower or even distort the stomach at will (Fig. 73) . By deep respiration the filled stomach may be lowered during inspiration and raised during expiration, the Fig. 73. — Stomach distorted by strong retraction of the abdominal wall. change sometimes affecting the cardia and media chiefly, or it may be slightly raised and lowered en masse. The hypertonic steer-horn stomach, lying high under cover of the costal arches, between which the abdominal wall is less lax, is not freely accessible to palpation and hence not easily moved about. The pendulous, hypotonic stomach is susceptible of wide shifting. In estimating mobility the relative tension of the abdominal wall should be taken into account, accordingly as it facilitates or hinders manipulation. FLEXIBILITY 99 Flexibility. — An important characteristic of the normal gastric wall is its flexibility. With the abdominal wall fairly relaxed, narrow palpation, i.e., with a single finger or the ulnar side of the hand, on the greater curvature, will produce a sharply outlined indentation closely corresponding to the palpated surface. If the abdomen is held rigid, as often happens, this maneuver is less practicable and less effective. Gas-bubble. — In the upper pole of the stomach is a quite constant transparent area, the gas-bubble, chiefly due to swal- lowed air. Its convex upper surface fits into the concavity of the left diaphragm. With an empty or partially filled stomach its base projects downward like a spindle. With a filled stomach its base becomes a transverse plane, level with the cardiac end of the esophagus. Its size varies considerably and without special significance. In the hypertonic stomach it is usually small and somewhat flattened, while in the orthotonic or hypo- tonic stomach it is more convex above and larger. In the markedly hypotonic stomach the gas-bubble is fusiform or balloon-shaped. Secretion. — The amount of secretion in the normal fasting stomach is so small that no accurate estimate can be made during the ordinary roentgen examination. After filling the stomach with the barium-pap an intermediate layer of fluid may usually be seen between the gas-bubble above and the barium-emulsion below. This fluid is partly gastric secretion but mostly water which has separated from the media employed. Hence the depth of the layer varies not only with the amount of secretion but also with the amount of water which happens to separate, and is not a reliable index of secretory activity. To determine the amount of secretion in the fasting stomach, Kaestle^ has made use of Sahli's opaque capsules; one, the ''swimming" capsule, floats upon the surface; the other, the ''sinking" capsule, falls to the bottom. The vertical distance between the capsules measures the depth of the secretion-pool. However, the total quantity of secretion depends not only upon its depth, but also upon the breadth of the lower gastric pole. 100 THE NORMAL STOMACH To our mind the amount of secretion can be determined more accurately by the gastroenterologist's tube than by roentgen methods. To measure the digestive power of the stomach, Schwarz^'^ has employed opaque ^'fibrodermic" capsules. The capsule itself is digestible and, when dissolved, releases its opaque contents. The time required for this can be determined by examination at frequent intervals. Peristalsis. — The ring-like constrictions encircling the stom- ach which progress to the pylorus, stroking the gastric contents toward the bowel, are seen on the screen as distally moving indentations of the curvatures. Fascinating in interest, sub- ject to alteration both in health and disease, and of high im- portance in the diagnosis of gastro-intestinal lesions, gastric peristalsis has been given much attention. Looking over the pubhshed descfiptions of normal peristalsis as seen by the roentgen-ray, a somewhat disconcerting conflict is noted between the various views expressed. Some of the discordance is doubtless due to a conscious or unconscious effort to harmonize the roentgenologic appearances of peristalsis with certain anatomic conceptions of the stomach, while other dis- crepancies are perhaps due to technical differences in the manner of observation. By the older anatomists it was believed that the stomach was partially divided by a transverse muscular band, separating the pyloric portion (antrum) from the remainder of the stomach. This view probably influenced Kaufman and Holzknecht^^ in their description of peristalsis. They observed the peristaltic furrows to deepen as they progressed pylorusward, and reach a maximum depth three or four fingerbreadths from the pylorus. At this place the constriction remains longer as a tonic and more energetic contraction of the gastric wall. The antral portion is completely cut off, they state, and a clear stripe is to be seen between the shadow of the antrum and the shadow of the corpus. The aDtrum then effaces itself by a process of con- centric contraction. PERISTALSIS 101 Kaestle, Rieder and Rosenthal, ^^ commenting upon the above observation and additional quotations from Holzknecht, offer the following contradiction: "Our investigation shows that during digestion there is no such division of the stomach into two distinct parts, and that a strongly differentiated antrum pylori in the old acceptation of the term does not exist. As our tracings show, the formation of the new antrum does not commence at the spot where the final emptying of its contents occurs, and is therefore not a mere relaxation of the contracted walls. If we adhere to the idea of an antrum pylori, then it is necessary to speak of two such antra existing side by side and at the same moment. We must speak of an old and a new antrum. As the old antrum dis- appears, a new antrum is developed from the wall of the body of the stomach. This new antrum passes pylorus ward, and ultimately exactly takes the place of the old antrum, whilst another new antrum begins to form. Moreover, if we wish to adhere to the term, our idea of the antrum pylori must be modified. In our opinion, there is no true antrum pylori; any more than there is a sphincter antri, in the sense of the older observers ; what we see in the regio pylorica is an in- crease in the energy of the gastric peristalsis and an increase in the height and depth of the wave-summits and depressions. Just as the roentgen examination shows no trace of a sphincter antri, so anat- omy fails to show any trace of a transverse muscular band, or anything in the nature of a true sphincter." The observations of Kaestle, Rieder and Rosenthal were made by bioroentgenography, a modification of kinematography. Twelve or thirteen plates were exposed during the course of a single peristaltic contraction — about twenty-two seconds — shortly after the ingestion of a bismuth meal. These plates show a continuous progression of the peristaltic waves to the pyloric ring. By superposing tracings of these plates a com- posite was obtained showing graphically the successive positions occupied by the wave. The wave is shown to begin at the incisura cardiaca, whence it travels pylorusward with slightly, but steadily, increasing depth. At no point is the stomach completely segmented (Fig. 74). Cannon ^^ cites the work of Kaestle, Rieder and Rosenthal as substantiating his own early contention that the pyloric end 102 THE NOKMAL STOMACH is normally not separated from the rest of the stomach, and that the waves are continued over the vestibule. Further on, how- ever, he adds: "As digestion proceeds, the constrictions in the region of the vestibule grow still stronger, and finally, when the stomach is almost empty, they may, as they come near the pylorus, completely divide the cavity. At all times, in the close neighborhood of the pyloric canal, the circular and longi- tudinal fibers, both of which are hpr^trongly developed, prob- F w \ I /I I I Fig. 74. — Composite diagram showing gastric peristalsis. (By Kaestle in Rieder- Rosenthal's Roentgenkunde.) ably cooperate to decrease simultaneously in all directions the terminal segment of the stomach." GroedeP* has noted several varieties of peristaltic move- ments, including very shallow waves, deep waves, and local contractions of the gastric wall. The shallow waves come on soon after the ingestion of food, travel rapidly, and are hard to see with the naked eye. The deep wave-movements are seen on the greater curvature, begin below the incisura car- diaca and end at the sphincter antri. The local contractions remain for a longer time, sometimes simulating hour-glass contracion, and he was unable to say whether they are normal PERISTALSIS 103 or pathologic. He accepts the theory of a concentric antral contraction. Avoiding the terms '^ normal" or ''abnormal," Cole^^ has made a studj^ of "unobstructed peristaltic contractions," as shown by a series of roentgenograms. He introduces the term "gastric cycle," there being as many "gastric cycles" as there are peristaltic contractions visible at the same time. Thus he notes one, one-and-a-half, two, three and four-cycle types, and regards the two latter as the more common. He holds also "that the gastric motor phenomenon is complex, rather than simplex, as evidenced by a systole and diastole of the stomach in addition to the peristaltic contractions passing pylorus ward." Making due allowance for possible slight variations resulting from different technics, the observations of Kaestle, Rieder and Rosenthal offer the simplest and most logical explanation of peristalsis, as we have seen it by the x-ray, although we were at one time inclined to accept Holzknecht's theory of a concen- tric antral contraction. The division of the stomach by physi- ologists into two portions with largely different functions may be freely granted, but the peristaltic phenomena that we have observed do not warrant the assumption of a sharp anatomical division between these two portions. It may be that the thick musculature of the vestibule undergoes some general contrac- tion other than that of the advancing wave, but, if there is such contraction, it is so slight that it cannot be determined and the advancing peristaltic ring completely dominates the view. The introduction of "gastric cycles, " each with its "systole " and "diastole," seems to us a needless complication of the matter, for we are unable to see any close similarity between the action of the stomach and the action of the heart. In the stomach there is no general systole as in the heart, but a localized moving peristaltic contraction; nor is there a general diastole, the gastric contents merely following up the advancing wave. The fact that the gastric musculature in addition to its circular fibers contains also longitudinal and oblique fibers, 104 THE NORMAL STOMACH justifies the presumption that these latter participate in the motor functions of the stomach. But as it seems to us, this participation is shown chiefly by a heightening of tone, with a closer embrace of the gastric contents (peristole) which con- tinues all through the period of peristaltic activity, and is further manifested in the symmetrical shrinking of the stomach as its contents are evacuated. During the first five or ten minutea^after filling the stomach with the opaque materials previously described, the peristalsis Fig. 75. — Single peristaltic wave, pyloric portion. that we have seen most commonly on the screen is limited to the pyloric portion of the stomach (Fig. 75). First is noted a slight deepening of the incisura angularis. Then on the greater curvature, opposite the incisura, a complementary depression is seen. The encircling constriction deepens, then moves slowly pylorus ward. The vestibule (antrum) is not completely segmented and the vestibular contents escape backward through the advancing ring, save for a small amount which may be PERISTALSIS 105 driven through the pylorus. The wave continues its journey to the pylorus, and, as it disappears, another wave is seen form- ing at the incisura angularis. Less commonly the wave begins in the pars media a little above the incisura angularis, its de- pressions are visible on both curvatures, and it forms while its predecessor is sweeping over the vestibule (Fig. 76). Thus only one wave, or at most two waves, can be noted as a rule, during the period mentioned. Fig. 76, — Peristaltic wave, pyloric portion; second wave forming in body of stomach. Peristalsis is sometimes a trifle delayed in its appearance after ingestion of the meal. Its advent may also be retarded by certain nervous states of the patient, such as fright or disgust for the meal. It may sometimes be induced by massage and quite vigorous peristalsis may thus be elicited, but it dies away quickly when the stimulus ceases. Although the experiments of Cannon on animals and the observations of others on man indicate that peristalsis continues without interruption until the stomach is empty, we have occasionally noticed an inter- 106 THE NORMAL STOMACH mittence during the early period after ingestion, activity alter- nating with absolute or comparative rest. The depth of the wave varies not only among individuals, but also varies in different parts of the stomach. In the pars media, on the greater curvature, the wave-depression is relatively broad and shallow, while its fellow on the lesser curvature is 'scarcely visible above the incisura angularis. Both depressions increase in depth as they approach the pars pylorica. From the incisura angularis to the pylorus the waves vary little in their depth, and are quite similar on both^curvatures. The energy of contraction is affected somewhat by tone, being greater in the hypertonic and less in the hypotonic stomach. It is apt to be increased with hyperacidity and diminished with achylia and fatty ingesta. It is perhaps a trifle more active with barium than with bismuth. Activity is also increased by a prone position of the patient, and two or three waves may be seen at one time. Ordinarily, waves succeed each other at regular intervals and hence with regular interspaces as noted on either curvature. On the greater curvature the depressions are farther apart than on the lesser curvature, the constriction tending to maintain a plane perpendicular to the curving long axis of the stomach. The time required for a wave to run its course depends partly at least on where it begins and the distance to be traversed. Twenty-two seconds has been stated by Kaestle as the average time of transit. His composite drawing shows the wave beginning high up at the incisura cardiaca. Motility. — The testing of gastric motility by the roentgeno- logic method has been of striking value in our own work. Before discussing this feature of the roentgen examination it may be well to recall some of the elementary facts as to the physiology of the gastric motor function. In this respect much of the in- spiring work of William Beaumont" remains uncontradicted to this day. For example he found that "the time required for the digestion of food is various, depending upon the quantity and quality of the food, state of the stomach, etc.; but that MOTILITY 107 the time ordinarily required for the disposal of a moderate meal of the fibrous parts of meat, with bread, etc., is from three to three and a half hours." Further, he drew the ''inference," as he expressed it, "that oily food is difficult of digestion" and that ''water, ardent spirits and most other fluids are not affected by the gastric juice, but pass from the stomach as soon as they are received." Of the more recent investigators. Cannon, ^^ by his painstak- ing experiments on animals, has given us reliable data, among which may be summarized the following: The chyme does not pass through the pylorus at the approach of every peristaltic wave but emerges occasionally, at irregular intervals, of from ten to eighty seconds. Acid above opens and acid below closes the pylorus. Fats when given are almost invariably present in the stomach during seven hours' observation. Water begins to enter the intestine almost as soon as it enters the stomach. Carbohydrates go through rapidly; proteins more slowly. When carbohydrates and proteins are given one after another the early rate of evacuation is largely the same as that of the first food given. Mixtures of carbohydrates and proteins have an empty- ing rate intermediate between that of carbohydrates and that of proteins. Fat retards the exit of either food-stuff from the stomach into the intestine. As to consistency of food materials, there is a marked retardation of the outgo of food from the stomach when hard particles are present. Considerable amounts of gas in the stomach retard the discharge of food. Rage, dis- tress, anxiety, grief, anger and violent emotions have a depressive effect on gastric motor activities. Besides the physiologic variations to which the gastric clear- ance time is subject, it may, of course, undergo numerous pathologic alterations, in the direction either of an exaggeration of a diminution of motility. It would seem that by no simple test can sharp and constant lines of demarcation be drawn between hypermotility, normal motility and hypomotility. Nevertheless, extreme variations in either direction, more especially toward hypomotility, have 108 THE NORMAL STOMACH high diagnostic significance, can be determined at least broadly, and efforts at such determination cannot safely be neglected. The method in most common vogue of testing gastric motility is the administration of a meal and the use of the stomach-tube to ascertain whether food remnants are present after the lapse of a certain time. The following citations will give a fair idea of this method. / Kemp^^ states that the impairment of the motor power is fully as important, if not more important, in many cases than damage to the secretory functions. He describes various test- meals used in gastric analysis including those of Riegel,* Ewald,t and Leubef and the test-breakfast of Ewald-Boas.|| Regarding; the specific question of motility he remarks: ''If five hours after a test-meal, a small amount of chyme is aspir- ated the motor power is good. If large quantities are found six hours after the meal the motor function is absolutely (or, if stenosis, relatively) decreased * * * Some employ the test-breakfast. Two hours later the stomach should be empty. If 100 c.c. or more are found at the- end of an hour, or varying quantities at the end of two hours, it shows- different degrees of motor insufficiency. The test-meal is more accu- rate. I sometimes administer a test-supper and aspirate in the morn- ing to test the motor function, following immediately with the test- breakfast to examine the secretory function." Kemp also describes without comment the motility tests with salol (Sievers and Ewald),^^ iodopin (Heichelheim),^° and oil (Klemperer)."^ Bassler^^ mentions as of value the Leube-Riegel test-dinner,, consisting of beef-broth, 400 c.c. ; beef, 150 gm. ; pure or mashed potatoes, 50 gm. ; and a roll of wheat bread. The exit of this, meal from the normal stomach should occur within five hours. But he goes on to say: *Riegel's test-dinner: Meat broth, about 400 c.c; beefsteak, 150 to 200 gm.;; mashed potatoes, 50 gm.; and a roll (35 gm.). jEwald's test-meal: Finelj^ chopped meat, 175 gm.; stale bread, 35 gm.; and butter. tLEtJBE's test-meal: A plate of soup, a beefsteak and a roll. II EwALD and Boas' test-breakfast: One or two rolls (35-70 gm.); one cup of/ tea or water (300-400 c.c); given in the morning in the fasting condition. MOTILITY 109 "A word of caution should here be given in assuming the existence of pathologic conditions when five or six hours afterward small quan- tities of food are extracted, for, while the great bulk of the meal is gone, tarrying remnants of food may be present even in the perfectly normal stomach up to the sixth and even the seventh hour after the time of ingestion. If at the sixth, seventh or eighth, and so on, hour of extraction after the taking of a mixed meal, considerable quanti- ties of the meal constituents are obtained from a stomach, the existence of the following conditions should be considered, namely: Pyloric obstruction, states of atony, a more or less low state of digestive dis- turbance from degrees of subacute and chronic gastritis accompanied with poor gastric function, and the existence of neurotic conditions of a depressing type affecting the entire motility of the organ. Another form of examination by the extraction of gastric food contents to diag- nose pyloric obstruction from any cause (particularly its high degree seen in malignancy) should be mentioned. In this the generally em- ployed procedure is to advise the patient to eat a full meal in the early ■evening, and then to wash out his stomach the following morning — about ten or twelve hours afterward. Should the patient not have vomited during the night, and food remnants be found in the morning, bona fide pyloric stenosis can almost invariably be diagnosed." Bassler states further that a simplification of this method, which he can endorse as of much value, is the eating of several raisins* in the evening and noting if their skins or seeds are obtained in the morning lavage water. While in this test the obtaining of vegetable skins is of much significance, a negative result does not always mean that no stenosis exists. A less complete degree of stenosis, particularly in the pyloric region but not directly at the pylorus, may give positive results with the six, seven or eight-hour extraction of the mixed meal, but a negative finding with the raisin-skin method. The matter, he thinks, is entirely one of degree of stenosis; the nearer the stenosis to the pylorus, the more accurate are the results by both methods; the less the degree of the stenosis, or the farther away from the pylorus it is situated, the better is the result * Bassler speaks of this as the "Mayo method." In fairness it should be said, however, that the addition of raisins to the Riegel meal is credited by CoHNHEiM ("Diseases of the Digestive Canal," Edit. 2, Philadelphia, J. B. Lippincott & Co., 1911, p. 35), to Boas. 110 THE NORMAL STOMACH from the mixed meal, and the less so from the raisin-skin method. Einhorn-^ gives a fair summarj'' of gastro-enterologic methods in common use when he says: The best and easiest waj^ to test the motor function of the stomach is to examine this organ bj^ means of the tube and lavage iir'the morn- ing in the fasting condition after the ingestion of a substantial supper on the night previous. Normallj^ the stomach is emptj'', and there- fore when the organ is found to contain a ciuantity of food, this is the best sign of retarded motion. Roentgenologic Tests of Motility. — Since the first employ- ment of the roentgen-ray in conjunction with an opaque meal for the diagnosis of gastro-intestinal disease, more or less atten- tion has been directed to gastric motility. By a few men this feature of the examination is considered almost indispensable; by others it is regarded as of secondary importance, though usually given some attention, while a few deem it of little moment. As might be expected, an investigation of the technic used by different roentgenologists shows considerable variance. Wide differences are noted as to : 1. The opaque salt used. 2. The character of the vehicle. 3. The proportion of opaque material to the medium of sus- pension. 4. The total quantity administered. 5. Management of the patient with regard to eating after the opaque meal has been taken. Mention has been made elsewhere of the various opaque salts used, including the subcarbonate and oxychloride of bis- muth, zirconium oxide, barium sulphate, etc. So far as we are able to discover from the published observations of others and from our own experience there seems to be little difference in the evacuation time of the various bismuth salts when given under equal conditions; but the difference in this respect between bis- muth salts and barium sulphate is marked, the latter leaving ROENTGENOLOGIC TESTS OF MOTILITY 111 the stomach distinctly earUer. Groeders-^ figures also indi- cate that with barium sulphate the stomach empties itself much faster than with bismuth. The vehicles employed have been of every sort conceivable, including water, milk, mucilage of acacia, bread and milk, cereal porridges, paps and gruels, mashed potatoes, fermented milk, and mixed meals containing meat. The proportion of opaque salt to suspension medium varies from 10 to 50 per cent, of the former, and the total quantity of the meal given ranges from 6 to 20 ounces or more. Finally, practice differs as to permitting the patient to follow his accustomed habits of eating and drink- ing during the period of examination. Often this important feature is not mentioned, yet it is known that the taking of food after ingestion of the opaque meal will markedly prolong the evacuation time of the latter. It is quite apparent that from these differing technics, differ- ing results must follow and this undoubtedly accounts very largely for the varying esteem in which roentgen tests for motil- ity are held. The prototype of all the opaque meals now in use was that devised by Rieder,-^ and consisted of 50 gm. of bismuth carbon- ate in 350 gm. of flour-pap. Rieder considered three to four hours as the normal emptying time, for this meal. Commonly half the meal is discharged within an hour. Toward the end of digestion, he remarks, there is a distinct slowing of emptying which he thinks is due to an intestinal reflex. He mentions the experiments of Wulach showing the emptying time of carbohy- drate mixtures to be from two and one-half to three and one- half hours, albuminous mixtures five or six hours, and fat from seven to eight and one-half hours. The roentgen method gives a good picture of gastric motility. But, Rieder adds, in spite of the great excellence of the roentgen motility test, the method formerly used alone of withdrawing a test-breakfast or test-meal will firmly retain its diagnostic worth because it will show in every case not only the motility but also the secretory function. Barclay^^ has used bismuth carbonate in the proportion of 112 THE NORMAL STOMACH 1 to 2 or 3 of the excipient, for which latter he employs bread and milk, thoroughly mashed up, or porridge. The total quan- tity given varied from 2 to 12 ounces. With regard to motility he says: ^ Retention of bismuth food is the result of pj'loric obstruction and Rieder laid it down that the whole of a bismuth meal should have left the stomach within five hours. For diagnostic purposes this is a good enough guide, but I never report definite obstruction unless the delay is well marked. In hospital practice eight hours' retention is my stand- ard, but in the vast majority of the cases recorded, some food was still present in the stomach after twenty-four hours. In private practice six hours is my standard, but I always repeat the observation on at least one occasion to verify this finding when the margin of delay is so small. GroedeP" at first employed the Rieder carbohydrate meal. An emptying time beyond four hours he regarded as abnormal. Later ^^ he began using barium sulphate 250 gm., mixed with 20 gm. each of maize flour, sugar and cocoa in 400 c.c. of water. This meal, he found, emptied normally in two hours. Kaestle^^ considers two and one-half to three and one-half hours as the normal emptying time of a fluid, carbohydrate (mondamin), contrast meal containing zirconium oxide and weighing 400 gm. A stiff mixture of the same weight may re- quire four hours. Slight delay of evacuation of the fluid meal, up to six hours, he states, may be caused by gastric atony, hyperacidity, reflex pylorospasm, and even beginning pyloric stenosis. Residues after twelve hours or longer occur only with organic pyloric stenosis. HjqDermotility may result from a gaping pylorus or strong expulsive energ}^ (hypertonus and hyperperistalsis) . Satterlee and LeWald^° in their description of the water- trap stomach remarked the occurrence of a residue from the bismuth meal in many of these cases. "The water-trap stom- ach," they say, ''might almost be considered as a ptosed organ, with the first portion of the duodenum and the pylorus fixed in proper position, giving the characteristic long pyloric arm and ROENTGENOLOGIC TESTS OF MOTILITY 113 resemblance to a water trap." The meal given consisted of 90 gm. of bismuth subcarbonate suspended in 600 c.c. of fer- mented milk. A residue from this meal, ''long after the usual emptying time" was noted in 50 per cent, of the cases. Cole^^ remarks: I have alreadj^ shown the fallacy of testing the gastric motor efficiency by administering bismuth suspended in fluid or mixed -with cereal, and the same is true for intestinal motor efficiency. If the test is to be of value the stomach and intestines must be called on to evacu- ate such a meal as is normally imposed on them. Therefore, the true test of gastro-intestinal motor efficiency is made by administering bismuth or barium suspended in fluid, preferably buttermilk, in con- junction with a Riegel meal of meat, potatoes and bread. ... If the stomach is high and of the cow-horn type, especially if a condition of diminished acidity or achylia exists, evacuation will be accomplished very rapidly, perhaps in two hours, whereas many a stomach present- ing no organic obstruction requires six hours for complete evacuation. Baetjer and Friedenwald^- gave a meal consisting of bismuth subcarbonate, 1/4 ounces; in an ordinary glass of water (about 12 ounces) with sufficient mucilage of acacia to make an emul- sion. They regard from three to four hours as the normal empty- ing time for a horizontal stomach; from five to six hours for a prolapsed fish-hook stomach. George and Gerber^^ call attention to the composition of the original Rieder meal and the fact that other mediums and much larger amounts of the opaque salts came into use. They offer this comment: As a result of the marked variation of bismuth meals it is impossible to use the same functional data for diagnosis .... This is a point which has not been appreciated by many roentgenologists. They have used various kinds of meals — not only buttermilk, but malted milk, plain milk, water, mashed potato, etc., and have varied the amount of bismuth or barium, and yet have attempted to apply to their work the conclusions based on the observation of functional dis- turbances in thousands of cases done under the Rieder technic. Ob- viously this is incorrect. The only proper course left for one who wishes to use these functional data is to accumulate a large number of • s 114 THE NORMAL STOMACH cases, done with more satisfactorj" mixtures and check them up with operative results. In a paper written a few- months prior to the above, George and Gerber^* venture this statement : ''The more we have accu- mulated evidence on this subject, the more w^e have become con- vinced that six-hour gastric stasis is the least important factor in roentgen bismuth diagnosis." Recently they^^ have reiterated this opinion. It should be noted that with their technic the patient is permitted to take food during the six-hour period. As a test of motility in those cases in which the stomach-tube is contraindicated or refused, Bassler^^ uses a mixed-meal method by w-hich he gives 25 gm. of bismuth subcarbonate with the Riegel meal and examines by the roentgen ray six hours later, at which time the stomach should be empty. In marked, pyloric stenosis he has noted a residue at twelve hours, or much later, even to five days. How'ever, in a subsequent publication, Bassler" has this to say: In the study of motility and exit from the stomach in 203 cases of distinct gastroptosia, in which hourly roentgen-ray observations were made, the conclusion was plain that the roentgen-ray method of diag- nosing stasis in the stomach is not as practical as the test-meal method. One hundred and twenty-six of these cases examined by the bismuth- roentgen-ray method showed delay of exit of six hours or more, while only 31 showed the delay by the test-meal method. . . . Instances were encountered in which bismuth was present in the stomach as late as eighteen hours after ingestion, while the stomach on a mixed meal was empty in fom' and one-half hours. ... It is apparent, whatever has been advanced to the contrary, that the method of ex- amination by food extraction is decidedly more to be depended on in gaining an idea of exit from the stomach than is the bismuth-roentgen- ray method, for it was strongly suggested that foods pass from the stomach in decidedly less time than will bismuth or any other form of metal salts used to throw a shadow, probably because of the pulverized salts adhering to the mucosa. The most faithful advocate of the roentgen motility test is Haudek,^^and tohimw^e are indebted for the double-meal method of examination, the establishment of the six-xxour limit and a ROENTGENOLOGIC TESTS OF MOTILITY 115 vast deal of information concerning the significance of disordered motility as shown by the roentgen ray. The rather chaotic application of the roentgen examination for motility led Haudek, in 1909, to establish his double-meal method, partly with the view of saving time and partly to make the test more precise. Accordingly, he began the administration of a Rieder meal in the morning, and examined the patient six hours later, at which time a second Rieder meal was given to complete the examination. The selection by Haudek of six hours as the division line between normal and delayed emptying was explained by him on the ground that while the normal stomach will drive out a Rieder meal in about three hours, as an average, delay to -five or six hours might result from physiologic causes. He cited as exam- ples the influence of rest and movement, right and left-side posi- tions, psychic factors, eating or drinking after taking the meal, and sedimentation of the opaque salt. Even after six hours or longer, minute residues might sometimes be found in normal stomachs, and he accordingly ignored mere traces. Small resi- dues, up to a quarter of the meal, he deemed, could be due not only to organic pathologic changes but also to hypomotility from atony, hyperacidity, or long hubhohe, that is, a long, vertical pars pylorica. Larger residues could be almost certainly ascribed to pyloric obstruction by organic stenosis or spasm from ulcer. He also pointed out that the test did not rest alone on the pres- ence or absence of a residue, but that the position of the ''head" of the six-hour meal gave gross information as to motility. Normally at or near the cecum, the ''head" would be advanced far into the large intestine by hypermotility or held back in the small intestine by hypomotility. Further, on giving the second meal, there could also be taken into consideration the tonus of the stomach, its peristalsis, the freedom of passage through the pylorus, the hubhohe, and thus the total picture would enable an estimation of "the great 'X' of motility, the functioning of the pylorus." An experience of years with thousands of cases has increased Haudek's confidence in the method. In a recent article, he^®; 116 THE NORMAL STOMACH goes SO far as to say that the roentgen determination of the ex- peUing forces of the stomach gives better results than the older methods, and that it is not only exact and reliable but also very simple. He shows that while the clinical examination cannot determine whether the increase or decrease of motility is due to a change of the expelling power or of the resistance, the roentgen examination can be much more decisive. While he had pre- viously considered atony to be an occasional cause of six-hour retention he now believes that atony, under otherwise normal conditions, causes only a slight lengthening of evacuation time, usually below six hours. The most important factor for the evacuation of the stomach is the condition of the pylorus. Lessening of resistance produces the picture of pyloric insuffi- ciency; an increase leads to the highest degrees of stagnation. For more than four years past our work has been based on the double-meal method of Haudek, and we can unreservedly endorse his claims. . For various reasons w^e have found it advisable to modify his technic in some particulars, but have retained the six-hour limit and adhered rather closely to his general princi- ples. A cereal porridge instead of a pap for the six-hour meal is employed and barium sulphate substituted for bismuth salts. (For detailed technic refer again to page 75.) Since barium leaves the stomach earlier than bismuth we believe that a six- hour retention of barium is even more significant than one of bismuth. Until the beginning of 1914 patients were required to take castor oil in the evening previous to the day of examina- tion, but this has been abandoned as unnecessary. The obser- vations of Hayes^° show that purgation results in a heightening of gastro-intestinal motility for a day or two. A comparison of our observations since 1914 with those made previously, in- dicates that this increase does occur, but that it does not mate- rially affect the six-hour test. With the stomach empty at the end of six hours and the head of the motor meal anywhere from the cecum to the hepatic flex- ure the gastric motility is considered normal, at least so far as the net result is concerned. It does not follow that this finding REFERENCES 117 absolutely excludes any disturbance of either the active or pas- sive factors of motility, since a diminution of one may be offset by an exaggeration of the other. For example, a somewhat stenotic pylorus or duodenum may be balanced by vigorous gastric peristalsis, or an achylia; or a so-called atonic stomach with weak peristalsis may evacuate its contents through an un- usually patent pylorus in average time. Hence a stomach that is empty at six hours, with the motor meal at or not far beyond the cecum, is, strictly speaking, normal as to motility only on condition that other elements are normal also, that is, acidity, peristalsis, tonus and pyloric functioning. If any of the latter are definitely abnormal, the presumption is that one abnormality is compensated by some other, and an analysis of the complica- tion may promote diagnostic nicety. With our present limita- tions, however, a calculation of this sort could easily lead to error by its intricacy. Likewise, between the average emptying time of say three hours and the arbitrary limit of six hours allowed for presumptively normal evacuation, is a rather wide zone for the play of physiologic and occasionally pathologic, factors causing hypomotility. It was precisely to make liberal allowance for these that Haudek drew his line at six hours, and for this reason we have adhered to that line, though our meal probably leaves the stomach earlier than Haudek's. If there is error it is, at all events, on the side of safety. A degree of hypermotility, as evinced by advancement of the meal beyond the hepatic flexure and by rapid discharge of the second meal through the pylorus, not rarely has a physiologic explanation, as, for example, a hypertonic, steer-horn stomach. But marked hypermotility should stimulate a search for possible pathologic causes. REFERENCES 1. Stiller, B.: "Die asthenische Konstitutions-Krankheit." Stutt- gart, F. Enke, 1907, 1-225. 2. Stiller, B.: "Kritische Glossen eines Klinikers zur Radiologie des Magens." Berlin, S. Karger, 1910, 1-28. 3. HoLZKNECHT, G. : ''Der normale Magen nach Form, Lage und 118 THE NORMAL STOMACH Grosze." Mitteilungen aus dem Lab. jiir Rad. Diag., 1906, i, 72-84. 4. Cannon, W. B.: ''Mechanical Factors of Digestion." New York, Longmans, Green & Co., 1911, 47-48. 5. ScHLESiNGER, E. : "Die Grundformen des normalen und patholo- gischen Magens und ihre Entstehung." Berl. klin. Wchnschr., 1910, xlvii, 1977-1981. 6. Barclay, A. E.: "The Stomach and Esophagus." Xew York, Macmillan Co., 1915, 59. 7. EwALD, C. A.: "Diseases of the Stomach." New York, D. Appleton & Co., 1902, 91-92. 8. Gray, H.: "Anatomy, Descriptive and SurgicaL" Philadelphia, Lea Bros. & Co., 1905, 1273. 9. Kaestle, K.: "Versuch einer neuen Methode zur Priifung der Verweildauer von Flussigkeiten im Magen." Muench. Med. Wchnschr., 1910, Ivii, 1837-1838. 10. ScHWARz, G. : "tJber Salzsaure Probe ohne Magenschlauch." Ver- handlungen der Deut. Rontgen-Gesellschaft, iii, II. Sitzung, 68-69. 11. Kaufman, R. and Holzknecht, G.: "Die Peristaltik am An- trum pylori des Menschen." Mitteilungen aus dem Lah. fUr Rad. Diag. und Ther., 1906, i, 66-71. 12. Kaestle, K., Rieder, H. and Rosenthal, J.: "The Bioroentgen- ography of the Internal Organs." Arch. Roent. Ray, 1910-11, XV, 3-12. Kaestle, K.: "Lehrbuch der Roentgenkunde," by Rieder-Rosen- thal, Leipzig, Barth, 1913, i, 504. L3. Cannon, W. B.: "The Mechanical Factors of Digestion." New York, Longmans, Green & Co., 1911, 53. 14. Groedel, F. M. : "Atlas und Grundriss der Roentgen Diagnostik." Munich, J. F. Lehmann, 1909, 193-194. 15. Cole, L. G.: "The Complex Motor Phenomena of Various Types of Unobstructed Gastric Peristalsis." Arch. Roent. Ray, 1911- 1912, xvi, 242-247. 16. In the "Life and Letters of Dr. William Beaumont," by J. S. Myer, St. Louis, C. V. Mosby Co., 1912, 201. 17. Cannon, W. B.: "The Mechanical Factors of Digestion." New York, Longmans, Green & Co., 1912, 84. 18. Kemp, R. C: "Diseases of the Stomach and Intestines." Phila- delphia, W. B. Saunders Co., 1911, 122. 19. SiEVERs, R. and Ewald, C. A.: "Zur Pathologic und Therapie der Magenektasien." Therap. Monatsh., 1887, i, 289-291. 20. Heichelheim, S.: Ztschr. f. klin. Med., 1900, xli, 321-331. REFERENCES 119 21. Klemperer, G.: "Uber die Motorische Tiitigkeit des Menschlichen :\Iagens." Deutsch. med. Wchnschr., 1888, xiv, 962-966. 22. Bassler, a.: "Diseases of the Stomach and Upper AHmentary Tract." Philadelphia, F. A. Davis Co., 1913, 158. 23. EiNHORN, M.: "Diseases of the Stomach." New York, Wilham Wood & Co., 1911, 119. 24. Groedel, F. M. : "The Influence of Various Contrast Substances on the Motility of the Intestinal Canal." Aixh. Roent. Ray, April, 1913, 420. 25. RiEDER, H. : "Das Roentgen- Yerfahren im Dienste der Pathologie und Therapie des Magen-Darm-Kanales," Yerhandl. cl. xxix, Deutsch. Kong. f. Lit. Med., J. F. Bergmann, Wiesbaden, 1912, 22. 26. Barclay, A. E.: "The Stomach and Esophagus." New York, Macmillan Co., 1913, 9, 36. 27. Groedel, F. M.: "Atlas und Grundriss der Roentgendiagnostik." IMunich, J. F. Lehmann, 1909, 176, 198. 28. Groedel, F. yi.: "The Influence of Various Contrast Substances on the Motility of the Intestinal Canal." Arch. Roent. Ray, 1913, xvii, 420. 29. Kaestle, K. : "Lehrbuch der Roentgenkunde (Rieder-Rosen- thal)." Leipzig, J. A. Barth, 1913, i, 531. 30. Satterlee, G. R. and LeWald, L. T.: "One Hundred Cases of Water-trap Stomach." Jour. A. M. A., 1913, Ixi, 1340-1344. 31. Cole, L. G.: "Relation of Lesions of the Small Intestine to Dis- orders of the Stomach and Cap as Observed Roentgenolog- ically." Amer. Jour. Med. Sci., 1914, cxlviii, 92-118. 32. Baetjer, F. H. and Friedenwald, J.: "On the Diagnosis of In- complete Forms of Pyloric Stenosis by Means of the Roentgen Ray." Boston Med. and Surg. Jour., 1914, clxxi, 261-264. 33. George, A. W. and Gerber, I.: "The Roentgen Diagnosis of Duodenal Ulcer." Surg., Gynec. and Obstet., 1914, xix, 395-403. 34. George, A. W. and Gerber, I. : " The Practical Apphcation of the Roentgen Method to Gastric and Duodenal Diagnosis." Jour. A.M. A., 1914, Ixii, 1071-1073. 35. George, A. W. and Gerber, I. : " Observations from the Study of a Thousand Gastro-intestinal Cases." Amer. Jour. Roent- genology, 1915, ii, 592-600. 36. Bassler, a.: "Diseases of the Stomach and Upper Alimentary Tract." Philadelphia, F. A. Davis Co., 1913, 213. 37. Bassler, A.: "Some Recent Conclusions on Abdominal Roentgen Ray Work." Jour. A. M. A., 1913, Ixi, 2217-2218. 120 THE NORMAL STOMACH 38. Hal-dek, M.: ''Die Technik und Bedeutung der Radiologischen ]Motilitatsprufung." Verhandl. d. xxix, Deutsch. Kong. f. Int. Med., J. F. Bergmann, Wiesbaden, 1912, 143. 39. Haudek, M.: "tJber die Radiologische Priifung der Magenmo- tilitat und Ihre Resultate." Fortschr. a. d. Geb. d. Roentgen- strahlen, 1914, xxi, 472. 40. HayeSj M. R. J.: "Roentgen Rays in the Diagnosis of Abnor- malities of the Intestinal Tract." Cliii. Jour., 1914, xliii, 529. Abstr. Surg., Gynec. and Ohstet., 1915, xx, 138. CHAPTER VII THE ABNORMAL STOMACH Form Variations. — Other things being equal, the general form of the stomach should correspond to the habitus of its possessor, and an inharmonious combination demands explana- tion. Thus, the steer-horn form of stomach, which is some- times seen normally in the broad habitus, is to be regarded with suspicion if seen in association with the habitus enteroptoticus^ and the possibility of a carcinoma or other lesion should be in- vestigated. On the other hand, the occurrence of a fish-hook stomach in a person of the broad habitus is not necessarily sig- nificant, unless the stomach be also hypotonic and elongated. The form of the stomach has some slight indicative value in predicating the nature of a lesion which may possibly exist. For example, ulcer is rarely found in a steer-horn stomach; by far the larger number of ulcers that we have seen occurred in the fish-hook type. In fact, the steer-horn type of stomach, which is itself infrequent, rather seldom show^s lesions of any sort. The apparent steer-horn occasionally seen in advanced scirrhous carcinoma is, of course, a result of the pathologic process. The hook-form is often preserved in medullary carcinoma of the stomach. A snail-form of the stomach, with acute flexion of the pyloric end toward the lesser curvature is found occasionally in gastric ulcer. Marked distortion and deformity of the stomach may occur with gastric carcinoma and tumors of all sorts, syphilis, ulcer, spasm, extrinsic tumors, ascites, or increased intra-abdominal tension from any cause, including voluntary contraction of the abdominal muscles. Hour-glass Stomach. — Some confusion has arisen from a rather indiscriminate use of this term. Broadly speaking, it 121 122 THE ABNORMAL STOMACH applies to anj^ stomach which is constricted or segmented so as to form two, and exceptionally three or more, distinct loculi, even temporarily. To the surgeon the word generally signifies an organic and permanent biloculation, and, failing to find such a condition at operation, he regards the diagnosis of hour-glass stomach as erroneous, although the roentgen findings may have been quite definite. Organic hour-glass stomach may result from ulcer, carcino- matous, syphilitic or other tumors of the gastric wall, or, rarely, Fig. -Perforating gastric ulcer a. Hour-glass constriction at b. from adhesion-bands. A few rare cases have been reported in which the condition was a congenital deformity (Adami and Nicholls^). Spasmodic hour-glass stomach, solely the result of spasm, may have as its antecedent cause a lesion within the stomach or an extrinsic condition. The organic hour-glass seen sometimes in association with gastric ulcer, usually results from the perforating type and is due not merely to spasm of the circular muscle-fibers but to in- filtration and adhesions (Fig. 77). As a rule, the canal joining HOUE-GLASS STOMACH 123 the two loculi is short and near the lesser curvature. Thus the stomach has some resemblance to a capital B. With syphilitic ulcer, hour-glass contraction seems to be common. The organic hour-glass of gastric carcinoma, syphilis and other tumor-producing lesions caused by the projection of the tumor-mass into the gastric lumen usually shows characteristic irregularity and shading of outline. The canal uniting the two segments is usually longer than that seen wdth the hour-glass of ulcer. Sometimes, and especially in carcinoma, the canal is Fig. 78. — Organic hour-glass at a. Cancer of the stomach. centrally placed, so that the stomach has the form of a script X (Fig. 78). The hour-glass form due to spasm is frequently of the B-type, resulting from a deep, incisure-like indentation of the greater curvature. This contraction may be caused by an ulcer or its scar; or it may occur in association with neuroses or conditions outside the stomach such as lesions of the gall-bladder, duodenal ulcer or appefidicitis. It may also occur independently of any 124 THE ABNORMAL STOMACH discoverable lesion. Sharpness of the constricted outline is fairly constant in spastic hour-glass. An extremely hypotonic, elongated stomach, with approxi- mated vertical walls, may superficially simulate an hour-glass, but upon pushing the barium upward the seeming constriction disappears. Tumors outside the stomach may so deeply indent the gastric contour as to give the stomach an hour-glass form; palpatory" manipulation will usually show the condition. Strong retraction of the abdomen or the dorsal position may result in more or less biloculation of the stomach by the vertebral ridge. Likewise, compression of the patient's abdomen against the plate while radiographing either in the standing or prone position may cause a similar segmentation. It is to be assumed that the ob- server will recognize a peristaltic constriction and will not con- found it with hour-glass constriction. The shadow of a large mammary gland merging with the gastric outline may appear somewhat like an hour-glass deformity. Differentiation of an hour-glass produced by a gastric lesion, from a spastic hour-glass due to conditions outside the stomach, is often possible. The purely reflex spasmodic hour-glass may often be relaxed by energetic manipulation during the screen- examination. If, in spite of this, it persists, belladonna given to physiologic effect (see page 166) will nearly always relax it. Organic hour-glass and the spastic hour-glass of ulcer constantly withstand these measures. Changes of Contour. — Irregularities of the gastric outline are of the highest importance in roentgenologic diagnosis. These alterations consist either of localized additions to or sub- tractions from the visualized gastric lumen. As examples of the former we have the niche of penetrating ulcer and the accessory pocket of perforating ulcer. The niche represents the crater of the ulcer, varies in size from that of a pea to -that of a cherrj^ or larger, and shows as a direct extension of the lumenal shadow (Fig. 79). It is more commonly located on or near the lesser curvature of the pars media, but may be found on the anterior wall, posterior wall, or greater cufvature. The CHANGES OF CONTOUR 125 Fig. 79. — Penetrating ulcer. Niche at a. Fig. 80. — Accessory pocket at a, due to perforating ulcer. 126 THE ABNORMAL STOMACH accessory pocket is an excavation produced by the extension of a perforating gastric ulcer into adjacent tissue, usually the liver or pancreas (Fig. 80) . It shows as a shadow the size of a filbert or Walnut outside but near the gastric lumen. Its channel of communication with the latter is not easilj^ demonstrable. Its own contour may be symmetrically rounded or irregular. Por- tions of the opaque meal in the bowel adjacent to the stomach may occasionally simulate a niche or pocket, but a change in the position of the patient and abdominal manipulation -will usually show the true condition. The bulge between two peristaltic waA'e depressions close to each other on the lesser curvature has a superficial resemblance to a niche except that it advances with the progress of the waves, while a niche remains stationary. Localized subtractions from the gastric outhne, known as filling-defects, may be actual and permanent if due to lesions in- volving the gastric wall, or apparent and non-permanent if due to extraneous conditions. Actual fiUing-defects are noted in carcinoma (Fig. 81), s^TDhihs, benign tumor, varicosities and adhesions. Apparent filhng-defects may result fromfas or feces in the adjacent bowel (Fig. 82), extrinsic tumors (Fig. 83), spasm of the gastric musculature, extreme intra-abdominal pres- sure,, fluid pent up in the pyloric end of the stomach, food rem- nants or foreign bodies in the stomach, fault}^ opaque mixtures separating irregularly, or the pressure of a kyphotic or lordotic spine. On the plate the displacement of the visuahzing meal, resulting from compression of the stomach against the spine (Fig. 84), is likely to be misinterpreted by the novice as an actual filhng-defect. Tests of the genuineness of a filUng-defect are its persistence under all conditions during the screen-exami- nation, its unaltered position and configuration after massage, its constancy upon all plates and at successive examinations, and, as a differential point from spasm, its resistance to antispas- modics. The incisura, often a relatively deep, narrow, finger-shaped, indentation, sometimes a small angular notch, almost always seated on the greater curvature, is seen occasionally in ulcer, as a CHANGES OF CONTOUE 127 Fig. 81. — Extensive filling defects, in the body of stomach, due to cancer at a. Fig. 82.- -Apparent filling defect along the greater curvature, due to gas in the colon at a. 128 THE ABNORMAL STOMACH Fig. 83. — Filling defect in vertical portion of the stomach, produced by an extrinsic tumor, at a Fig. 84. — Apparent filling defect, caiisnl 1>,\ iiiessure of stomach against the spine, seen at a. ALTERATIONS OF TONE' 129 result of spastic contraction of the circular muscle-fibers in the plane of the ulcer (Fig.. 85). Similar incisurse may be pro- duced by an adhesion-band, or by reflex spasm from conditions outside the stomach. The wide, relatively shallow, spastic in- drawing of the curvature seen now and then opposite a carcin- oma is sometimes spoken of as a wide incisura. The incisura of gastric ulcer occupies a constant situation and is usually per- sistent, although some observers have claimed that shallow ul- FiG. 85. — Penetrating ulcer at a. Incisura at h. cers or erosions may give rise to intermittent incisurse. Two ulcers in different planes may give rise to a double incisura. The incisura arising from an extrinsic reflex is most often of an exaggerated type, being deeper and wider than the incisura of ulcer. Frequently it is associated with a tumultuous, irregular peristalsis, and travels like a peristaltic wave. Again, it may persist at one spot, or recur there intermittently. Alterations of Tone. — The hypertonic stomach, though found in normal persons, is also a common accompaniment of non- 130 THE ABNORMAL STOMACH Fig. 86. — Hj-pertonic stomach. Fig. 87. — Hypotonic stomach. ALTEEED POSITION 131 obstructing duodenal ulcer, and it may result reflexly from other irritated foci outside the stomach (Fig. 86). The small shrunken stomach of scirrhous carcinoma or fibromatosis is only appar- ently hypertonic. The hypotonic stomach is not rarely observed without any lesion, especially in asthenic persons and those with relaxed abdominal walls (see '^ Normal Stomach, Tonus"). Loss of tone and dilatation of various degrees may occur as a sequence of long-continued spastic or organic obstruction at or near the pylorus from gastric ulcer, carcinoma, benign tumors, lesions of the gall-bladder, obstructive duodenal ulcer, etc. (Fig. 87). Altered Position. — The cardiac end of the stomach being fixed and the pyloric end being little less so, we are concerned in most instances with displacement of the body of the stomach, more especialy the lower pole, which may be dislocated in any direction. Displacement of the lower pole upward and to the left may be produced by perforating gastric ulcer, extrinsic tumors, ascites, pregnancy, heightened abdominal tension, or spasm; downward in hypotonus from any cause, dilatation, or ptosis. Lateral displacement, to either side, by gas in the in- testine or by tumors outside the stomach, is not uncommon. Rarely the fundus itself may be displaced upward in dia- phragmatic hernia or eventration, and Schlesinger- holds that it may participate to some extent in the downward displacement of gastroptosis. The pylorus, tethered by the duodenojejunal ligament, is not easily susceptible to any considerable dislocation in an indi- vidual case. But its position varies markedly in different indi- viduals, in correspondence with the form of the stomach and the habitus (see "Normal Stomach"). Sometimes, also, its position is not in harmony with the general position of the stom- ach, and a degree of displacement may be obvious. Thus with the curled-up, snail-form of stomach, seen rarely in gastric ulcer, the pylorus may lie well to the left of the median hne. Excep- tionally, the pyloric end may be drawn upward and to the right by pericholecystic adhesions. While we have observed broad 132 THE ABNOEMAL STOMACH variations as to the height of the pylorus in persons without any gastric lesion, GroedeP considers pyloroptosis as a sign of gas- troptosis, and with the ptosis is associated a greater mobility of the pylorus. Occasionally there is noted an apparent torsion of the fish- hook stomach to the right side on its long axis, so that the cor- pus lies in front of the pylorus; this displacement seems most often to be produced by causes outside the stomach, and is with- out other import. Transposition of the stomach, as a feature of situs inversus, deserves only casual mention. Alteration of Size. — Diminished size (capacity), real or ap- parent, may be due to hypertonus, increased intra-abdominal tension, carcinoma, syphilis, benign tumors, spasm, starvation, esophageal obstruction, operative resection, or gastro-enteros- tomy. Increased size may be the result of hypotonus, functional atony, or dilatation consequent upon obstruction at or near the pylorus (gastric ulcer, carcinoma, benign growths, obstructive duodenal ulcer, adhesions from pericholecystitis, etc.). The elongated (ptosed) stomach shows an incidental increase of capacity. The functionally hypotonic or atonic stomach is ex- panded chiefly at its lower pole; the elongated stomach largely retains its tubular form; the dilated (ectatic) stomach is enlarged throughout, including its pyloric portion, which is not only ex- panded but also extends well to the right. Altered Mobility. — It should here be repeated that lessened mobility is seen normally in high-seated and hypertonic stom- achs, not only because they are situated unfavorably for man- ipulation, but also because they are short and more or less tensed between their chief suspension-points. Apparent dim- inution of mobility may result also from increased tension of the abdominal muscles. However, fixation of various degrees and at various points may ensue from perforating ulcer, carcinoma or any perigastric inflammation producing adhesions. Such fixation may be evidenced not only by the ineffectiveness of efforts at shifting by palpation, and changing the patient's posi- LESSENED FLEXIBILITY 133 tion, but also by the failure of deep respiration to alter the posi- tion of the affected gastric area. In rare instances, bands of ad- hesions may produce irregularity of the gastric contour at the adherent point. Fixation of the pyloric end of the stomach as a result of inflammatory processes in the right upper abdominal quadrant (pericholecystitis, perforating duodenal ulcer) we have found determinable rather seldom. Palpatory pressure some- times merely dislocates the gastric contents and gives the im- pression that the gastric wall is moved also, although the latter may be adherent. On the other hand, an apparently fixed area may be found entirely free at operation. Excessive mobility of the lower pole is a common feature of hypotonic, atonic and ptosed stomachs. Lessened Flexibility. — Loss of flexibility, as shown by a lack of response of the gastric wall to narrow palpation, may result from any infiltrative process, but is seen characteristically in extensive carcinoma and in the ''leather-bottle stomach." Here the infiltrated, stiffened wall of the stomach glides away from the palpating finger, which in the normal stomach produces a correspondingly narrow indentation. This lack of pliability is also confirmed by the local or general restriction of expansion upon adding to the contents of the stomach. Somewhat similar stiffening, though usually of a lesser degree, may be seen in gastrospasm, but an intense spasm of the pars pylorica may temporarily constrict it to a narrow, rigid, palpable tube. In judging flexibility, the examiner should take into account the accessibility of the stomach to palpation. A high-seated stom- ach can be little affected by manipulation. Gas-bubble. — Variations as to size of the gas-bubble have little or no pathologic significance. In aerophagy the bubble is often quite large, and may or may not diminish after the pa- tient belches. Normally regular and symmetrical in outline, its contour may be broken by a tumor of the cardia, by splenic or hepatic tumors, by a gas-distended splenic flexure of the colon, or by herniation through the diaphragm. Carcinoma, which is by 134 THE ABNORMAL STOMACH far the most common intrinsic tumor involving the upper cardia, usually implicates the lesser-curvature side, and opaquely de- forms this aspect of the gas-bubble. Gas in the splenic flexure is more likely to distort the outer aspect of the gas-bubble, and the haustrated, translucent colon is easily distinguished. Secretion. — An excessive amount of secretion is sometimes discoverable by the roentgen examination. The upper level of the accumulated fluid may reach nearly or quite to the gas- bubble, and the barium as swallowed descends through it slowly. After filling the stomach the translucent layer between the gas- bubble and the opaque ingesta is extraordinary wide. Such hypersecretion, or retention of secretion, is more likely to be ob- served in any obstructive condition near the pylorus, but more particularly in gastric ulcer, or duodenal ulcer. It is frequently associated with a retention from the six-hour meal, and often with some degree of gastric dilatation. Absence or diminution of secretion may be also more or less evident in the achylia of carcinoma or after gastro-enterostomy. Abnormal Peristalsis. — Gastric peristalsis is susceptible of considerable diversity as to the number of waves to be seen simul- taneously, their energy as shown by their depth, their frequency, regularity of succession and point of origin and termination. While these variations may occur in non-pathologic conditions, as mentioned in the discussion of the normal stomach, they often possess diagnostic significance, although, as Kaestle^ says, the line is not at present drawn sharply enough to make it always possible to say positively where the normal ceases and the ab- normal begins. Sluggish peristalsis, with diminution of the number and depth of the waves, may be consequent upon low acidity, hypotonus, fright or disgust. Kaestle^ remarks that in atonic ectasia the peristaltic waves are shallow and sluggish, and new-formation of the "antrum" is lacking. This faintness of peristalsis in the so-called atonic stomach we have observed repeatedly, but when a wave definitely formed we have been able nearly always to follow its progress to the pylorus. With low acids peristalsis ABNORMAL PERISTALSIS 135 is also less active. While Cannon" admits the concomitant variation of acid gastric contents and peristalsis, he has observed deep and strong peristaltic waves in the stomach when the con- tents were strongly alkaline. In our experience nervous or apprehensive persons have usually shown markedly diminished peristaltic activity, and its initiation was often delayed until they regained their composure. The increase of peristaltic vigor by hyperacidity has often been noted and the tendency of hyper- tonus to be associated with well-marked peristalsis has already been mentioned. From a diagnostic standpoint, therefore, neither moderately diminished nor moderately increased peris- talsis has any import. There are peristaltic phenomena, how- ever, which are definitely abnormal and which have strong diag- nostic significance. These include absence of peristalsis, either general or local, hyperperistalsis, irregular peristalsis and anti- peristalsis. General absence of peristalsis may be due to extensive car- cinoma, fibromatosis, syphilis or general gastrospasm. The complete inertia of the stomach is striking, although in non-ob- structive cases there is usually also a continuous and copious drainage of the gastric contents through a gaping pylorus. In addition to the absence of peristaltic movement, the gastric contour is manifestly deformed by widespread filling-defects, and, if gastrospasm be eliminated, the presence of an intrinsic organic lesion is practically certain. Absence of peristalsis from a local area may be caused by a new-growth, inflammatory infiltration, adhesions, or localized spasm involving that segment of the stomach. While the af- fected zone remains immobile, peristalsis may be noted in the uninvolved musculature above or below, and this feature is often of service in detecting early or small organic lesions. Hyperperistalsis, with an increase of the number and depth of the waves on both curvatures, is seen typically in obstructing lesions of the duodenum (Fig. 88). WTiereas, with the technic previously described, the stomach of the standing patient nor- mally shows but one or two peristaltic constrictions, there are 136 THE ABNORMAL STOMACH now seen three or more waves, rather equally indenting both curvatures and regularly succeeding each other. The appear- ance of hyperperistalsis is often delayed for several minutes after filling the stomach, in which case it may succeed ordinary and average peristalsis. Periods of hyperperistalsis may alter- nate with less active periods. Hyperperistalsis may occur also with non-obstructing duodenal ulcer and as a reflex from other extrinsic irritations (disease of the gall-bladder or appendix, Fig. 88.— Hyperperistalsis. etc.) but, while the number of waves is increased, their depth is less exaggerated than in duodenal obstruction. The hyperperistalsis accompanying organic obstruction at, or proximal to, the pylorus, as we have observed it, contrasts markedly with the hyperperistalsis of duodenal obstruction. The hyperperistalsis of pyloric and prepyloric obstruction is erratic in character. It affects the greater curvature chiefly, or at least more than the lesser curvature. The waves are often eccentric and disorderly ; deep and shallow waves alternate with each other and often with irregular spacing between (Fig. 89). In this ABNORMAL PERISTALSIS 137 connection the remarks of Kaestle'' are worthy of quotation. He says: ''In pyloric stenosis there is found a deepened, vigorous peristalsis, beginning abnormally high in the stomach. The finding of stenotic peristalsis in an ectatic stomach justifies the diagnosis: 'Obstructive ectasia, not atonic' With continued loss of muscular power in pyloric stenosis and obstructive ectasia, there remains, at least early after ingestion, visibly deepened peristalsis. Later on, one sees deep contractions of the gastric wall only in the first moments after taking the meal, often Fig. 89. — Hyperperistalsis of the irregular type. only while the ingesta are flowing in. Finally, only by energetic massage does one obtain a contraction, deep, immovable, and remaining in one place, until this also no longer occurs and the mass of contents lies motionless on the floor of the stomach." Barclay^ states: "A normal stomach that occasionally shows very powerful waves (or successions of waves) of peristalsis with periods of inactivity between, is suggestive that peristaltic action is becoming worn out, and if this sign is observed on one 138 THE ABNORMAL STOMACH or two occasions it is practically certain that obstruction is present." Antiperistalsis, the first radiologic observations of which were published by Jonas, ^ consists in the passage of contraction waves in a reverse direction, i.e., from the pylorus toward the cardia (Fig. 90). Haudek^"^ states that the waves usually arise in the antrum pylori, may be followed along the greater curva- ture to the point separating the lower from the middle third, vary in their depth, and may alternate with normal peristaltic Fig. 90. — Antiperistalsis. All the waves here seen are moving from the pylorus toward the cardia. waves. He considers it needless to say that the occurrence of vomiting has nothing to do with antiperistalsis of the stomach. He regards antiperistalsis as a sign of some organic alteration in the walls of the stomach or duodenum, and has noted it most frequently in pyloric stenosis, usually on a basis of carcinoma or ulcer, although it is not an invariable concomitant of stenosis. He mentions, without specific reference, the finding by Hol^- knecht and Robinsohn of antiperistalsis in the gastric crises of DISORDERED MOTILITY 139 tabes, and the observation by Salomon of this phenomenon in neurasthenic persons. We have observed antiperistalsis in a considerable number of cases. Without exception, obstruction was present or motil- ity interfered with by a lesion of the wall of the stomach, as in- dicated by a six-hour retention, and no case at operation failed to show an organic lesion. In most instances the lesion involved the pyloric ring or the prepyloric segment of the stomach, and was usually ulcer or carcinoma. The exact point of origin of the antiperistaltic waves which we have seen was not closely investigated, but for the most part they were first noticed in the vestibular region, and were seen only on the greater curvature. Their rate of regression seemed to be about the same as the forward progress of peristalsis, and they disappeared in the pars media. Wider than normal waves, they are nearly always relatively shallow, sometimes so shallow that careful inspection is required to detect them, although in the illustration here shown (Fig. 90) the waves are well marked. Generally they appear to follow each other in fairly regular sequence, but run only for short periods. Haudek expresses the opinion that if there is a tendency to antiperistalsis the amplitude of the waves, and hence their visibility, can be increased by any stimulus which will increase the depth of ordinary peristalsis. Disordered Motility. — Abnormal motihty may be manifested either as an acceleration or retardation of the gastric clearance. It is evident that the double-meal method does not concern itself with hypermotiUty in terms of exact time of evacuation, although this can be established with either the first or the second meal if desired. As a rule, the degree of hypermotiUty can be reckoned by the advance of the head of the first meal beyond the cecum, plus the freedom and continuity of exit of the second meal through the pylorus. It is true that the position of the six-hour meal is the net result of the motility both of the stomach and intestine, but in the absence of intestinal obstruction as shown by other roentgen signs, or severe obstipa- 140 THE ABNORMAL STOMACH tion or diarrhea as indicated by the anamnesis, the intestinal factor can be disregarded. In the presence of a decided hypermotihty we have to con- sider as possible causes duodenal ulcer, gastric carcinoma, an- acidity and diarrhea. The report of the gastric analysis or the clinical history will decide as to anacidity or diarrhea, respect- ively. The most typical hypermotihty is seen in cancer with its gaping pylorus, which may be infiltrated and stiffened or merely relaxed by the anacidity. The flow through the pyloric open- ing is continuous and frequently voluminous, and the six-hour meal may have advanced into the transverse colon or beyond. The hypermotihty of gastric cancer is not incompatible with actual narrowing of the pylorus, which remains steadily open and thus more than compensates for the narrowing. Over 90 per cent, of gastric cancers will reveal other roentgen evidence (filling- defects), so that hypermotihty is by no means a principal sign. The hypermotihty of duodenal ulcer is commonly attributed to interference with the pylorus-closing reflex as well as to hyper- tonus and hyperperistalsis. Here, again, these factors may balance or even overcompensate a slight organic or spasmodic stenosis at the site of the ulcer. In any event, most of the cases of duodenal ulcer will show hyperperistalsis or deformity of the bulb. An initial rapid rate of clearance of the second barium meal through the pylorus is not alone a dependable sign of hypermotil- ity; advancement of the six-hour meal in the colon should be present also. We have seen numerous cases of cholecystitis (with and without periduodenal adhesions) chronic appendicitis, hypochlorhydria from all causes, and general reflex gastrospasm, in which the clearance was large and uninterrupted during five or ten minutes' examination, yet this clearance was probably not characteristic of the whole period of digestion, since the six-hour meal was not advanced beyond its average position. By the process of elimination, few cases of actual hypermotihty remain unexplained, and on the whole, it is of less practical importance than its converse. DISOKDERED MOTILITY 141 In many cases, although the stomach is empty at six hours, retarded evacuation is evinced by the motor meal lying proxi- mal to the cecum, together, sometimes, with scanty initial py- loric clearance of the second meal. For such retardation, with an emptying time greater than three hours but less than six hours, there is a host of possible causes, including depressive psychic states, weak peristalsis, hypotonus or so-called atony, high hub- hohe, ptosis, all of which occur commonly in asthenic persons, hyperacidity, reflex spasm of the pylorus and slighter grades of Fig 91. — Six-hour residue. Retention of about half the motor meal. stenosis, whether uncompensated or only partially compensated. In our own experience organic stenoses causing delayed gastric evacuation, but within six hours, have not been frequent. Shortening the time limit to say five hours in order to detect such cases would probably result in greater error by including physiologic and functional delays. The six-hour limit allows for delay resulting mainly from weakened active factors of motility — tonus and peristalsis. De- lay beyond six hours as shown by a definite residue (Fig. 91) 142 THE ABNORMAL STOMACH signifies, as a rule, some disturbance of the passive factor, namely, organic or spastic obstruction at or near the pylorus. It should be reiterated that this delay must be exhibited in a substantial and visible residue, not mere traces held in the gastric folds nor a collection in the lower pole so small that it can be seen only with difficulty. With a retention of one-fourth or more of the meal, there is probably either obstruction of an or- ganic character or a serious lesion interfering reflexly with empty- ing. Among the causes of organic- obstruction we have noted duodenal and pyloric ulcer with cicatricial contraction, hyper- trophic pyloric stenosis, pedunculated benign tumors (polyposis) pyloric cancer, syphilis of the stomach, carcinoma of the upper jejunum, and adhesion-bands from inflammatory processes in the right upper abdominal quadrant, usually pericholecystitis. Other causes of obstruction mentioned in the literature are foreign bodies (hair-balls, fruit-stones, etc.), kinking of the prolapsed stomach at its duodenal anchorage, adhesions from chronic appendicitis, and tumors outside the duodenum press- ing on it, although we have not encountered a six-hour reten- tion attributable to any of these, except possibly the last. Small residues down to an eighth or less of the motor meal may, of course, result from organic narrowing. A more common cause is spasm of the pylorus occurring reflexly from a lesion of the stomach itself, such as ulcer, or from an extrinsic pathologic focus, most often the gall-bladder or appendix, and also, but rarely, from more remote abdominal lesions. Holzknecht^^ has noted the possibility of a six-hour bismuth residue from py- loric spasm due to morphinism or a single administration of morphin at the time of examination. In explaining the mechanism bj^ which gastric retentions are produced in the absence of an organic stenosis, roentgenologists have frequently assigned ''pylorospasm" as a cause. By the clinician, the term is limited to a spasmodic contraction of the pylorus accompanied by pain, vomiting, etc., occurring com- monly as a symptom of extragastric conditions. Roentgenolog- ically, the word has been used rather broadly, perhaps somewhat DISORDERED MOTILITY 143 loosely, to cover an irritable, or hypertonic, or spastic pylorus, which relaxes less freely or less frequently than the normal pylorus, regardless of symptoms. A pylorus which is not organically stenosed is not infre- quently seen to remain closed continuously or for abnormally long periods during the roentgen-ray examination of anatomically normal stomachs showing a six-hour retention, and w^hether the term ''pylorospasm" be strictly applicable or not, the condition cannot be ignored as a probable cause of gastric retention. To differentiate retention due to pylorospasm from that pro- duced by organic stenosis, Sahli^^ has made use of sinking and swimming capsules. The distance between the floating capsule and the heavier capsule lying at the bottom of the stomach gives an idea of the amount of fluid in the stomach. The evacuation- time of water can be shown thus; this is usually normal in pjdoro- spasm but prolonged in stenosis. According to Holzknecht and Sgalitzer^^ the administration of papaverin hydrochloride shortens the emptying time in pylorospasm to normal, increases it in stenosis and has no effect on a combination of the two. It may be given in a dose of ^4 to 1 grain, an hour before the in- gestion of the meal for a second examination. As remarked previously, Hauclek has mentioned the high hubhohe, that is, a long, steeply ascending pyloric arm, as a cause of hypomotihty. Of very similar character is the ''w^ater-trap stomach" of Satterlee and Le Wald/"* in many cases of which, with the technic used, six-hour residues were noted. In both of these conditions there is usually a degree of gastric atony. Can- non^^ holds that in the normal stomach, drainage by gravity is an unfortunate conception, that the food is in exact equihbrium and that muscular action is necessary to its progression. Hau- dek claims, on the other hand, that the existence of an impeding action of a high level of the outlet has been shown experi- mentally, the evacuation-time being shortened when the patient lies in the right lateral position and prolonged when the patient lies in the left lateral position. Neilson andLipsitz^*' have found from experiments on healthy 144 THE ABNORMAL STOMACH young men that lying on the right side produces a more rapid evacuation of water than does any other position, and that lying on the back causes a quicker emptying than the upright posture. In the light of these statements it would appear that while gravity probably plays a minor role in gastric evacuation, as compared with other factors, it cannot be altogether disre- garded. Whether a high situation of the pyloric outlet, without an associated gastric atony, may or may not cause delay of evacuation, we have not seen such delay beyond six hours with the barium meal. Nor have we noted a six-hour residue attribu- table simply to hyperacidity, atony, or intestinal stasis with or without ''kinking of the duodenum. " . While the motility of the stomach in a given case is susceptible to some variation from time to time, we have seldom seen a six-hour retention which did not recur at a subsequent examination if a lesion was present. However, in the case of a residue without any other diagnostic indications, the test with the motor meal should be repeated be- fore conclusions are drawn. The interpretation of the results from the double-meal method may be either simple or complex as desired. The ob- server may be content with determining the presence or absence of a residue at the end of six hours. With the presence of such a residue he can be fairly certain of organic pathology somewhere in the gastro-intestinal tract, and probably in the stomach or duodenum. Again, he may take cognizance also of hypermo- tility or lesser degrees of hypomotility. Still again, he may consider the results in the light of all the discoverable factors pertaining to motility, including the gastric form, position, tonus, peristalsis, and acidity. Finally, he may combine and correlate his findings with other roentgenologic signs, the phys- ical examination and the clinical history. By the construction of "symptom-complexes" in this manner Holzknecht^^ was enabled to make diagnoses which he could not make otherwise. Although some of his complexes can hardly be accepted implic- itly, his general plan of weighing the roentgen signs in com- bination with each other and in conjunction with clinical data DISORDERED MOTILITY 145 is well worth while and we have followed it to advantage. While this has been criticized as an "indirect" method in comparison with the "direct" method, namely, that of proving the presence of a lesion by showing local deformity of contour, we can only say that we have often failed to discover such deformity although the symptom and sign-complex established the diagnosis. Cer- tainly deformity of contour is of the highest roentgenologic value and should be zealously sought, but, like all other signs, it fades gradually into the realm of uncertainty. A six-hour residue is a strong stimulus to careful search for other signs, and if the latter are found, the presence of a retention is added assur- ance of the presence of a lesion and that it is interfering with motility, which latter information is highly important. Gastric retention can be combined into various indicative complexes. A six-hour residue with a stomach of normal con- tour, showing hyperperistalsis, means, more than ninety times out of a hundred, obstructive duodenal ulcer. Residue plus an apparently normal gastric outline, plus an irregular, vigorous peristalsis, chiefly on the greater curvature, usually signifies a lesion involving the pyloric end of the stomach. A residue with an achyUa, but without gross alteration of the gastric con- tour, should suggest the probability either of a small obstructing pyloric carcinoma, or obstruction of the duodenum by peri- cholecystic adhesions; careful attention to the pyloric and duod- enal contours will usually make the distinction. Residue with hyperacidity and no irregularity of the gastric or duodenal out- line would indicate a stomach reflexly affected by some other abdominal condition, notably cholecystitis or appendicitis. The possibilities of the roentgenologic estimation of motility are by no means exhausted. The method described in detail deals with the evacuation of a carbohydrate meal only. We can freely endorse its convenience and trustworthiness in the diagnosis of the graver and usually surgical conditions. By a mixed meal and extension of the time limit, by examination at short inter- vals, or by testing the motility of each individual for carbohy- drates, proteins and fats separately, the diagnosis of slighter 146 THE ABNOKMAL STOMACH disturbances of motility, amenable to medical treatment, might be assisted. However, with all the work of the experimental physiologists before us, no meal can be devised the normal emptying-time of which can be foretold with certainty, and any test must be proved by trial with abundant material. ZONES OF MOTILITY BASED ON THE SIX-HOUR MOTOR MEAL Hour Zone of Hypermotility Zone of Normal Motility Early emptying, pathologic. (Non-obstruct- ing gastric carcinoma. Duodenal ulcer. Diarrheic conditions. Achylia gastrica.) Early emptying, physiologic. (Hypertonic, steer-horn stomach.) Early emptying, pathologic, but slight, or partially compensated. (Duodenal irrita- tion. Duodenal ulcer with obstruction suf- ficient to prolong the evacuation-time to two hours in spite of associated hyperperis- talsis, hypertonus and free pyloric patency.) Normal emptying. (A mornal stomach func- tionating in a normal manner.) Disordered motility with abnormal but balanced factors. (Stenosing carcinoma with achylia; average emptying-time.) Delayed emptying, physiologic. (Hypotonic fish-hook stomach.) Delayed emptying, pathologic, but slight or partially compensated. (Slight stenosis. Stenosis with hyperperistalsis.) Zone of Hypomotility Delayed emptying, pathologic. Stenosis, (a) Organic. (Obstructing pyloric carcinoma. Pyloric ulcer. Obstructing duodenal ulcer. Periduodenal adhesions, etc.) (fe) Spasmodic. (Reflex pylorospasm from ulcer on well above the pylorus, cholecystitis, appendicitis, and remote abdominal lesions.) Etc. A diagrammatic representation of motility may assist to a clearer understanding. Taking as a basis a meal which leaves the normal stomach in an average time of say three hours, such ZONES OF MOTILITY 147 as the bariumized carbohydrate meal, we may divide gastric evacuation time as represented on a scale of hours into three periods or zones, viz.: (1) A zone of normal motility; (2) a zone of pathologic hypermotility, and (3) a zone of pathologic hypomotility. 1. The zone of normal motility must extend from an empty- ing-time somewhat less than three hours to an emptying-time considerably greater than three hours, since we can fix the three- hour point only as an average on either side of which a variation may be due to purely physiologic causes. Within this zone we are obliged also, as a conservative measure, to include slighter tendencies to hypermotility or hypomotility from causes which, though pathologic, are not pronounced or are compensated wholly or in part. General knowledge justifies the assump- tion that such variation toward hypermotility is not wide, and for the purpose of this diagram, we may choose the two- hour point as the normal minimum. The variation toward hypomotility we may grant to be much wider; Haudek makes a generous allowance to the end of the sixth hour which we will accept. The contents of this normal zone would then include : (a) Normal motility. (Example: A normal stomach func- tionating in a normal manner.) (5) Early emptying, physiologic. (Example : A hypertonic, steer-horn stomach.) (c) Early emptying, pathologic, but partially compensated. (Example: Duodenal ulcer with obstruction sufficient to pro- long the evacuation-time to two hours in spite of an associated hyperperistalsis, hypertonus and free pyloric patency.) (d) Disordered motility with abnormal but balanced factors. (Example: Stenosing carcinoma with achylia, yet with a net emptying- time of three hours.) (e) Delayed emptying, physiologic. (Example: A some- what hypotonic fish-hook stomach.) (/) Delayed emptying, pathologic, but partially compen- 148 THE ABNOEMAL STOMACH sated. (Example: Stenosis with hyperperistalsis, emptying be- ing retarded, but within six hours.) 2. The zone of hypermotihty, restricted to an emptying- time less than two hours, would include such frankly pathologic conditions as non-obstructing gastric carcinoma, duodenal ulcer and diarrheic conditions. 3. The zone of hypomotility, beyond six hours, would com- prise the stenoses, both organic and spasmodic, as examples of which may be mentioned obstructing pyloric carcinoma or ulcer, markedly obstructing duodenal ulcer, and reflex pylorospasm from disease of the gall-bladder, or gastric ulcer remote from the pylorus. As a matter of fact we know that these zones may overlap each other and that time alone will not delimit normal from abnormal motility. The diagram, while somewhat practical in a way, illustrates the time factor only, and as said before, a final opinion must rest on an analysis of all the factors. The roentgen method renders this analysis both possible and prac- ticable, and herein lies its superiority to the test-meal and tube. Comparison of the Results Obtained by the Roentgen -ray and the Stomach-tube. — Our own statistics indicate that the six-hour, bariumized, carbohydrate meal is a more sensitive test of gastric motility than the method used by the gastroenterologist.* At the Mayo Clinic during the year 1914 we ran a series of 950 patients who had been examined both by the roentgen-ray and the test-meal and went to operation. (This, of course, does not include several hundred operated cases in which one or the * At 6 p.m. previous to the day of examination the patient takes a modified Riegel meal; that is to say, he is instructed to eat an ordinary meal which must include bread, meat and potatoes. An hour later he eats 20 raisins, the skins of which are easy to identify and tend to remain in the stomach somewhat longer than the usual food materials. The gastroenterologist's examinations are begun the next day, about 8 a.m., and depending on the number of patients to be exam- ined, the interval after the motor meal varies from fourteen to sixteen hours. The estimate of motility is based on the presence or absence of food-bits or raisin- skins from this meal as shown by tubing at the morning examination. The gastro- enterologist's technic includes also the administration of a modified Ewald test- breakfast for the chemical examination, but with this we are not here concerned. ROENTGEN-RAY AND STOMACH-TUBE 149 other motor test was omitted.) Two hundred and twenty of these, or 23.1 per cent., showed at the roentgen examination a gastric residue from the six-hour meal. One hundred and thirty- one, or 13.7 per cent., had food remnants. In other words, the roentgen-ray show^ed approximately 70 per cent, more reten- tions than the clinical test-meal. The lesions found w^ere: Dis- ease of the appendix, 125 cases; disease of the gall-bladder, 311; gastric ulcer, 109; gastric cancer, 137; duodenal ulcer, 268. The accompanying table shows the incidence of retention in each of these conditions, as found by the roentgen-ray and stom- ach-tube, respectively. The preponderance of six-hour barium residues over food remnants from the clinical test-meal is note- worthy, being twice as great in gastric ulcer and lesions of the gall-bladder; almost twice as great in duodenal ulcer; and half again as large in gastric cancer. In the 125 cases with lesions of the appendix, a retention was noted by the roentgen-ray in only 1 case, and found in only 2 cases by the stomach-tube. In only 12 of 311 cases with lesions of the gall-bladder was retention noted either by the roentgen-ray or by tubing. The vast major- ity (209 or 90.4 per cent.) of the 220 patients showing a barium retention were found at operation to have cancer or ulcer of the stomach or ulcer of the duodenum. In 16 cases representing all five conditions, the stomach- tube revealed food remnants, while no six-hour retention of barium was found by the roentgen-ray. On the other hand, 105 patients had roentgen residues but no food remnants. In 8 of the cases tabulated under gastric ulcer there was also a duodenal ulcer. All of these patients showed a residue from the barium meal, and 6 of them had food remnants. Besides the cases tabulated above, residues were found by the roentgen-ray in one patient in each of the following conditions : Cancer of the pancreas, tumor of the ileum, cancer of the com- mon duct, hydronephrosis, tumor about head of pancreas, tumor of left kidney, subdiaphragmatic abscess, and cancer of the as- cending colon. In the four first mentioned, retention was noted also by the gastroenterologist. 150 THE ABXOEMAL STOMACH How can the discrepancy between tlie gastroenterologist's results and our own be explained? 1. It would seem probable that the time elapsing between the ingestion of the gastroenterologist's meal and its withdrawal is too hberal, and that the stomach was empty in many instances in spite of an actual and pathologic h3T)omo- tihty. 2. It is quite possible that the tube may have failed occasion- ally to bring up food remnants which were present. Harmer and Dodd/' by watching with the roentgen-ray the introduction of the tube, frequently noted that the tip impinged against the gastric wall, weU above its most dependent portion, and continued efforts to pass the tube simply caused it to ctirl and displace the tip further upward. In other instances it was foimd that by passing the usual length of tube in cases of ptosis, the tip might fail to reach the residuum. This, they beheve. is a common error. The posture of the patient and the position the stomach occu- pies in the abdominal ca^dty affect the success of tubage. From their observations they regard it as "obvious that failure to recover gastric residuum with the unaided stomach-tube from a fasting stomach or after the ingestion of a 1 " - X X ! r5 ^^^^ -^"'"^ \^ C-3 ^ — ~ " ~ — ro ^ 1 < i5 ooo^ac 3 z ^— ■ - - - r« ^ -^ — •3 - r« cj ^ I — 2 S~ ^ rj M SO 4-^ if ^ = = = =; =3 £"§ ^^ ^ ^ cj -^ «o -=-j£; Dj •^ inches in diameter, attached to the anterior wall, as found at exploration. It produced a spherical central filling-defect at the junction of the antrum and pars media. On account of the patient's condition it could not be removed, and its exact nature was not determined. In the third case there were two papillo- adenomas, one ^^ inch, the other 1^ inches long, attached to the posterior wall 3 inches from the pylorus. They produced finger-print-like filling-defects in the screen-image and roent- genogram, and were centrally located in the antrum. Hyper- motility and hyperperistalsis were also noted. A neoplastic form of tuberculosis of the stomach, more often affecting the pyloric portion, is occasionally noted. Aside from actual neoplasms, the gastric lumen may rarely be intruded upon by varicosities, by a phlegmon in the gastric wall, or by a local hypertrophy of the musculature such as occurs in benign thickening of the pyloric ring. Syphilitic gummata, infiltrations and fibromatosis have been discussed elsewhere. While all the conditions enumerated should be kept in mind by the roentgenologist as possibilities in cases showing an evi- dent tumor of the stomach, it should equally be remembered that the chance of their existence is relatively small. Few of them have been examined by the roentgen-ray, and no general conclusions as to their roentgen manifestations can be drawn from this scant material. The case of polyposis reported by Myer^ illustrates both the clinical and roentgenologic aspects of the condition. The ob- servation of this case extended over a period of eight years. The patient's antecedent history was indicative of syphilis. POLYPOSIS 243 When seen jfirst in 1904 he was complaining of abdominal dis- tress one or two hom^s after meals and had lost weight rapidly. Examination of the gastric contents showed achylia, lactic acid and mucus. Subsequently the amount of mucus became ex- traordinarily large. Five years later, while being subjected to lavage, a polyp the size of a pea was expressed through the tube and upon microscopic examination was found to be a simple benign adenoma. In 1912 the patient had severe hematemesis. Fig. 180. — Gastric polyposis. Upon physical examination, resistance was found over the; pylorus and peristalsis was visible. Fluoroscopic and roentgenographic examinations by one of us (Carman) revealed an almost total obliteration of the pars py- lorica and distal pars media. The main bismuth mass lay to the left of the vertebral column and had an irregular, indefinite con- tour. Small amounts of bismuth trickling through the right half of the stomach gave it a mottled appearance and suggested irregular masses projecting from the gastric wall. The motility 244 TUMOR-PRODUCING LESIONS OF THE STOMACH of the stomach was not tested by the roentgen method (Fig. 180). Operation: Gastrotomy. Gastric mucosa hterally covered from the cardia to within an inch of the pylorus with pedicled polypi (Fig. 181). Excision of one large pedunculated papillo- matous tumor, the size of a fist, attached 3 inches above pylorus. Fig. 181. — Gastric polyposis. Photograph of stomach removed post raortem, show- ing the entire mucosa, with the exception of a small area near the cardiac orifice, liter- ally covered with polyps; a, a large grapelike bunch of polyps, a portion of which had invaginated the pylorus. Microscopic section of the polyp showed that its chief mass con- sisted of hypertrophied mucosa, with immensely hypertrophied glands. Small cysts were noted in various parts of the stomach. In addition to Myer's case, our own experience has included instances of dermoid cyst, fibromyoma, hypertrophy of the pyloric ring and tuberculosis. The case histories follow. REPORT OF CASES 245 Case 136,147; boy aged 8. About four years ago the parents noticed a small lump in his abdomen, which seemed to be more promi- nent at times, especially when standing. The lump has grown gradually and has been quite marked during the past six months. Aside from some urinary frequency, the patient has no symptoms. Hemoglobin 70. Large, freely movable, not tender, mass filling upper and central abdomen. Roentgen findings: No retention from the six-hour meal. Stomach very high, occupying a transverse position. The displace- FiG. 182. — Case 136,147. ment upward is due to a large palpable tumor which is extrinsic and does not deform the gastric lumen (Fig. 182). Finchng at operation: Gourd-shaped tumor attached to posterior wall of stomach and pro- jecting into the lesser cavity of the peritoneum. Tumor larger than the stomach itself. Resection of area of attachment. Pathologist's report: Dermoid cyst (Fig. 183). Weight 1000 gm. Case 142,665, female, aged 65. Operation elsewhere four years ago for the removal of gall-stones. Soon afterward she discovered a mov- able mass in the epigastrium and began to have attacks of sharp epi- gastric pain, coming at any time, and vomiting immediately after meals. The present attack has lasted six weeks. Weight loss, 50 pounds in three j^ears. Nodular tumor can be felt in left epigastrium. Hemoglobin 44. Total acidity 6; all combined. Roentgen findings: 246 TUMOR-PRODUCING LESIONS OF THE STOMACH No retention. Extensive filling-defect involving pars pylorica and media, and part of cardia. Slight hindrance to entrance of barium through esophageal opening (Fig. 18i). Diagnosis: Carcinoma; inoperable. (To tliis report the examiner added the statement that the filling-defect was very unusual.) Findings at operation: Timior posterior wall of stomach, 3 inches above pylorus, the size of a small orange. The tumor has invaginated through the pylorus into the Fig. 183.— Case 1.36,147. Dermoid cj-st. duodenum. Exsection of tumor and area of attachment. Patholo- gist's report : Fibromj'oma. Case 80,723, female, aged 29. Ten years ago she began to have attacks each spring of indigestion, but would be entirely well the rest of the year. Four years ago the trouble became worse; after each meal she would have epigastric burning, vomiting, and gas distention. Food gives relief but is vomited. The attacks last for weeks, with intervals of perfect health. During the past year the pain has fre- REPORT OF CASES 247 Fig. 1S4. — Case 142,665. Fig. 185. — Case 80,723. 248 TUMOE-PRODUCING LESIONS OP THE STOMACH quently been severe and cramp-like, hypodermatic injections being given for relief. Total acidity 30; all free. Epigastric tenderness. Roentgen findings: Retention of half the six-hour meal. Hypotonic, low-lying stomach with strong peristalsis. Prepyloric narrowing seen on the screen. Diagnosis: Pyloric obstruction. The roentgenogram, Fig. 185, does not show the lesion, due to the fact that the plate was made with the patient standing and the barium has settled away from the area involved. The case illustrates the necessity of making at least some of the plates in the prone position. Findings at operation: Great thickening of pylorus, feeling like a tumor. Much thick, Fig. 186. — Case 152,198. ascitic fluid in abdomen. Edematous thickening of upper jejunum with many enlarged glands in mesentery. Resection 4 inches pyloric end. Anterior gastro-enterostomy. Pathologic report : Hypertrophy of muscular and mucous layers of stomach; 14 mm. at pylorus. Small adenomatous polyp near pylorus. Marked hypertrophy of annular fibers of pylorus, with the opening narrowed to about 5 mm. Glands from mesentery inflammatory. Case 152,198, male, aged 42. Two years ago he first noticed epigastric heaviness and distress immediately after meals. After a few months he began having attacks of vomiting two or three hours after meals. Six months ago the attacks of vomiting became more TUBERCULOSIS OF STOMACH 249 frequent and as early as a half hour after meals. Surgical exploration (elsewhere) revealed what was considered to be an inoperable cancer of the stomach. Following this operation the patient improved some- what until three weeks ago, since which time the vomiting has been worse, food being rejected as soon as taken. Normal weight 135; present 100. Palpable mass in right abdomen, thought to be kidney. No epigastric mass. Hemoglobin 70. Total acidity 12, all combined ; food remnants; Oppler-Boas bacilli. Roentgen findings: Retention of three-fourths of the meal at the end of six hours. Hour-glass con- tracture of stomach in pars media with some irregularity of contour. Pars pylorica replaced by a filling-defect (Fig. 186). Diagnosis: Cancer; operable. Findings at operation: Tumor of stomach near pylorus. Marked spasm; stomach not dilated. Resection about one-third of stomach. Pathologist's report: Tuberculosis of stomach and glands. REFERENCES 1. Campbell, A. M. : "Benign Tumors of the Stomach." Surg., Gynec. and Ohstet., 1915, xx, 66-71. 2. Wade, H.: "Intussusception of the Stomach and Duodenum due to a Gastric Polypus." Surg., Gynec. and Ohstet., 1913, xvii, 184-190. 3. Sherken, J.: "External Polypoid Tumors of the Stomach." Brit Med. Jour., 1911, ii, 593. 4. Geay, G. M. and Nesselrode, C. C: "Report of a Case of Des- moid of the Stomach, Etc." Jour. Kansas Med. Soc., 1911, xi, 498-505. 5. Nassetti, F.: " Smooth Muscle-tumors in the Stomach." Tumori (Rome), 1914, iv. No. 3. Abstr. Jour. A.M. A., 1915, Ixiv, 867. 6. Basch, S.: "Primary Benign Growths of the Stomach." Surg., Gynec. and Ohstet., 1916, xxii, 165-170. 7. Myer,J.S.: "Polyposis gastrica (Pol yadenoma)." Jour. A. M. A., 1913, Ixi, 1960-1965. CHAPTER XIII GASTRIC ULCER The succession of events in developing the roentgenologic diagnosis of gastric ulcer has been orderly, and few steps have been taken which had to be retraced. Even Hemmeter's^ effort to demonstrate the site of an ulcer by the adherence of a fleck of bisrauth was not so far beside the mark. Though impractical in its original appUcation, his employment of an opaque salt and the roentgen-ray had its influence in stimulating others to more successful attempts. With the advent of the Rieder meal, the Continental roent- genologists were able to find the more striking secondary mani- festations of gastric ulcer, notably hour-glass deformity, and gave heed to six-hour retention and other general indications of gastric pathology. Then Reiche succeeded in demonstrating the cavity of an ulcer, and Hemmeter's dream came true. With additional experience it became possible to differentiate secondary gastric phenomena produced by an intrinsic cause from those due to an extrinsic cause, and to combine the former with chnical data into practical syndromes. At its present stage the accuracy of the roentgen diagnosis of gastric ulcer is greater than is generally appreciated, and con- siderably exceeds that of customary clinical methods. It would seem that in the opinion of some gastroenterologists the usefulness of the roentgen-ray in this connection is Hmited in the main to differentiating gastric from duodenal ulcer. How- ever, they thus unwittingly concede its absolute value in the diagnosis of either condition. We are also obliged to dissent from the assumption that the clinical examination is quite sufficient to confirm or negate the presence of an ulcer, though it may not be able to fix its site. 250 TYPES OF ULCER 251 From our own statistics we can say that nine-tenths of the ulcers of the stomach give distinct roentgenologic indications of gastric disease, and in an overwhelming majority of these the roentgen signs are either pathognomonic or strongly presump- tive of ulcer. From a gross and microscopic study of 445 cancers of the stomach, Wilson and McDowelP regard it as probable that gastric cancer rarely develops except at the site of a previous ulcerative lesion of the mucosa. While this should not be misconstrued as saying that all ulcers become carcinomatous, it does indicate that many ulcers are potential cancers. Hence, the advantage of an exact diagnosis of gastric ulcer, as afforded by the roentgen-ray, is apparent. As seen at operation, four classes of gastric ulcer may be distinguished: 1. Small, exceedingly shallow, mucous erosions and minute slit-like ulcers. 2. Penetrating or callous ulcers with relatively deep craters. 3. Perforating ulcers, with or without the production of an accessory cavity. 4. Carcinomatous ulcers. Of these four classes, the first — the small, shallow, mucous erosions — offer the greatest difficulty to roentgenologic detec- tion. They are either superficial denudations, or mere slits in the mucosa, incapable of holding enough barium to make a visible projection from the gastric lumen. Unless accompanied by secondary roentgen phenomena, such as the incisura and six- hour retention, their presence is not likely even to be suspected. The penetrating ulcers which have burrowed more or less deeply into the gastric wall, produce a definite crater jutting out from the lumen of the stomach. The degree of facility with which this crater can be seen by the roentgen-ray depends more on its location than its size. Perforation of an ulcer, with a continuation of the destruc- tive process into adjacent tissues, results in the formation of an accessory cavity outside the stomach. Such a cavity can nearly 252 GASTRIC ULCER always be seen, both on screen and plate. Perforation may, of course, occur without any excavation of the tissues beyond the stomach. In this event the roentgen-ray should show the ulcer-crater, plus, in some instances, the distorting effect of adhesions. Early carcinomatous ulcers are not, as a rule, distinguishable from non-malignant ulcers, their roentgenologic signs being the same as those of penetrating or perforating ulcer. ROENTGENOLOGIC SIGNS OF GASTRIC ULCER The roentgen signs of ulcer may be divided into (1) those which are primary and practically pathognomonic, and (2) those which are secondary and corroborative, but not absolutely diagnostic. The first class comprises two signs, namely, the niche and the accessory pocket. The second class includes: Spastic manifestations: (a) The incisura. (6) Spasmodic hour-glass stomach. (c) Diffuse gastrospasm. Organic hour-glass stomach. Retention from the six-hour meal. Gastric hypotonus. Acute fish-hook form of the stomach. Alterations of peristalsis. Localized tenderness. Lessened mobility of the stomach. The Niche. — For convenience we shall Umit the application of this term to the visualized crater of a penetrating ulcer, the cavity of which lies entirely in the wall of the stomach. The first to show definitely the projection of a bismuth-filled ulcer- crater from the gastric lumen, was Reiche." Later, Haudek'^ called it the ''nischen-symptom" and applied it to every form of recess produced by an ulcer, whether penetrating or per- forating. THE NICHE 253 The niche shows as a bud-hke prominence on the peripheral outline of the stomach (Fig. 187). It is often regularlj^ cres- centic, but may be irregularly shaped. Its size may vary from a mere fleck to a considerable protuberance. It is worthy of note that a niche may be demonstrable even though the ulcer has not penetrated very deeply (Fig. 188). As an ulcer may occur in any part of the stomach, it follows that the niche may also be found anywhere. By far the larger number, however, are noted either on the lesser curvature, usually above the Fig. 187. — Barium-filled crater of gastric ulcer at a. incisura angularis, or on the posterior wall near the lesser cui;\'a- ture. When situated upon the vertical portion of the lesser curvature, a niche will usually show plainly in the antero- posterior view. If located on the posterior wall of the vertical portion of the stomach, an oblique view is often necessary to discover it. When the niche is seated on the lesser curvature of the pyloric portion, it may be hard to distinguish. Quite often an ulcer in the pyloric portion is on the posterior wall and detection of the niche is hampered by the difficulty of obtaining 254 GASTRIC ULCER any but an anteroposterior view. A small niche in any situation may be hidden or partially obliterated when the stomach is distended, so that careful observation should be made while the stomach is filling, especially while the patient is drinking the aqueous mixture (Fig. 189). The niche accompanies the gastric wall in its movements, whether by palpation or respira- tion. It fills and empties directly with the stomach. Fig. 188. — Gastric ulcer at a. Note that the crater is not deep, A small collection of barium in the bowel adjacent to the gastric outline, especially the lesser curvature, may superficially imitate a niche, but manipulation will readily show the differ- ence. The bulge between two peristaltic waves close together on the lesser curvature often looks very much like a niche. Conversely, a true niche may be mistaken for this bulge. How- ever, as the waves progress, the bulge moves toward the pylorus, while a niche remains stationary, so that a little study of the screen-image will easily make the distinction. THE NICHE 255 Fig. 189. — Gastric ulcer with high hour-glass, persistent after belladonna. In this instance a small niche in the plane of the hour-glass constriction was noted at each examination while the patient was drinking the barium-water mixture, but could not be seen after filling the stomach. Fig. 190. — Accessory cavity due to perforating ulcer at a- 256 GASTEIC ULCER Accessory Pocket. — The accessory pocket, as previously stated, occurs as the result of perforation of an ulcer and exten- sion of the ulcerative process into adjoining structures, produc- ing a cavity (Fig. 190). If situated high up, ulcers of the lesser curvature or anterior wall are apt to perforate against or into the liver, while those lower down and on the posterior wall are more likely to invade the pancreas. Instances have also been noted of perforation between the layers of the lesser omentum, into the anterior abdominal wall, and into the spleen. We have purposely avoided using the term ''diverticulum" generally employed by roentgenologists to describe the cavity formed by a perforating ulcer. In a strict anatomo-pathologic sense a diverticulum must have the same lining-cells as the vis- €us from which it springs. Inasmuch as an ulcer begins with destruction of these cells, the production of a diverticulum by an ulcer is hardly possible. When visualized by the barium meal the contents of the pocket are stratified like those of the stomach; the opaque barium at the bottom has a translucent layer of fluid above it, and this in turn is capped by a small gas-bubble. Accessory pockets range in diameter from 1 to 5 cm. or more. They are usually spherical in outline, but may be irregu- larly shaped. A pocket in the liver moves with respiration, while one in the pancreas does not, and a more anterior situa- tion of the former may be shown by an oblique view. If within reach, a pocket is commonly immovable by palpatio q and tender to pressure. The canal joining it to the gastric cavity may or m.ay not be distinctly visualized by the barium. Barium remains in the pocket when the gastric contents settle to the lower pole of the stomach, and this feature distinguishes a pocket from a niche. A six-hour rest in the stomach is often associated with an accessory pocket. Organic hour-glass stomach sometimes ac- companies an accessory cavity, but not invariably. If the stomach is acutely flexed, the beginner may at first mistake a partly filled duodenal bulb for an accessory pocket. CONTRIBUTORY SIGNS OF ULCER 257 and he should be careful to exclude this possibility. A true diverticulum of the stomach, most often a congenital anomaly, might be mistaken for the excavation of an ulcer, either pocket or niche, but this condition is exceedingly rare. Contributory Signs of Ulcer. — To produce either a niche or accessory pocket it is plainly necessary that the ulcer shall have eroded the gastric wall to a depth sufficient to make a demonstrable projection from the gastric lumen. While this occurs in the majority of the cases examined, there remains a large number of cases in which the ulcer is so shallow that no excavation can be detected. In these, if a roentgen diagnosis can be made at all, it must be based on indirect phenomena. Spasmodic Manifestations — The Incisura. — Chief among the spasms excited by ulcer and perhaps the strongest contribu- tory sign of this lesion, is the incisura. Exploited early as a practical roentgenologic indication of ulcer, it has been given abundant attention in the literature, possibly more than it deserves, since it occurs in only a small percentage of cases. The incisura is an indentation of the gastric wall opposite an ulcer (Fig. 191). Its production is generally believed to be due to irritation of the ulcer, causing a spastic contraction of the circular muscle-fibers in its plane. An incisura may also occur in association with the scar of a healed ulcer. Theoretically, it may occur anywhere in the stomach and be seen on either curva- ture. However, we have never observed one on the lesser curva- ture. Practically, the vast majority are found on the greater curvature, and most commonly in the vertical portion of the stomach. Occasionally they may be noted in the pyloric portion (Fig. 192). Incisurse have considerable variation as to width and depth. They may be so deep as almost to bisect the stomach, or so shal- low as merely to dimple the curvature. The angle of view, of course, affects the apparent depth. The outline of an incisura is commonly sharp and regular, but occasionally some irregularity may be noted. Each of two or more ulcers, even though closely situated, may have its separate incisura. 17 258 GASTRIC ULCER Fig. 191. — Incisura at b, opposite gastric ulcer a. Fig. 192. — Prepyloric incisura at a which was permanent. No visible niche/marked dilatation of first part of duodenum, with irregularity of superior wall at b. Diagnosis: Prepyloric ulcer with adhesions obstructing duodenum. SPASTIC MANIFESTATIONS 259 Recognition of an incisura is not difficult as a rule. The stomach should be watched during the process of filling; after repletion an incisura may be more or less concealed by over- lapping of its borders. Overlapping may be so marked that gentle pressure is necessary to visualize the indentation. The patient should be turned about to permit oblique or lateral in- spection of the gastric contour. An incisura high up in the ver- tical portion of the stomach may lie wholly in the fluid zone above the opaque meal and thus escape notice. Occasionally a little barium may settle above the incisura, as upou a shelf, but the incisura will not be clearly visible as such unless the opaque meal surrounds it. Hence the barium should, if nec- essary, be forced upward by manipulation during the vertical screen-examination, and plates should be made in the prone position. Incisurse in the pars pylorica are usually small, and this region should be studied closely. True incisurse must be differentiated from the normal incis- ura angularis and incisura cardiaca, from the occasional inden- tation of the greater curvature where the left costal arch crosses it, from the effect of adhesion-bands, and from spasmodic incis- urse arising from causes outside the stomach. The normal incisura angularis in the angle of the lesser curva- ture, and the incisura cardiaca at the junction of the esophagus with the stomach should be familiar ' to the roentgenologist. Slightly less familiar is an indrawing of the greater curvature beneath the left costal arch, produced either by the pressure of the arch or by tension of the abdominal muscles. Commonly this indentation is broad, shallow, and obviously not an incisura. However, the depression may be so narrow and sharp that the observer is uncertain. Pushing up the lower pole of the stom- ach tends to narrow and deepen the indentation and thus add to the uncertainty. In fact, this sort of manipulation may easily produce an apparent incisura in almost any stomach and should be avoided. Palpatory pressure should be directly backward and not upward if an incisura is being sought. An adhesion-band may constrict the stomach in such fashion 260 GASTRIC ULCER as to simulate an incisura. Fig. 193 represents such an instance, the onty one that we have encountered. The most annoying imitations of true incisurse are those produced by extrinsic spasms, that is to say, spasm excited by causes outside the stomach. Such incisurse are often associated with disease of the gall-bladder or appendix, or with duodenal Fig. 193.— Incisura at a, persistent at a second examination after belladonna. Diagnosis: Ulcer of stomach. Operation: Xo ulcer. Hour-glass due to adhesion band. ulcer. These reflex incisurse frequenth^ have an appearance and position identical with true incisurse. They may be stationary or migratory. Their reflex spasmodic character is evident if they move toward the pylorus. Even though stationarj^, they may be assumed to have an extrinsic cause if they relax and dis- appear upon massage or after the administration of an anti- spasmodic. The opinion has been advanced that non-per- manent incisurse maj^ sometimes be caused by shallow erosions but decisive proof of this is lacking as yet. SPASMODIC HOUR-GLASS 261 It follows that a true incisura must be subjected to and withstand the following tests: It must be constant and stationary. It must be present when the stomach hangs in its natural position. It must survive manipulation. It must persist after the patient has been given an antispas- modic to physiologic effect. Spasmodic Hour-glass. — Any stomach which is indented by an incisura may be broadly considered an hour-glass, but unless the constriction is quite deep the term hour-glass is not usually applied. In many instances, however, the local contraction is extreme, the typical character of an incisura is lost, and the hour-glass form is dominant (Fig. 194). The spasmodic hour- glass of gastric ulcer is characterized by a relatively short canal joining the two chambers, the canal being usually near the lesser curvature, thus giving the stomach a B-shape. Spasmodic hour-glass due purely to reflex spasm arising from sources out- side the stomach may exactly simulate the hour-glass of ulcer. Therefore, the usual tests should be applied to exclude extrinsic spasm. It must be remembered that the spastic hour-glass of ulcer disappears under general anesthesia, and consequently will not be found by the surgeon. Other Forms of Spasm. — Besides the localized incisura or spastic hour-glass, gastric ulcer may also give rise to more ex- tensive spasm. Regardless of the situation of the ulcer, this diffuse spasm usually affects the pyloric portion of the stomach, and the entire pars pylorica may be involved (Fig. 195). On the screen and plate this area is vaguely shadowed, resembling the filling-defect produced by a prepyloric cancer. The spastic distortion is constant, and cannot be effaced by massage. Since similar spasms may be set up by conditions outside the stomach, these must be excluded if possible. Differentiation.- — Given any of the foregoing varieties of spasm, the examiner's first task is to determine whether they arise from lesions within or without the stomach. Differential 262 GASTRIC ULCER Fig. 194. — Hour-glass stomach. Hour-glass constriction at o. Fig. 195. — Two ulcers shown at a Note prepyloric spasm b. ORGANIC HOUR-GLASS 263 characters have been discussed at some length in the chapter on ''Gastrospasm." Exchision of extrinsic spasm by giving belladonna and reexamining is most important. An incisura, hour-glass or diffuse gastrospasm which is not relaxed^by this drug, usually means a lesion of the stomach, most often an ulcer. Among the exceptions, which are not numerous or freciuent, are these : Fig. 196. — Gastric ulcer with organic hour-glass stomach. Ulcer and constriction at a. The lower loculus of the hour-glass is only partly filled, and the canal joining the two loculi is short, although the thin stream of barium trickling down the lesser curva- ture gives the impression of a long canal. 1. Duodenal ulcer occasionally gives rise to a gastric incisura or hour-glass which resists belladonna. In any doubtful case, therefore, a routine examination should be made for duodenal ulcer, in order to confirm or exclude its presence. 2. Exceptionally a small gastric cancer may have an incisura as its sole indication. Such instances are so rare that the ex- aminer is justified in his usual diagnosis of ulcer. Organic Hour-glass. — Organic hour-glass stomach is an occasional sequence of penetrating or perforating gastric ulcer. 264 GASTRIC ULCER The constricted portion is infiltrated or involved in adhesions, and is present at operation. Roentgenologically it cannot be differentiated from the spastic type of hour-glass resulting from ulcer but should be subjected to the same tests as the latter. Like the spastic form it is usually of the B-shape, with a short canal near the lesser curvature (Fig. 196). This serves gener- ally to distinguish it from the cancer hour-glass, which is more often of an X-shape, with a long canal, centrally placed. Residue. — A distinct residue in the stomach from the six- hour meal, amounting to an eighth or more of the quantity taken, is a relatively common accompaniment of gastric ulcer. In a series of 215 consecutive cases, we noted a retention in 118 or 55 per cent. Thus gastric ulcer stands a close second to gas- tric cancer in this respect. The manner in which an ulcer causes a gastric retention is not definitely known. An ulcer immediately in the pyloric ring, which is relatively uncommon, may cause a narrowing of the ring either by localized spasm or by scar-contraction. But by far the greater number of ulcers are situated at variable dis- tances from the pylorus. The retentions which they produce have been assigned respectively to pylorospasm excited by the ulcer or by an accornpanying hyperacidity, to impairment of peristalsis and to the hypotonus which is often associated with ulcer. An extreme type of organic hour-glass due to ulcer may cause a retention in the upper loculus. A residue in the stomach resulting from an ulcer is some- times the only definite evidence which the examiner can discover. However, a retention alone is not sufficient for the diagnosis of ulcer, since various causes may operate to produce a six-hour residue. These have been discussed in the chapter on ''Ab- normal Stomach." Gastric Hypotonus. — An evident loss of tone, as shown by sagging and expansion of the lower gastric pole is a frequent accompaniment of ulcer, not only of ulcers causing obstruc- tion (Fig. 197) but occasionally also of ulcers situated rather high in the stomach (Fig. 198). Taken alone, hypotonus GASTRIC HYPOTONUS 265 Fig. 197. — Gastric ulcer, immediately prepj'loric at a. Stomach large and hypotonic. Fig. 198. — Large hypotonic stomach. One-half the motor meal present at the end of six hours. No organic obstruction at pylorus. Gastric ulcer at a. 266 GASTRIC ULCER possesses little significance, for it is an expected finding in the numerous patients with enteroptotic build. However, if the hypotonus does not accord with the habitus of the patient the possibility of an ulcer should be thought of. In conjunction with other secondary signs, hypotonus has a contributory value, depending on the circumstances. The Acute Fish-hook. — An acutely flexed, fish-hook form of the stomach, with displacement to the left and downward. Fig. 199. — ^Acute fish-hook form of stomach. Ulcer at a. noted by the older observers as a minor roentgenologic sign of ulcer, has perhaps received more prominence than it merits (Fig. 199). It may occur with or without an ulcer. The snail- form of Haudek, an extreme degree of flexion due to scar-con- traction on the lesser curvature, is of some importance, but cor- roboration by other signs is necessary for a positive diagnosis. Abnormalities of Peristalsis. — The variations of peristalsis met with in gastric ulcer include weak peristalsis, hyperperistal- LESSENED MOBILITY 267 sis, especially of irregular type, absence of peristalsis from the ulcer-bearing area and antiperistalsis. None of these is peculiar to ulcer but all of them are more or less suggestive of a gastric lesion. Gastric hypotonus is a common accompaniment of gastric ulcer, and hypotonus is usually associated with sluggish peristal- sis. An ulcer at the pylorus, producing obstruction, may give rise to vigorous irregular peristalsis, if loss of tone has not fol- lowed. Pyloric ulcers, however, are relatively infrequent. All organic lesions of the gastric wall tend to interfere with peristaltic movement in the area involved. If an ulcer is situ- ated in that portion of the stomach where peristaltic waves are commonly visible, there may be a noticeable local absence of the wave-depression, especially if infiltration about the ulcer is extensive. Antiperistalsis is occasionally noted with gastric ulcer, most often when six-hour retention is also present. While not nec- essarily indicative of ulcer, antiperistalsis generally denotes the existence of organic disease either in the stomach or near beyond. Tender Point. — A sharply localized pressure-tender point over a niche is of confirmatory value. If limited to an area on the curvature opposite an incisura, but without the existence of a niche or accessory pocket, suspicion of an ulcer is increased, nevertheless a diagnostic opinion should be guarded. To be of any value, a pressure-tender point must be narrowly circum- scribed, as most persons have more or less tenderness in the epigastrium. Lessened Mobility. — A local fixation of the gastric wall often results from perforating ulcer with the production of adhesions. However, fixation may ensue from any perigastric inflammation. Besides, satisfactory determination of the actual mobility of the stomach depends considerably upon its form, tone and position and the relaxation of the abdominal wall. Unless the observer can satisfy himself that definite fixation is present at a certain point, he should not be unduly influenced by what seems to be a lessened mobility of the stomach as a whole. 268 GASTRIC ULCER Value of Sign-groups. — In this analysis we have endeavored to emphasize the niche and the accessory pocket as being the only conclusive roentgen signs of ulcer. The exact worth of the contributor^' signs enumerated cannot, of course, be stated precisely, yet in various combinations they may sustain a quah- fied diagnosis of ulcer. Chief among the secondary manifesta- tions are the six-hour residue and the spastic phenomena — incism'a, hour-glass and diffuse spasm. When any form of gas- trospasm persists after belladonna has been given to physiologic effect, the existence of an intrinsic lesion is faMy pro^^ed, and most often the lesion is an ulcer. If a six-hour retention is in- cluded in the complex, it is strongly corroborative. Antiperis- talsis is also generally indicative of serious pathology. TMien only secondary signs are found, the conservative roentgenologist win be content with the opinion that a lesion is present. By ex- cluding duodenal ulcer and gastric cancer when possible, and by correlating the roentgen e^'idence with the chnical and labora- tory findings the diagnosis can often be made more specific. Association of Gastric with Duodenal Ulcer. — In an extensive series of gastric ulcers which came under our observation, 15 per cent, were associated with duodenal ulcer. This frequency of double lesions suggests that the roentgenologist should not be satisfied simply with finding a gastric ulcer, but should always carrj^ his investigation to the duodenum (see Fig. 215). Carcinomatous Ulcer. — The roentgenologic signs of ulcer differ so much from those of carcinoma in the vast majority of cases that differentiation requires no effort. For example, a penetrating ulcer with niche and incisura, or a perforating ulcer with pocket formation bears no roentgenologic resemblance what- ever to a well-developed cancer, and patients with only such cancers are hkely to come for roentgen examination. In a gen- eral way, ulcers project as an addition to the gastric ca^dty, while cancers encroach on the gastric lumen. Between the t^T^ical ulcer and the t^T)ical cancer, however, there is a smaU percentage of cases in which roentgenologic differentiation is difficult or impossible. CARCINOMATOUS ULCER 269 An example of this class is the ulcer which on microscopic study shows cancer-cells. Here, the roentgen signs are those of ulcer, and no other diagnosis can usually be offered. At opera- tion the lesion is macroscopically an ulcer, and only microscopic examination can give final judgment. Extreme size of an ulcer-crater, as shown by a very large niche, should make one suspicious of malignancy, a fact which has been impressed upon us by experience. An ulcer with a niche 3 cm. or more in diameter is likely to prove cancerous (Fig. 200). Fig. 200. — ^Large gastric ulcer at a; found, to be carcinomatous at operation. In the pyloric region, differentiation of ulcer from cancer is often troublesome. The only roentgenologic signs may be a six-hour rest and an atypical irregularity of contour, and the examiner can only say with certainty that a lesion exists. A small cancer may have an incisura as its sole index, and the observer will be incUned to suspect ulcer rather than cancer, but this sort of mistake will rarely occur and can hardly be consid- ered a grave error. 270 GASTEIC ULCER Fig. 201. — Case 115,292. Niche of perforating ulcer at a. Fig. 202. — Case 122,649. Gastric ulcer. Very small niche at a. Acute fish-hook form of stomach. As will be seen by the pathologist's report, the crater of the ulcer was only 2 millimeters broad. Such an ulcer in an unfavorable situation might easily escape observation. REPORT OF CASES 271 Case 115,292, male, aged 46 years. Trouble with stomach for seven weeks; no prior history, except possibly acid regurgitation after meals during past few years. He now complains of gnawing epigastric pain, worse an hour after meals. There is no definite food-ease, though he feels better immediately after meals, which he attributes to keeping quiet. Water relieves pain for a few minutes; exercise ag- gravates it. Some pain at night, at different times. Five weeks ago he vomited on frequent occasions one to two hours after meals. No hiematemesis. His stools have been continuously black. Weight loss, 10 pounds. Marked epigastric tenderness. Hemoglobin 45. Total acidity 64; free 52; combined 12. Roentgen findings: Reten- tion of one-fourth the motor meal. Niche on lesser curvature, just above incisura angularis (Fig. 201). Diagnosis: Gastric ulcer. Find- ings at operation: Ulcer of lesser curvature, perforating posteriorly against pancreas, and adherent to it. Gastro-enterostomy. Case 122,649, female, aged 40 years. Trouble with stomach for fifteen years. The complaint is of two kinds: first, much nausea without vomiting. The nausea is worse before breakfast and is eased by taking food or water. Second, for six years occasional attacks of epigastric pain, radiating to the right costal margin and to the back. The pain comes a half hour after meals and lasts to the next meal, or is relieved a half hour by eating between meals. Relief also by lying down. Never night pain or vomiting. The attacks last for two or three weeks with free intervals of two to three months. Gradual weight loss for twelve years. Hemoglobin 78. Total gastric acidity 38; free 26; combined 12. Roentgen findings: No retention. Small niche on lesser curvature (Fig. 202). Diagnosis: Gastric ulcer. Find- ings at operation : Small ulcer about the middle of lesser curvature of stomach. Excision. Posterior gastro-enterostomy. Pathologist's report: Ulcer. Crater 2 mm. in diameter. Case 87,913, male, aged 40 years. Ten year history of trouble with stomach, at first only three or four times a year, but the attacks have increased in duration and frequency. He now complains chiefly of epigastric pain and vomiting. The pain is referred to the right epigas- trium, radiates to the back, and comes three or four hours after meals. With the pain there is vomiting of food and sour fluid. On occasions he has noted in the vomit, food taken the day before. After appendec- tomy two years ago he had no symptoms for six months. Weight loss, 34 pounds in four months. Hemoglobin 68. Total acidity 42, all combined; food remnants. Roentgen findings: Large stomach. Retention of three-fourths the motor meal (Fig. 203). No hour-glass contracture. Accessory pocket just outside lesser curvature (Fig. 272 GASTRIC ULCER Fig. 203. — Case 87,913. Perforating gastric iilcer. Small six-hour retention in accessory pocket at a; with fluid and gas above it, Retention of practically the entire motor meal in stomach, b. Fig. 204.— Case 87,913. Filled stomach, showing accessory pocket outside gastric lumen, a. REPORT OF CASES 273 204). Peristalsis vigorous. Duodenum not seen during period of examination. Diagnosis: Perforating gastric ulcer. (The hyper- peristalsis should have suggested the possibility of a duodenal ulcer to^the examiner, but the gastric ulcer being evident, no further exami- nation was ^made.) Findings at operation: (1) Ulcer of lesser curva- ture of stomach perforating onto pancreas and transverse colon. (2) Large, hard, obstructing ulcer of the duodenum just below pylorus. Anterior gastro-enterostomy. Case 30,520, female, aged 30 years. When first seen in the Mayo Clinic in 1909 she had had attacks of pain in the region of the left costal Fig. 205. — Case 30,520. Incisura well up on greater curvature at a. arch for two years. The pain was severe, came several times daily and lasted ten or fifteen minutes each time. Occasionally morphin was required for relief. She returned to the Clinic in January, 1913. Under medical treatment she had been well until the autumn of 1912. Since then she had had daily attacks of pain at the left costal arch, radiating to the back, graduallj^ growing worse, and again requiring morphin. No vomiting, belching or sour eructations. Weight loss, 18 pounds in four months. Total acidity 54; free 50; combined 4; trace of altered blood. Roentgen findings: No retention. Incisura, greater curvature, vertical portion of stomach. This was persistent at a second examination after giving belladonna (Fig. 205). Diagnosis: 18 274 GASTEIC ULCER Fig. 206. — Case 127,214. Organic hour-glasfe stomach of gastric ulcer at a. No "nischen symptom." Fig. 207. — Case 107,257. Multiple gastric ulcers. Pyloric cud puckered and adherent to lesser curvature. Snail form of stomach. Pylorus at a. EEPORT OF CASES 275 Gastric ulcer. Findings at operation: (1) Ulcer the size of a quarter, high on the lesser curvature and posterior wall, firmly adherent to pancreas. (2) Chronic appendicitis. Operation: Excision of ulcer. Appendectomy. Pathologist's report: (1) Simple gastric ulcer. (2) Chronic catarrhal appendicitis. Case 127,214, female, aged 37 years. For five years past, about once a week, she has had attacks of pain in the left epigastrium radiat- ing between the shoulders. The pain is fairly severe at times, especially with change of weather. It seems to be brought on by eating but may come at any time. Five months ago for a period of two months, she had daily attacks, then a respite until three weeks ago, since when the attacks have been of daily occurrence. She belches gas, and vomitS' bitter fluid. Deep inhalation causes pain at the left costal arch. No weight loss. Hemoglobin 80. Total acidity 54; free 40; combined 14. Roentgen findings: No retention. Hour-glass stomach. Reray after belladonna: Hour-glass stomach still present. Tender point corre- sponding to constricted area (Fig. 206). Diagnosis: Gastric ulcer. Findings at operation : Ulcer on lesser curvature, 5 inches above py- lorus. Band producing hour-glass contraction. Gastro-enterostomy. Case 107,257, female, aged 52 years. For twenty-five years she has had attacks of gnawing epigastric pain, coming a half hour to one hour after meals and continuing for several days or a week, with free intervals of four to six weeks. Nine years ago she vomited a cupful of blood, but did not have severe pain on that occasion. During the past year the pain has been more frequent ; sometimes relieved by food and sometimes not. For six months past she has had spells of pain at 11 p.m. Two months ago she again vomited a cupful of blood. Alto- gether she has vomited rarely. There is much gas and occasional sour eructations. Appendix removed nine years ago. Weight loss slight. Hemoglobin 80. Total acids 10; all combined. Roentgen findings: Retention of half the six-hour meal. Antrum acutely flexed and adher- ent to lesser curvature. Diagnosis: Lesion of stomach (Fig. 207). Findings at operation : Multiple ulcers causing an acute fish-hook form of stomach, with puckering of the lesser curvature and pylorus. Operation: Finney plastic. Case 98,523, female, aged 37 years. Starting about 20 years ago, for nine years, from September on through each winter, the patient had attacks of hard, griping, epigastric pain. The pain came an hour after each meal and lasted to the next meal. It was eased by food, soda, rest and change of posture. Thirteen years ago the attacks became shorter but more severe, coming several times a year and last- ing two or three weeks with intervals of entire freedom between. The 276 GASTRIC ULCER Fig. 208. — Case 98,523. First examination. Large hypotonic stomach with incisura at a. Fig. 209. — Case 98,523. Second examination. Niche at a; hour-glass constriction at 6. REPORT OF CASES 277 pain has not been accompanied by sour eructations or vomiting. During the past year the attacks have come at short intervals, and on two occasions the pain was so severe as to requii'e niorphin. Weight loss slight. Two gastric analyses : (1) Total acidity 36; free 30; com- bined 6. (2) Total acidity 64; free 54: combined 10. Roentgen find- ings: First examination. January 10. 1914: Large stomach with retention of half the six-hour meal. Incisura, greater curvature. Second examination, after belladonna: Conditions unchanged (Fig. 208). Diagnosis: Gastric ulcer. Exploration was advised but re- fused. The patient returned October 22. 1915. At this time a third examination revealed the same conditions as previously, except that a small niche was now visible on the lesser ciuwature 'Fig. 209j . Find- ings at operation: (1) Ulcer very high on lesser ciu'vatm'e, with semblance of hom"-glass. (2) Stones in gall-bladder. Cautery exci- sion of ulcer; gastro-enterostomy. Cholecystectomy-. Pathologist's report: Chronic catarrhal cholecystitis; cholelithiasis. Case 94,543, female, aged 28 years. For six years attacks of pain in the left epigastrium coming two or thi'ee hours after meals and accompanied by vomiting and lasting from one to four weeks. She vomited blood six years ago and again three years ago. Pvecently she was in bed for several days with incessant vomiting. The pain radiates to the left shoulder and at times requires codeine for relief. IN'o defi- nite food-ease, but she states that she has less pain immediately after meals. Little loss of weight. Hemoglobin 70. Total acidity 60; free 52; combined 8; food remnants definite. Roentgen findings: Large stomach with retention of thi'ee-fourths of the motor meal. Niche on lesser curvature seen on oblique xievr only (Fig. 210j. Incisura opposite on greater cui vatui e. of irregular type. Diagnosis : Gastric ulcer. Figs. 211, 212, 213, 214. Findings at operation: (1) L'lcer on the lesser ctu'vature at incism'a ang-ularis, and a contact ulcer on the posterior wall, causing hour-glass stomach. Fleer very adher- ent to liver and pancreas. (2) LTcer of duodenmn, anterior wall, moderately obstructive. Operation: ilj Sleeve-resection of stomach. (2) Excision duodenal ulcer; Finney pyloroplastj'. Pathologi5t's re- port: Multiple simple ulcers of stomach (Fig. 214). Post-operative roentgen finchngs: Five weeks after operation: Very small stomach with contraction on greater cinvatm'e at site of sleeve resection (Fig. 212) . Four and one-half months after operation: Stomach shows marked increase in size (Fig. 213). One year after operation: Retention of one-fourth the motor meal. Contracture still present at site of resec- tion. Stomach still larger in size. Case 150,820, female, aged 66 years. Intermittent gastric dis- 278 GASTRIC ULCER Fig. 210. — Case 94,543. Oblique view. Niche, a, on lesser curvature. ineisura at b. Wavy Fig. 211. — Case 94,54.3. Dorso-ventral view. Suggestion of a double ineisura on greater curvature. No niche seen on lesser curvature. REPORT or CASES 279 Fig. 212. — Case 94,543. Stomach soon after sleeve-resection. Note small size of stomach and the contraction, a, at suture-line. Fig. 213. — Case 94, .543. Stomach approximating normal capacity a few months after operation. Contraction, a, at suture-line still present. 280 GASTRIC ULCER turbances for the past 12 years; food distress rather than food-ease; epigastric soreness, more marked on the left side. Patient says she is nauseated most of the time and vomits often without effort or rehef. For years unable to lie on left side, because of nausea. No bleeding. Always light eater; lived on pint of milk and cream daily for years. In the past six months she has been progressively worse. Soreness left side, no desire for food, because of nausea and vomiting. Weight early 125 pounds, two years ago 103 pounds, now 99 pounds. Total acidity 34, free HCl 28; combined 6. Hemoglobin 88 per cent.; reds 4,624,000. Roentgen findings: Stomach large, with a number two Fig. 214. — Case 94,543. Photograph of resected specimen, showing multiple ulcers and puckered areas of healed ulcers. retention at the end of six hours. Small six-hour retention in the duodenum. Peristalsis vigorous and of irregular type. Niche, pre- pyloric, lesser curvature. Cap deformity (Fig. 215). Diagnosis: Gastric ulcer; duodenal ulcer. Operative findings: Double ulcer: Ulcer of the stomach 3 inches above the pylorus on lesser curvature. Ulcer duodenum extending up to pjdoric ring. Operation: 1. Cau- tery excision gastric ulcer. 2. Pylorus blocked by two silk mattress sutures. 3. Posterior gastro-enterostomj^ Case 135,028, male, aged 37 j^ears. Trouble with stomach one year, almost continuous, never well more than two or three days in succession. Burning epigastric pain, two to three hours after meals, and at 10 p.m. Relief by soda; partial food relief. Belching and water-brash. Vomited once, ten months ago; some blood. No vomit- REPORT OF CASES 281 ing since. Feels best with stomach entirely empty. Some loss of weight. Hemoglobin 90. Two gastric analyses: (1) Total acidity 32; free 24; combined 8. (2) Total acidity 50; free 36; combined 14. Roentgen findings: Screen and plate examination negative (Fig. 216). Findings at operation : Ulcer on lesser cm'vature of the stomach, high up near cardiac end. Operation: Cauterization of ulcer. Posterior gastro-enterostomy. Case 139,094, female, aged 47 years. For twenty years she has had attacks of "heartburn" with some pain in the stomach about three times a week. This has been getting more frequent and now occurs Fig. 215. — Case 150,820. Niche of gastric ulcer at a. Spastic deformity of duodenal bulb at b, constant at screen-examination and on all plates. The spasm was intrinsic and due to duodenal ulcer. about one hour after each meal. Acids and baked potatoes cause most discomfort; milk and crackers least. The attacks last several hours; relief by soda. She is free from distress in the intervals. There is much gas, bloating and belching, and frequent sour eructations, but never vomiting. Normal weight 100; present 76. Hemoglobin 35. Firm mass, dull to percussion 1 inch to right of mid-line, extending from costal margin to 1 inch below the level of the umbilicus and 4 inches to the left of mid-line. Total acidity 46; free 30; combined 16; altered blood. Wassermann negative. Roentgen findings : Retention 282 GASTRIC ULCER Fig. 216. — Case 135,028. Gastric ulcer, lesser curvature, high up in cardia. Screen and plate findings negative. Plates made with patient prone.J Fig. 217. — Case 139,094. Large perforating ulcer at a. Hour-glass contracture at 6. REPORT OF CASES 283 of three-fourths of the six-hour meal. Hour-glass stomach. Large perforating ulcer, on the lesser curvature, of the mid-portion of stom- ach (Fig. 217). Patient died one week after the examination. Post- mortem findings : The stomach is filled with a fibrinous clot. There is a carcinoma which has developed on a large saddle ulcer which has perforated against the pancreas. At one point in the base of the ulcer, the origin of the hemorrhage, which occurred from an artery in the pancreas, can be seen. The edges of the carcinomatous ulcer are thickened and calloused. Fig. 218. — Case 151, 968, Niche higli on lesser curvature at a. Case 151,968, male, aged 59 years. Gastric trouble for the last five or six years. Present trouble began six months ago, and has been more or less continuous. Gastric symptoms consist of dull epigastric pain coming on soon after meals with soda-ease. Much gas, sour eructations, occasional heartburn and water-brash. Vomiting is a prominent feature since onset, coming on from one-half to three hours after meals. Never has been any food-ease, patient always feeling better when stomach is empty. Usual weight 155 pounds, now 139 pounds. Hemoglobin 85 per cent.; reds 5,200,000. Total acidity 26; free HCl 0; combined 26. Wassermann negative. Roent- gen findings: Large stomach with retention of three-fourths of the 284 GASTRIC ULCER Fig. 219. Fig. 220. Fig. 222. Fig. 221. Figs. 219, 220, 221, 222. — Gastric ulcers with niches of various sizes and situations. The niche is shown at a. ULCER-NICHES 285 Fig. 223. Fig- 225. Fig. 224. \-^^' 1^12 r Fig. 226. Figs. 223, 224, 225, 226. — Gastric ulcers with niches of various sizes and situations. The niche is shown at a. 286 GASTRIC ULCER Fig. 227. Fig. 228. Fig. 229. Fig. 230. Figs. 227, 228, 229, 2.30. — Perforating gastric ulcers with accessory pockets, with and without hour-glass contracture. Accessory pocket, a. Hour-glass constriction, b. ORGANIC HOUR-GLASS 287 Fig. 231. Fig. 232. Fig. 233 Fig. 234. Figs. 231, 232, 233, 234. — Gastric ulcers producing organic hour-glass contracture, b. No visible niche. 288 GASTRIC ULCER Fig. 236. Fig. 235. Fig. 237. Fig. 238. Fig. 235. — No niche, no evidence of any indurated area. Barium excluded from prepyloric region at a. There was also a retention of one-fourth the motor meal. At operation 'a^ small slit-like ulcer was found on the lesser curvature, body of stomach. See Fig. 236. FiG.l236. — Photograph of specimen from case shown in Fig. 235. The minuteness and^shallowness of the ulcer explain the absence of a visible niche. Fig. 237. — Prepyloric irregularity at a. Diagnosis: Prepyloric lesion. At opera- tion, gastric ulcer, just above pylorus, posterior wall. Fig. 238. — Large shallow niche of a saddle ulcer at a. Such a niche might easily be mistaken for the bulge between two peristaltic waves. REPORT OF CASES 289 lolfGf Fig. 240. — Photograph of specimen showing cavity of ulcer. Fig. 239. — Accessory pocket of per- forating ulcer at a. Oblique view. Perforation against pancreas. See speci- men, Fig. 240, Fig. 241. — Gastric ulcer near pylorus, Fig. 242. — Photograph ofi section producing irregularity and obstruction at from stomach showing crater of penetra- a. Shadow of gallstone at b. Barium in ting ulcer at c, duodenum, c. 19 290 GASTRIC ULCER Fig. 244.- sected from ulcer at c. -Photograph of ulcer re- stomach. Crater of Fig. 243. — Gastric ulcer. Niche at a. Incisura at b Resected specimen shown in Fig. 244. Fig. 245. — Photomicrograph, 4x, of cross section through an ulcer. The destruction extends to the musculature, but not into it. The excavation, c, is the niche seen in the roentgenogram. Fig. 243. Fig. 246 — Large stomach with retention of half the six-hour meal. Prepyloric narrowing at a. Diagnosis: Obstructive lesion on gastric side of pyloric ring. At operation : Fairly large ulcer high on lesser curvature. (The diagnosis was based wholly on the secondary signs The prepyloric narrowing was due to spasm). REFERENCES 291 motor meal. Small niche high on the lesser curvature. Peristalsis of vigorous irregular type. Practically no barium seen passing from stomach into the duodenum. Diagnosis gastric ulcer; obstruction just beyond pylorus (Fig. 218). Operative findings: Small ulcer high on the lesser curvature. Ulcer duodenum producing obstruction. Duode- num was completely sealed against the gall-bladder. Empyema of the gall-bladder which was filled with stones. Gall-bladder had per- forated into duodenum, producing a fistulous tract between. Opera- tion: (1) Cautery excision, ulcer of stomach. (2) Posterior gastro- enterostomy. (3) Cholecystectomy. (4) Closure of fistulous tract between gall-bladder and duodenum. Pathologist's report: Gall- bladder with stones, chronic cholecystitis. REFERENCES 1. Hemmeter, J. C: "Neue Methoden zur Diagnose der Magenge- schwiirs." Arch.filr Verdauungshranhheiten, 1906, xii, 357-364. 2. Wilson", L. B. and McDowell, I. W.: "A Further Report of the Pathologic Evidence of the Relationship of Gastric Ulcer and Gastric Carcinoma." Amer. Jour. Med. Sci., 1914, cxlviii, 796- 816. 3. Reiche, F.: "Zur Diagnose des Ulcus Ventriculi im Rontgenbild." Fortschritte a.d. Geh. der- Rontgenstrahlen, 1909, xiv, 17.1-173. 4. Haudek, M.: ''Die Rontgendiagnose cles kallosen (penetrieren- den) Magengeschwiire und ihre Bedeutung." Munch. Med. Wchnschr., 1910, Ivii, 2463-2466. CHAPTER XrV MISCELLANEOUS GASTRIC CONDITIONS Hair-ball and Other Foreign Bodies — Diverticula — Diaphragmatic Hernia and Elevation of the Diaphragm — Gastroptosis HAIR-BALL Unique among the foreign bodies which are occasionally found in the stomach, the hair-ball (trichobezoar) possesses almost theatrical interest. Butterworth^ was able to collect 42 cases from the literature including 1 of his own. He gives an extensive bibliography. Moore- has found 11 additional published reports, to which he gives references, and adds 1 himself. Burchard^ reviews some of the cases that were examined by the roentgen-ray, including Franke's'^ and Schwarz's.'^ In Franke's case there was a hard, smooth, painless tumor in the region of the stomach. In the roentgen picture there was an irregularly mottled shadow ending in an arch above. The diag- nosis of trichobezoar was made on the combination of the cUnical and roentgen findings and w^as confirmed at operation. Schwarz's case showed no complete bismuth shadow of the stomach, but only a streak along the greater curvature. In Kampmann's^ case also, that of a ten-year-old girl, the mass filled the stomach. The roentgen-ray showed uneven dis- tribution of the bismuth meal. Xo gas-bubble was present. Clairmont and Haudek^ describe a case in which a hair-ball of moderate size could be displaced into the upper portion of the stomach and its arched shadow could be seen in the gas-bubble. Huttenbach^ gives extensive details of the case of an eighteen- year-old woman. At the roentgen examination of the stomach the contrast meal showed an uneven splotching. The gas- 292 HAIR-BALL 293 Fig. 247. — Holland's case of hair-balls in the stomach. Fig.. ^248. — Hair-ball in the stomach (Ramsbottom and Barclay). The projection of the hair-mass into the gas-bubble is well shown. 294 MISCELLANEOUS GASTRIC COXDITIOXS bubble could not be seen. At operation the hair-ball was found to form a complete cast of the gastric cavity, with a small pro- jection into the duodenum. It was quite hard, though porous, and covered with a grayish-white bacterial growth. Holland's^ patient was a young woman, aged 29. The upper abdomen was occupied by a very large tumor which reached to the umbilicus. When examined with the screen, the barium sulphate mixture rapidly mapped out the stomach though somewhat faintly, but showed two dark transverse bands. Later, a definite history of hair-swallowing was obtained. At operation three large hair-balls were removed. They filled the stomach almost completely. The pecuhar roentgen appearance was evidently due to the barium mixture flowing between the wall of the stomach and the hair-balls, and to a certain extent sticking to the surfaces of the latter, while the dark hands were caused by the opaque meal entering the joints between (Fig. 247). The case reported by Ramsbottom and Barclay ^° was that of a woman, 28, who gave a history of gastric disturbance for a few weeks only. In the left abdomen was a large, but not tender, freely movable tumor, which was at first believed to be the spleen. WTien examined roentgenoscopically b}^ Barclay the bismuth meal surrounded the mass and outhned the curvatures of the stomach. By palpation the tumor could be shifted upward, the top of it rising above the bismuth and showing a rounded shadow in the gas-bubble (Fig. 248). Barclay gave the opinion that the mass was a hair-ball. Subsequently it was learned that twenty years previously in an attack of scarlet fever the patient had eaten practically aU of her hair. At opera- tion the hair-baU was found to be 9 inches long by 3 inches wide, with a process extending into the duodenum. For obvious reasons, by far the greater number of hair-balls are found in females, and more often under the age of 20. Three or 4 cases, however, have been reported in boys and men. Neu- roses, dementia, mania, and idiocy play a part. The form and size of the hair-masses vary. Large bezoars usually form casts of the gastric lumen; the smaller ones may be spherical or kidne}^- HAIR-BALL 295 shaped. In one case reported, the mass weighed more than 4 pounds. The symptoms of the condition are not distinctive. They include loss of appetite, pressure, distress, pain and vomiting. The patients usually complain most after eating (Hiittenbach) . In some instances small hair-masses have been discovered in the Fig. 249. — Case 148,917. Photograph of hair-ball after removal from stomach, show- ing a mass of hair, hay, and rags. stools, and in one case they were ejected by vomiting. The palpable tumor is freely movable, and has been variously mis- taken for a splenic, pancreatic or renal growth, or a fecal ac- cumulation in the colon. In most of the cases that were subjected to roentgen examina- tion it is noteworthy that the opaque meal penetrated between 296 MISCELLANEOUS GASTRIC CONDITIONS the wall of the stomach and the hair-mass, thus visualizing a regular gastric contour, but the area occupied by the hair-ball was only faintly and diffusely shadowed. When, in addition, the tumor-mass can be displaced upward into the gas-bubble^ the evidence of a foreign body is complete. Combination of the roentgenologic and clinical findings should always establish the diagnosis. During the past two years 2 cases have been seen in the Mayo Clinic. Unfortunately, neither of the patients was examined by the roentgen-ray. Fig. 250.— Case 107,244. Photograph of hair-ball. Case 148,917, female, aged 32 years. The patient has been an inmate of the State Hospital for Insane during the past eighteen months, and on previous occasions for a year at a time in other hos- pitals. She complains of attacks of abdominal pain, coming at inter- vals of one to six months, and lasting two weeks. The pain is rather diffuse but worse on the left side and is associated with nausea and vomiting. Hemoglobin 75. Movable mass, Hke a floating spleen, in left epigastrium. Findings at operation: Hair-ball 10 inches long in stomach, was removed through anterior longitudinal incision. Patho- logical report: Foreign body. Mass composed of hair, hay, strings and cloth. Weight 240 gm. (Fig. 249). FOREIGN BODIES 297 Case 107,244, female, aged 10 years. Scarlet fever at 9 years of age. Well until ten days ago, when she had a "bilious attack," with headache, cramping abdominal pain, and nausea; sHght fever. She is restless at night and pulls and chews her hair. Hemoglobin 75. Large, hard, irregular, freely movable, mass, extending obliquely from left costal margin to right abdomen. The mass is not tender and crepitates on palpation. Findings at operation: Large hair -ball, al- most filling stomach. Gastrotomy and removal of mass. Patholo- gist's report: Hair-ball. Weight 2 pounds (Fig. 250). OTHER FOREIGN BODIES The foreign bodies which are swallow^ed either accidentally or intentionally are most often metallic, and their detection in the stomach by the roentgen-ray is not usually difficult. Occa- sionally, when it is uncertain whether the object is within the stomach or has passed into the bowel, the opaque meal or enema may be of assistance. If the shadow of the foreign material is enveloped in that of the meal in the stomach, at all angles of view, its intragastric location msiy be assumed. The meal may also aid in finding non-opaque bodies. Case 141,504, female, aged 29 years. Patient at the Rochester State Hospital for Insane, in good physical health and apparently suffering no distress. By chance, the nm'se in charge saw a teaspoon disappear into the woman's mouth and she was brought to our clinic. Roentgen findings: Spoons in stomach nested together. Hair pin (Fig. 251). At operation seven teaspoons Ijdng together ''spoon fashion" were found, together with a hair pin, some straw and small pieces of twigs. Xo injury to the gastric mucosa was discovered. The spoons, which were of plated metal, were not eroded. They were each 6 inches in length and l}^ inches across the bowl. Recovery was uneventful. Case 151,406, infant, ten months old. The youngster pulled off its stocking, removed an open safety-pin and swallowed it. The roent- genogram herewith shows the open safet3-pin in the stomach (Fig. 252) . The case is remarkable from the fact that the pin, though open, passed through without hindrance. DIVERTICULA Few cases of gastric diverticula have been found in man. The excavation into adjacent tissues sometimes produced by 298 MISCELLANEOUS GASTRIC CONDITIONS '^.yV'xx^, Fig. 251. — Case 141,504. Nested spoons and a hairpin in stomach. Fig. 252. — Case 151,400. Open satety pin in infant's stomach. DIVERTICULA 299 perforating gastric ulcer is not really a diverticulum, though often thus called. Even the designation ''false diverticulum" is hardly applicable, and we have therefore selected the term ''accessory pocket" (see "Gastric Ulcer"). Pathologists cus- tomarily divide diverticula into the "true" and "false." In the former the diverticular sac contains all the coats of the vis- cus-mucosa, muscle and serosa; in the false type one or more Fig. 253. — Case 90,125. Diverticular sac at d. layers are missing, most often the muscular, in which case the condition has been described as "hernia mucosae." Falconer^^ reports a congenital diverticulum of the stomach, found at autopsy. It arose from the pyloric canal on the greater curvature side, was j-i inch in length and admitted the forefinger. In C. H. Mayo's^^ case the diverticulum was on the anterior wall of the stomach, 2 inches from the pylorus. It was l^i inches in length and contained a well- marked carcinoma in its outer portion. One case of gastric diverticulum has come under our observa- tion: 300 MISCELLANEOUS GASTRIC CONDITIONS Fig. 254. — Case 90,125. Photograph of specimen. Diverticulum at d; ulcer at u. Fig. 255. — Case 90,125. Outside view of diverticular sac, d. DIAPHRAGMATIC HERNIA 301 Case 90,125, male, aged 54 years. Twenty-year history of stomach trouble. Attacks usuallj^ in autumn, lasting some weeks, of epigastric pain, two hours after meals, relieved by vomiting. Present attack has lasted three months, the pain is of a burning character, comes two or three hours after meals, and is relieved by vomiting. Weight loss, 25 pounds. Total acidity 36, all free; food remnants. Hemoglobin 60. Roentgen findings: Small retention from the six-hour meal in what was believed to be the duodenal bulb. Hyperperistalsis. Bulb irregular. Diagnosis: Duodenal ulcer (Fig. 253). Findings at opera- tion: Obstruction at the pylorus believed to be due to a duodenal ulcer. Operation: Gastro-enterostomy. Findings at autopsy: The specimen taken from the stomach, post-mortem, is illustrated in Figs. 254 and 255. In Fig. 254 two depressions are seen just proximal to the pyloric ring. One of these is a callous ulcer, the other, near by, is the opening of a diverticulum. DIAPHRAGMATIC HERNIA AND ELEVATION OF THE DIAPHRAGM (EVENTRATION) Diaphragmatic hernia, with protrusion of the stomach or other abdominal viscera into the thoracic cavity, and a related condition, elevation of the diaphragm, though not common, are of some practical importance. Both may give rise to marked gastric symptoms. The former is an actual rupture of the dia- phragm. The latter is not, although the term ''eventration," w^hich is frequently used as a synonym, implies a rupture. While either may affect the right half of the diaphragm, nearly all the cases reported have been left-sided. Elevation is usually, if not always, congenital, or due to inborn weaknesses. It is not surgical. Diaphragmatic hernia may be either congenital or acquired. It is generally surgical. In the traumatic form, the history of a crushing injury of the lower thorax and upper abdomen, or a sudden doubling of the body with the knees against the chest, can often be obtained. The clinical symptoms and physical signs of the two condi- tions are not essentially different, and the roentgen examination affords the most effective means of exact diagnosis and of differ- entiating the one from the other. Among those who have written concerning the roentgen signs may be mentioned Giffin,^^ 302 MISCELLANEOUS GASTRIC CONDITIONS Becker/^ Sailer and Rhein/'^ Arnsperger,^'^ Kienbock,^^ Hilde- brand and Hess,^^ and Koniger.^^ Examination with the opaque meal is preferable, although much can be determined without it, or by inflating the stomach. With the patient recumbent, either prone or supine, the eleva- tion or herniation is more accentuated than in the standing position. In left-sided elevation of the diaphragm (eventration) the left arch of the diaphragm, which is normally lower than the Fig. 256.— Case 136,932. Barium-iiUed stomach high in left chest. right, is now seen to be markedly higher than its fellow, and its convexity is increased. The heart is either raised or displaced to the right. The gas-bubble (patient standing) is forced up- ward with the arch, is increased in size, and no shadows of lung- tissue are seen within the transparent area of the bubble. Both arches show respiratory movement, though the excursions may be shorter. On filling the stomach with the barium meal, its high-lying position becomes evident. DIAPHRAGMATIC HERNIA 303 Fig. 257. — Case 130,932. Colon-ray on two plates. The splenic loop extends up to the second left intercostal space. 304 MISCELLANEOUS GASTEIC CONDITIONS In left-sided diaphragmatic hernia the roentgen signs are usually more exaggerated. The heart is displaced to the right b}^ the herniated stomach. Through the gas-bubble, which is usually! increased in size, lung-markings may be seen. The dome-shape of the left arch is lost, if the arch can be made out at all. Especially notable is the "paradoxic respiratory phe- nomenon"; on forced inspiration the right diaphragm descends while the clear area in the left chest rises; in expiration the Fig. _'o>. — Case 136,932. Stomach after operation. reverse occurs. This point differentiates hernia from elevation. By giving a barium meal the herniation of the stomach can be established. In some instances the colon also takes part in the hernia, and this can be shown by examination with an opaque enema. Case 136,932, male, aged 47 years, conductor. Four years ago in a railway accident his chest was crushed' by logs falhng from a car. Following this he began to have severe gastric distress about two hours after meals. At times the pain is extreme. It is made worse by food. Relief is secured by abstinence from food or a quick physic. JMeats, DIAPHRAGMATIC HERNIA 305 Fig. 259. — Case 1.36,932. Colon after operation. left side. Ri^t^icLe. Fig. 260. — Case 136,932. Note the left diaphragm after repair. The broken ribs may also be seen on the left side. 20 306 MISCELLANEOUS GASTRIC CONDITIONS potatoes and fruits are especially distressing. He is sometimes con- scious of gurgling and rumbling in the left chest. Total acidity 20; free 10; combined 10. Physical examination showed displacement of the heart to the right. Under forced respiration splashing sounds of fluid and air were heard as high as the left nipple. Roentgen findings : No retention from six-hour meal. Stomach high up in left chest, is distorted and partially rotated (Fig. 256). Old fractures of left ribs. Diagnosis: Hernia or eventratio diaphragmatica. Colon ray: Spleoic Fig. 261. -Case 28,068. Eluvatioii of left diaphragm (eventration). Barium in stomach, s. flexure in left thoracic cavity. Diagnosis: Hernia diaphragmatica (Fig. 257). Findings at operation: Hernia through left diaphragm. Hernial opening about 6 inches in circumference. Chest-cavity con- tained part of small intestine and the greater portion of the colon spleen and stomach. The opening was sutured. The patient also has a gastric ulcer on the lesser curvature about 1>^ inches from the pylorus, and an ulcer on the posterior wall of the duodenum which may GASTROPTOSIS 307 require operation later. (Neither of these could be determined at the roentgen examination, because of the malposition and distortion of the stomach.) The condition after operation is shown in Figs. 258, 259 and 260. Case 28,068 (x-ray No. 18,292), male, aged 58 years. The patient complains of shortness of breath on exertion. He has noticed this for ten years or more. No pains in left chest. He has known for ten years that his heart is on the right side. No marked tympany at left base; slight change in note. Breath sounds distant. Vocal fremitus much diminished at left base. Coin sound not typical but rings with coin just inside left nipple. Tinkhng sounds from stomach heard in front. Signs not definite. The roentgenogram (ventro- dorsal view), Fig. 261, shows the high-arched diaphragm reaching to the fourth costal interspace. Its unbroken outline can be traced throughout. Beneath the diaphragm is the stomach containing a small quantity of bismuth food. The heart shadow lies entirely to the right. On fluoroscopy both arches of the diaphragm moved in unison during respiration. GASTROPTOSIS Notwdthstanding a wealth of literature on the subject of gastroptosis there is still widespread disagreement, not only as to its significance and proper treatment, but even as to W'hat constitutes the condition. The w^ork of Glenard, who is gen- erally credited with the first detailed descriptions of ptosis of the thoracic and abdominal viscera, attracted a large retinue of followers, especially during the past two decades. Nephro- ptosis received the bulk of attention for some years, and its rise and decline in clinical and surgical favor is a familiar story. Later, gastroptosis and enteroptosis came into greater promi- nence, and have been given recent emphasis by Lane's w^ork on stasis. The lexicographer has no difficulty in defining gastroptosis (or the preferred form, gastroptosia) as a "dow-nward displace- ment of the stomach." But here, as wdth many other medical terms, the definition is by no means equivalent to a description of the condition, nor does it carry an unvarying meaning. At first thought gastroptosis appears to be a simple term w^hich designates a specific thing, yet the most casual scanning of the 308 MISCELLANEOUS GASTRIC CONDITIONS literature reveals a broad divergence of opinions as to what gastroptosis is. The clinical conception of gastroptosis was based originally on the physical signs obtained after inflation of the stomach, the patient being examined in the recumbent position usually. The stomach was outlined by percussion and the umbilical level was taken as the normal limit of the lower gastric pole. Descent of the greater curvature below this level was regarded as indica- tive either of gastroptosia, or gastrectasia, or both combined. Then came the roentgenologic method of examination with the opaque meal. Patients were examined in the standing position as a rule, but the umbilical landmark for the greater curvature was retained. Consequently, roentgenologists were annoyed to find that the majority of stomachs fell below the normal stand- ard. Hampered by this fixed idea, the effort to establish a normal roentgenologic stomach which would harmonize with the normal clinical stomach was laborious. Many condemned the roentgenologic stomach as an artefact. It was contended that the weight of the bismuth dragged the stomach far below its natural level and distorted its form. In respect to this con- tention it should be stated that while the stomach does lie at a lower level when the patient is standing than when he is re- cumbent, the difference is not due to any extraordinary weight of the opaque meal. Nevertheless, the general acceptance of gastroptosis as an important entity has obliged many roentgenologists to attempt its diagnosis. As a result they offer conflicting diagnostic criteria. Hertz^° states that "complete gastroptosis is present when the stomach is not only abnormally low in the erect posi- tion, but the greater curvature reaches below the umbilicus in the horizontal position." Kaestle^^ says: ''If the greater curva- ture of a stomach, not dilated, stands below the navel, with a more or less high-lying pylorus above, one speaks of gastropto- sis." On the other hand, GroedeP^ puts pyloroptosis in the first place, recognizing it by the course of the pars horizontalis superior, the low position of the pylorus and its abnormal mo- GASTROPTOSIS 309 bility. Further, he notes fundus-ptosis, resulting in a small gas- bubble. Schlesinger^^ holds that the cardia must take part in the ptotic process. Of greater indicative value than sinking of the pylorus, he thinks, is its turning out of its original horizontal position into a vertical or left oblique direction. He sums up the three factors in gastroptosis as follows: (1) Lengthening of the gastric wall. (2) Drawing down of the cardia and upper pole of the stomach. (3) Sinking and rolling up of the pylorus, Beclere and MerieP'^ point out that the stomach never leaves its attachment to the diaphragm. They prefer, therefore, to speak of the ''lengthened stomach" rather than the "ptosed stomach." They distinguish two kinds of lengthened stomach; one with normal tone, tubular in form; the other atonic, with expanded lower pole, inclining to delayed motility. In our discussion of the normal stomach (Chapter VI) we have endeavored to emphasize the relation of the form and posi- tion of the stomach to gastric tone, abdominal tension and — chief of all — the habitus of its possessor. Habitually in eateroptotic persons and quite often in persons of normal build, we have found the lower gastric pole far below the umbilical level. In most instances no definite gastric symptoms existed. When they did exist the stomach was usually found to be anatomically normal at operation, and the symptoms were explained by the discovery of some other lesion within the abdomen. On the whole, we are quite willing to record the opinion, from a roent- genologic standpoint, that the position which the stomach occu- pies in the abdominal cavity is its least important characteristic. The clinical status of gastroptosis is likewise somewhat pre- carious. Recent writers on diseases of the stomach speak guard- edly of ptosis. Bassler^^ says that "the special objective signs that constitute a prolapsed stomach are to some extent still a matter of personal equation with each observer." Stockton^^ states that "gastroptosis is usually unaccompanied by symp- toms sufficierrtly specific to lead one to suspect its presence." Much of the import of gastroptosis rests on the assumption of gastric drainage by gravity, a conception which Cannon regards 310 MISCELLANEOUS GASTRIC CONDITIONS as unfortunate. The functioning of the pylorus and the gastric tone have far more effect upon gastric motihty than the height of the pylorus above the lower pole. The low-lying stomach is usually hypotonic, and for the latter reason is likely to show moderate delay of evacuation, but we have not seen a delay be- yond six hours from this cause alone. Lack of familiarity with the numerous surgical lesions in other parts of the digestive tract, even entirely outside of it, which give rise to gastric symptoms, is possibly accountable for many of the diagnostic favors which have been bestowed upon gastroptosis. Zealous use of the roentgen-ray in the search for abnormalities of the stomach is seldom unrewarded, and some degree of '^gastropto- sis" is the rule rather than the exception. The roentgen-ray will show the position of the stomach, and the roentgenologist may, indeed he should, report this as a detail of his findings to the physician in charge. But the examiner should not, as is sometimes done, inform an enteroptotic hypo- chondriac that his trouble is a ''dropped stomach," and thus give the patient additional cause for somber introspection. It is doubtful whether the roentgen examiner is ever justified in a diagnosis of "gastroptosis," in view of the varying weight which attaches to the term. Responsibility for this diagnosis belongs to the patient's medical counselor. Though we are not here directly concerned with the treatment of gastroptosis, whether medical or surgical, the following remarks by Stiller" are interesting. "Surgery, intoxicated by its triumphal invasion into the domain of the internist, has brought out various operative methods in the treatment of gastroptosis, which correspond to the narrow gross anatomical viewpoint. If the atonic stomach is too broad, they cut out a piece of the gastric wall ; if it has sunk down, they stitch it up, shorten it by folding it, fasten it to the liver, or fix it to the rib-cartilages, in order to eliminate the re- spiratory movability which a wise nature has provided. Por- tions of the weak abdominal wall have actually been excised. From the standpoint of the asthenia this is all raw vandalism. REFERENCES 311 For, wholly apart from the fact that suppressing the symptoms does not mean the cure of the great underlying asthenic trouble, we cannot as yet regard the stomach as simply an anatomical pouch; it has indeed, so to speak, a physiologic importance. If there is impairment of its motor function, which the surgeons wish to improve by their operative arts, it will not be made better by a resection-scar, by stitching up, by folding, or by fixation to the belly- wall, whereby the natural movability of the organ is directly harmed." REFERENCES 1. BuTTERWORTH, W. W. : ''Hair-ball or Hair-cast of the Stomach and Its Occurrence in Children." Jour. A. M. A., 1909, liii, 617-623. 2. Moore, G. A. : ''Hair-cast of the Stomach with Report of a Case." Bos. Med. and Surg. Jour., 1914, clxx, 8-11. 3. BuRCHARD, A.: "Bezoare in der alten und in der modernen Medizin." Fortschr. a.d. Geb. d. Rontgenstrahlen, 1914-15, xxii, 321-326. 4. Franke: "Trichobezoar." Korrespondenzblatt des Meckl. Arz- tevereinbundes, Nr. 343. Quoted by Burchard, loc. cit. 5. ScHWARz, G.: "Ein Fall von Trichobezoar." Lijekcnickivijesnik 1913, XXXV, 38-44, Rev. Zentralhl. f. Chir., 1913, xl, 1571. 6. Kampmann, E.: "Ein Trichobezoar im Magen." Munchen. Med Wchnschr., 1911, Iviii, 413-414. 7. Clairmont, p. and Haudek, M.: "Die Bedeutung der Magen- radiologie ftir die Chirurgie." Jena, Fischer, 1911, 98. 8. HtJTTENBACH, F. : "Ein Fall von Trichobezoar des Magens bei Infantilismus." Mitt. a.d. Grenzgeb. d. Med. u. Chir., 1912, xxiv, 85-107 (with 29 references). 9. Holland, C. T. : "Radiography in a Case of Hair-ball in the Stomach." Arch. Roentgen Ray, 1913, xviii, 46-47. 10. Ramsbottom, a. and Barclay, A. E.: "The Diagnosis of a Hair-ball in the Stomach." Arch. Roentgen Ray, 1913, xviii, - 167-169. 11. Falconer, A. W. : "A Case of Congenital Diverticulum of the Stomach." Lancet, 1907, i, 1296. 12. Mayo, C. H.: "Diverticula of the Gastro-intestinal Tract." Jour. A. M. A., 1912, lix, 260-264. 312 MISCELLANEOUS GASTRIC CONDITIONS 13. GirriN, H. Z.: ''The Diagnosis of Diaphragmatic Hernia." Annals of Surgery, 1912, Iv, 388-397. 14. Becker, T. : "Rontgenuntersuchungen bei Hernia und Even- tratio diaphragmatica." Fortschr. a.d. Geh. d. Rontgenstrahlen, 1911, xvii, 183-195. 15. Sailer, J. and Rhein, R. D.: "Eventration of the Diaphragm." Amer. Jour. Med. Sci., 1905, cxxix, 688-705. 16. Arnsperger, H. : ''Ueber Eventratio diaphragmatica." Deutsch. Arch, fur Jdin. Med., 1908, xcih, 88-97. 17. Kiekbock, R. : "Ein Fall von Zwerchfellhernie mit Rontgenim- tersuchung." Ztschr. f. Uin. Med., 1907, Ixii, 321-330. 18. HiLDEBRAND, H. and Hess, 0.: "Zm- Differentialdiagnose zwis- chen Hernia diaphragmatica und Eventratio diaphragmatica." Miinclien. Med. Wchnschr., 1906, hi, 745-748. 19. Koniger, H.: "Zm' Differentialdiagnose der Zwerchfellhernie." Munchen. Med. Wch7ischr., 1909, Ivi, 282-285. 20. Hertz, A. F.: "Gastroptosis." Arch. Radiology and Electro- therapy, 1915, XX, 143-150. 21. Kaestle, K.: ''Roentgenkmide." Rieder-Rosenthal, Leipzig, Earth, 1913, i, 516. 22. Groedel, F. M.: "Grundriss and Atlas der Roentgendiagnostik." Miinchen, Lehmann, 1914, 390. 23. ScHLESiNGER, E. : "Weitere Aufschltisse iiber den Befund und die Genese der Gastroptose durch das Rontgenbild." Deutsch. Arch. f. hlin. Med., 1912, cvh, 552-572. 24. Beclere et Meriel: "L'exploration radiologique dans les affec- tions chirurgicales de I'estomac et de Tintestin." Ann. internat. de chir. gastro-intest., 1912, vi, 132; 190. 25. Bassler, a.: "Diseases of the Stomach." Philadelphia, Davis, 1913, 708. 26. Stockton, C. G. : "Diseases of the Stomach." New York, Appleton, 1914, .540. 27. Stiller, B.: "Die asthenische Konstitutionskrankheit." Stutt- gart, Enke, 1907, 222. CHAPTER XV THE STOMACH OF INFANTS AND CHILDREN Flesch and Peteri/ who examined 72 children by the roent- gen method, state that the normal stomach of infants, ''filled with physiologic fluid food, " has the form of a bagpipe, has a large gas- bubble, is horizontally situated, and shows no peristalsis. When given pap-hke food, the air-bubble is smaller, the stomach shows a descending and a horizontal portion, and peristalsis is present. Alwens and Husler^ find that the form and position of the infant stomach depends on the amount of filling, position of the body, etc., and manifests peristalsis with both fluid and pap-like foods. They found the evacuation-time for fluid food to be about three hours, but occasionally they noted small bismuth residues after five hours in healthy sucklings. The normal evacuation time of 200 c.c. of pap is from three to three and a half hours. Ladd^ observed a curious lack of peristalsis in the normal infant's stomach as compared with that of adults. The stomach appeared to squeeze out the food by contracting as a whole upon its contents, seldom showing the marked indentations so char- acteristic of peristaltic waves in the adult. In the normal case, he states, some of the food appears in the small intestine as soon as the plate can be taken after feeding. The emptying process goes on rapidly at first, the major part of the contents being ex- pelled in from one and one-half to two and one-half hoars, both in breast-fed and bottle-fed babies. After two hours there is a slowing of the emptying process and four to five and a half hours may elapse before all traces of bismuth disappear. In one case, a normal baby, he noted a considerable residue after seven and one-half hours. The age of the child and its individual pe- culiarities, the quantity and composition of the food, may all be factors influencing gastric motility. The suggestion is strong, 313 314 THE STOMACH OF INFANTS AND CHILDREN he observes, that the casein of cow's milk when given in high per- centage decidedly prolongs the evacuation-time. If the casein is precipitated before giving it, emptying is greatly accelerated. The presence of fat has no retarding action, and in some cases seems to favor the exit of the gastric contents. Sever^ examined 83 children to find the position of the lower gastric border. The stomachs were nearly all of the fish-hook form, and plates were made with the patient standing. The lower border was at the fourth lumbar vertebra in 25 ; at the level of the iliac crests in 9 ; and well below the crests in 49, often 3 or 4 inches below. He thinks, therefore, that a low-lying stomach in a child does not necessarily mean a pathologic ptosis. Willox^ concludes that the shape of the stomach with con- tents in children is not a fixed one, but presents many differences during the process of digestion. As a rule, in infants the shape is more or less globular, becoming elongated and J-shaped as the child grows older. He found the average emptying-time of the stomach to be three and three-quarters hours, and thinks that the composition of the food has less effect than bulk and con- sistence on gastric motility. In some cases the food begins to pass through the pylorus practically as soon as the meal has been taken, while in others there appears to be a resting stage before peristalsis commences. Pisek and Le Wald^ in their investigations used 10 per cent, bismuth subcarbonate fed by gavage. They concluded that there is no definite normal type of stomach in the infant. It is horizontal rather than vertical in position as compared with the adult stomach. They noted three forms, the ovoid (bagpipe), the tobacco-pouch (retort-shape) and the pear-shape. The shape of the stomach seems to depend largely on the quantity of gas which it contains or acquires, and the amount of gas is less when semi-solid food is taken. The Rieder hook-form was ob- served only once, occurring in a six-months-old infant. The lesser curvature often was not clearly outlined. In the majority of cases the pylorus was comparatively high and behind the py- loric third. Food passed out rapidly. A large number of CONGENITAL PYLORIC STENOSIS 315 stomachs practically emptied themselves within an hour. The stomach tends to expel its gas accumulation soon after the entry of food, to diminish in size generally and to shorten its axis by drawing upward and to the left. CONGENITAL PYLORIC STENOSIS While the symptom-complex of vomiting, visible peristalsis and palpable pyloric tumor is deemed pathognomonic of infantile, pyloric stenosis, the aid of the roentgenologist is sometimes solicited, especially in the spastic and atypical cases. Opinions as to the value of the roentgen examination are contradictory. La Fetra^ thinks that the roentgen-ray is not at all essential for the diagnosis and is often misleading. Richter^ says that it cannot be relied on implicitly, as bismuth will pass through the pylorus, though slowly, in some cases of stenosis. Reuben^ re- gards the roentgen-ray as of little value. He mentions a case which he sent to a roentgenologist, who told the mother of the child that an operation would be necessary as no bismuth passed into the duodenum during twenty minutes' observation, although Reuben states that the patient was doing perfectly well under medical care. On the other hand, Dunn and HowelP° found the method useful in determining the degree of pyloric obstruction, the emptying- time and size of the stomach. Their experience in- cluded 6 cases of pyloric spasm, 6 of complete stenosis and 3 of partial stenosis. Le Wald,^^ whose observations have been extensive, argues strongly for the roentgen examination. He presents a series of roentgenograms showing different grades of pyloric obstruction. In one instance some of the meal is seen going through the pylorus early; operation was not performed. In another case none of the meal passed out into the duodenum, even up to fifty-two minutes after ingestion, and operation was regarded as imperative (Fig. 262). Dilatation was also marked in the latter case. 316 THE STOMACH OF INFANTS AND CHILDREN From the material published it would appear on the whole, that the roentgen-ray can give substantial aid in the diagnosis of congenital pyloric stenosis, whether spastic or organic. Cer- tainly the degree of pyloric patency, the time required for gas- tric evacuation and the presence or absence of dilatation can be determined better by this than by any other means. The differentiation of organic from spasmodic stenosis ought to be possible by a reexamination after giving belladonna or papaver- ine, though we have found no recorded instance in which these °-4* Fig. 262. — Congenital pyloric stenosis in an infant eight weeks old. No bismuth passing the pylorus up to fifty-two minutes. (From Le Wald, in Johnson's Thera- peutics.) drugs were thus employed in infants. The opinions above quoted, adverse to the value of the roentgen examination, doubt- less arose from faulty technic or incautious interpretation of the results. Admitting our absolute lack of personal experience with the roentgen manifestations of infantile pyloric stenosis, we would venture to suggest, nevertheless, that the examiner should be careful in basing a diagnosis upon the early rate of gastric evacuation alone. In adults we have repeatedly seen instances in which no barium was seen to pass the pylorus for a consider- able time after its ingestion, yet no organic stenosis existed, and it is not irrational to suppose that this might also occur in infants. It would seem that the examiner should take account not only of the initial pyloric outflow but also of the total time required AEROPHAGY IN INFANTS 317 for gastric evacuation, the presence or absence of gastric dilata- tion, and the total clinical picture. AEROPHAGY IN INFANTS Leven and Barret^'- agree with other observers that the nor- mal infant stomach contains considerable air. While nursing, the air is usually expelled in proportion as the stomach is filled. But they have seen cases in which the air was not expelled and gave rise to vomiting. Immediately after nursing, the quantity of milk in the stomach would be quite small and the air-bubble very large, lifting up the left half of the diaphragm. Then there would be a sudden contraction of the stomach followed by vom- iting. In such a case if the infant was given more abundant nursiugs at longer intervals the air was expelled and replaced by the milk, and vomiting averted. Leven and Barret also noted another type of air-retention and vomiting, which they believed was due to a spasm of the cardia. The same phenomena were observed radioscopically as in the other type, except that the air was at no time expelled, and spasm of the cardia was deemed to be the cause. In order to lessen the intragastric tension, small but frequent feedings were employed. Regarding the teaching in most training schools for nurses, that the baby should be kept in the horizontal position after nursing. Smith and Le Wald^^ state: ^' Air is swallowed with food by many if not all infants. The erect posture favors eructation of this air; the horizontal posture prevents it. The horizontal posture, by preventing eructation, is an important cause of vomiting, colic, indigestion and disturbed sleep." They, there- fore, advise that the infant be held upright before and after feeding to encourage eructation of the air. Feeding should be given at as long intervals as possible, they believe, and each feeding should not be given too slowly. REFERENCES . 1. Flesch and Peteri: Cited by Alwens and Husler. 2. Alwens, W. and Husler, J.: " Roentgenuntersuchung des kindlichen Magens." Verhandl. d. deutsch. King. f. innere Med., 1912, xxix, 168-170. 318 THE STOMACH OF INFANTS AND CHILDREN 3. Ladd, ]\I. : ''The Influence of Variations of Diet upon Gastric Ivlotilitj- in Infants." Arch. PediaL, 1913, xxx, 740-746. 4. Sever, J. V. : " The Position of the Stomach in Children." Arch. Pediai., 1914, xxxi, 38-44. .5. WiLLOX, L. : "Gastric Radioscopy in Children." Practitioner, 1915, xcv, 599-641. 6. PiSEK, G. R. and Le Wald, L. T.: "The Further Study of the Anatomy and Physiology of the Infant Stomach Based on Serial Roentgenograms." Am. Jour. Dis. Child., 1913, vi, 232- 244. 7. La Fetra, L. E. : "The Roentgen-ra}^ as a Diagnostic Help to the Pediatrist." Arch. Pediat., 1914, xxxi, 761-763. 8. RicHTER, H. M. : "Congenital Pyloric Stenosis." Jour. A. M. A., 1914, Ixii, 353-356. 9. PtEHBEN, jNI. S.: "Pjdoric Stenosis in Infancj^" Arch. Pediat., 1914, xxxi, 809-828. 10. DuxN, C. H. and Hottell, W. W. : "Diagnosis and Treatment of Pyloric Stenosis and Pjdoric Spasm." Arch. Pediat., 1915, xxxii, 42&-433. 11. Le Wald, L. T.: In Johnson, A. B.: "Operative Therapeusis." New York, Appleton, 1915, iv. 212-214. 12. Leven, G. and Barret, G.: "Radioscopie Gastrique." Paris, Doin, 1909, 180-186. 13. Smith, C. H. and Le Wald, L. T.: "The Influence of Posture on Digestion in Infancy." Am. Jour. Dis. Child., 1915, ix, 261-282, CHAPTER XVI THE STOMACH AFTER OPERATION Operations most commonly performed upon the stomach in- clude gastrojejunostomy, gastroduodenostomy, sleeve resec- tion, partial gastrectomy with gastro-enterostomy, pyloroplasty, gastrostomy, gastropexy, gastroplication and local resection of ulcers or tumor-bearing areas. After any of these interventions a roentgen examination is often advantageous in determining the functional behavior of the operated stomach and finding the cause of an occasional unsatisfactory result. When a gastro- jejunostomy has been made, information is sometimes desired as to the exact site of anastomosis, the patency of the stoma and the general mechanical results of the operation. After a re- section for cancer the question of a possible recurrence is of deep interest. One of the most elaborate studies of the enterostomized stomach is that by Hartel,^ who reports his findings in 22 cases. In several cases as the stomach was filled with the bismuth meal, it was noticed that the ingesta lagged below the air-bubble. Filling of the pyloric portion was often slower than normal. Before the stomach was completely filled, evacuation through the stoma commenced. In every case the contents passed rather freely through the anastomosis, and, in some cases, through the pylorus also. Emptying took place in from one to three hours. In 7 of the cases, the flow through the stoma was intermittent. In 1 case it was rhythmic and synchronous with inspiration. The periodic flow in the other cases corresponded to the peristal- tic waves. Hartel believes that a peristaltic wave passing over the stoma tends to narrow it momentarily, and that this ex- plains the intermittent outflow which by others has been ascribed to the new development of a sphincter-mechanism at the stoma. Owing to the rapid emptying of the enterostomized 319 320 THE STOMACH AFTER OPERATION stomach, it is rather difficult to determine its size as compared with that before operation. Most writers agree that there is a shrinkage. Hartel indorses this view and attributes it to an increase of tone, and thinks that the process takes place gradually in the course of several months. He did not observe any marked alterations of peristalsis. From a study of 6 cases in which posterior gastro-enterostomy had been performed, and from a review of cases reported by others, Outland, Skinner and Clendening- conclude that gastro- enterostomy if properly done is a drainage operation, and that if the stoma is at the lowest part of the stomach in the erect posi- tion, the food leaves the stomach almost exclusively by the gastro-enterostomy opening, the stomach emptying with great rapidity. In cases in which the gastro-enterostomy does not quite drain the stomach, the food leaves both by the stoma and the pylorus. Case^ thinks that gastro-enterostomized stomachs may be divided into three classes : 1. Those with a very large gastro-enterostomy opening, the food dropping in an apparently passive way from the stomach into the small bowel. These patients, he says, frequently complain of a sickening distress, especially after the ingestion of a meal consisting largely of warm Uquid, and Case attributes the distress to sudden overdistention of the small bowel. 2. The stomachs which do not empty well after the opera- tion, probably not because the opening is too small, but because it is placed too high or too far from the pylorus. The stomach empties quickly until the level of the opening is reached, after which it empties very slowly, the residue at that time remaining for eight, ten or more hours. 3. The normally functioning cases — those patients in whom the passage of material from the stomach occurs very much as in the normal patient. A few moments elapse before food is seen in the jejunum, the passage of food boluses is irregularly intermit- tent, and the total time required for clearance of the opaque meal averages from four and a half to six hours. AFTER GASTRO-ENTEROSTOMY 321 Case found also that unless organic pyloric obstruction existed, it was the rule to find some of the barium passing through the pylorus as well as through the stoma. In several cases in which the pylorus was blocked by mattress sutures, it became patent again as early as the fifth or sixth week after operation. In 2 out of 4 cases in which pyloroplasty had been done, Case was able to confirm Cannon's and Blake's finding that too rapid exit of food from the stomach was prevented by the formation of rhythmically contracting constriction rings in the duodenum. At times he also noted analogous phenomena after gastro-jejun- ostomy, namely, a sort of sphincter-action in the jejunum at a point 3 to 6 cm. below the gastrojejunal opening. Obviously it is impossible to define closely the normal, ex- pected and desirable conditions following operation. These will depend largely upon the particular case at hand, the nature and extent of the original lesion, and the character of the intervention, which is often controlled by circumstances rather than choice. Yet some conception of what may be considered the normal se- quences of operation is necessary for the judgment of abnormal results. Customarily, after a gastrojejunostomy we have ob- served the following : 1. The opaque meal passes freely through the stoma. This is the rule, with rare exceptions, even after the lapse of years. The flow through the anastomosis may be continuous, intermit- tent, or rhythmic. It is perhaps somewhat more voluminous and continuous shortly after operation than it is when months or years have elapsed, but the stoma does not tend to contract materially as time goes on. 2. Unless the pylorus is obstructed by the original lesion or was blocked at operation, a part of the gastric contents may pass through the pylorus spontaneously, or can usually be driven through it by manipulation. When the pylorus has been blocked at operation it may reopen within a few weeks or months. As a rule, even with a patent pylorus, the bulk of evacuation apparently takes place through the stoma. 3. There is no retention from the six-hour meal in the stom- 322 THE STOMACH AFTER OPERATION ach, duodenum, or jejunal loop. The stomach empties ia con- siderably less time than the normal unoperated stomach. We are unable to endorse Case's theory- that after gastro-enterostomy the stomach should empty preferably" in normal time; this result would militate against the most common purpose of the operation. 4. The stomach is usually smaller than before operation, unless marked dilatation existed previous^. 5. The stomach is not deformed as to its general contour (unless by the original lesion or its resection-scar), and has no tendency toward hour-glass form or spastic distortion. 6. The gastric contour at the stoma is not usually deformed saving occasionally a slight, smooth, incurvation at that point. 7. Extensive adhesions about the stoma simply as a result of operation are uncommon, and the stomach is at least moderately mobile. 8. Peristalsis is not overactive. If there is any change at all, it would seem to be toward lessened activity. 9. The efferent jejunum is neither narrowed nor dilated nor markedly irregular in outline. 10. The duodenum is not dilated. Any departure from this summary should be viewed with mistrust, but should be carefully interpreted in conjunction with the surgical and chnical histories. Figs. 263, 264 and 265 illus- trate presumably normal conditions folloT^ing gastro-enter- ostomy, the roentgen examination showing no evidence of secondary pathology, and the patients having no symptoms demanding further surgery. After a sleeve resection, the stomach, besides being diminished in size proportionately to the amount exsected, may also show more or less hour-glass contraction at the suture hne, or an in- cisura at that point on the greater curvature (Fig. 266). In time such a constriction tends to become less pronounced. If only a small gastric sac remains as a result of the resection, its capacity gradually increases to some extent. Faulhaber and V. Redwitz'* observed circular contraction at the site of a sleeve GASTROJEJUNOSTOMY 323 Fig. 263. — Normal conditiou after gastrojejunostomy. Stoma at s. Meal leaving stomach chiefly through gastro-enterostomy, though some barium has passed the pylorus. Fig. 264. — Normal condition after gaatrojejunostomy. The patient was corpulent and the pressure of the abdomen, while the plate was being made, displaced the stomach upward into a transverse position. The undeformed stoma is seen at s. Pylorus patent. 324 THE STOMACH AFTER OPERATION Fig. 265.- -Normal condition after gastrojejunostoui\'. Stoma at s. barium passing into duodenum. Small amount of Fig. 266.- tomosis, ■ -Stomach after sleeve-resection, showing contracture at point of anas- (Other details of this case will be found in the chapter on Gastric Ulcer.) RESECTION 325 resection, and this was associated with a small stomach which emptied rapidly through the pylorus. Following an extensive ablation of the pyloric portion, clos- ure of the duodenum and making a gastro-enterostomy, the remnant of the stomach shows as a small, vertically hanging pouch, with the stoma at the lowest point. Subsequently the pouch enlarges to a degree. It should be smoothly contoured, pliable and expansible, if all diseased tissue has beenl^removed (Fig. 267). Fig. 267. — Stomach after resection, duodenal closure, gastro-enterostomy. Roentgenologically normal. Pyloroplasty obliterates the normal constriction at the ring and the duodenal loop merges directly into the gastric cavity. Gastric] drainage is copious and the evacuation- time is shortened. The few cases of gastropexy (for ptosis) which we have ex- amined did not show any roentgenologic signs of the operation. Cohn,^ in three patients upon whom gastrostomy had been performed, noted persistent hour-glass contraction at the site of the opening. Notwithstanding a notable lack of peristalsis the 326 THE STOMACH AFTER OPERATION gastric contents were rather rapidly and continuously evacuated through an open pylorus. The roentgenologic determination of post-operative compli- cations is not easy because of the inevitable physical and func- tional changes incident to operative intervention. To safeguard his conclusions, the examiner should be informed as fully as possible concerning the conditions found at operation, what was done, and the subsequent clinical history. Roentgenograms made prior to operation are especially valuable for comparison with those made after. The important complications following gastric surgery in- clude jejunal or gastrojejunal ulcer, so-called vicious circle, and recurrence or new development of cancer or ulcer. Concerning these the roentgen examination can often give fairly precise in- formation. Besides these candidly pathologic conditions, un- satisfactory results are sometimes due to imperfect surgical technic. Since surgeons differ widely among themselves as to technical details, it is not in the province of the roentgenologist to decide whether or not a gastro-enterostomy opening is too large or too small, too high or too near the pylorus, or whether the afferent jejunal loop is of proper length. But the a;-ray should show the site of the stoma, its patency, and, with an un- obstructed pylorus, the length of the afferent loop. Final judgment in these matters may be left to those directly con- cerned. JEJUNAL AND GASTROJEJUNAL ULCERS Ulcers developing in the vicinity of the stoma after gastro- jejunostomy have been variously designated jejunal and gastro- jejunal ulcers. A post-operative ulcer situated in the jejunum well away from the gastro-enterostomy opening, is, strictly speaking, jejunal. An ulcer involving the stoma, both on its gastric and jejunal aspects, is more properly described as gastro- jejunal. Paterson^ was among the first to draw attention to these ulcers, and in his comprehensive article collected 51 cases from JEJUNAL AND GASTROJEJUNAL ULCERS 327 the literature. Other cases have been reported by W. J. Mayo/ Moynihan and Tatlow/ Mayo-Robson^ and Soresi.^° In 1915, one of us (Carman) m collaboration with Balfour^^ collected 13 cases from the records of this clinic, and since then additional cases have come under observation. All of these were of the gastrojejunal type, and we shall confine ourselves to that term in subsequent discussion. All post-operative ulcers in the neigh- borhood of the stoma, whether involving it or not, have pre- sumably similar causes, and have like symptoms, so that their designation is immaterial. An important etiologic factor appears to be the use of a con- tinuous suture of unabsorbable material in making the anastomo- sis, silk or linen sutures being found at the site of the ulcer in many instances. However, these ulcers have also occurred after the use of the Murphy button. Pathologically, they are usually of considerable surface ex- tent, with much induration and hyperemia. The line of anas- tomosis is usually involved, but the ulcer tends to spread further on the jejunal than on the gastric side. Adhesions were present in the majority of our cases. Clinically, they do not give rise to any symptoms or signs which can be considered definitely diagnostic. After a variable period of relief by the gastro-enterostomy, the patient again develops pain and other symptoms, often somewhat like those prior to operation, but without any fixed and decisive complex. Any aid to the discovery of these ulcers is, therefore, of distinct value. The results in our own cases convince us that by the roentgen-ray such aid can be obtained, and that in many in- stances the condition can be positively diagnosed. Post-operative ulcers perforating into the colon have previ- ously been given passing mention by roentgenologists, but simple gastrojejunal ulcers have not heretofore been extensively stud- ied from the roentgen viewpoint. Mathieu and Savignac^^ state that in jejunal ulcer perforating into the large^bowel, the direct passage of bismuth into the colon can be demonstrated. They state further that the colon may be narrowed by adhesoins 328 THE STOMACH AFTER OPERATION about the fistula, and the small intestine may be dilated in all or parts of its length, which conditions are susceptible of demon- stration by roentgenoscopy. Their remarks seem to be based largely on 5 cases of jejunocolic fistula reported by Lion and Moreau.^^ One of these was examined with the roentgen-ray by Beclere. Moynihan and Tatlow's case of gastrojejunal ulcer was rayed by Rowden, but his report was non-committal. Barsony^^ reports a case of gastrojejunal ulcer in which the roentgen-ray showed a pocket at the line of anastomosis, the size ^_iiLalkrone>. Some five hours later the pocket was still filled with bismuth after the stomach was empty. Barsony lays strong emphasis on the persistence of bismuth in the ulcer-cavity as a characteristic. But, excepting one of the cases hereinafter reported, we have not noted any roentgenologic evidence of a cavity resembling the niche of penetrating gastric ulcer or the accessory pocket of perforating ulcer. The nature of the ulcer rather precludes any probability of visualizing its crater as a niche, for the reason that the ulcer is most often characterized by surface area rather than depth. In a series of 14 cases in this clinic examined by the roentgen- ray, all were of the non-fistulous type, yet all but 2 showed dis- tinct signs of secondary pathology. These manifestations in- cluded deformity about the stoma, narrowing and deformity of the efferent jejunum, diminished patency of the stoma, dilatation of the stomach, retention from the six-hour meal, hyperperistal- RoENTGEN Findings in Fourteen Cases of Gastrojejunal Ulcer Case Number Roentgen-ray findings Deformity about stoma Exaggerated peristalsis Large stomach Gastro-enterostomy not freely pa- tent Retention from six-hour meal. ... Lessened mobility of stomach. ... Dilatation of duodenum , Spacticity of stomach Irregularity of jejunum + , + + ' - + . - + : - + ■ + + + +1 + - ! - +■ + _ i + + - ; - -' + Mod. + + , + + ' + + ' + Mod. - + Mod. + + + ^^ S ^ + + i- i- JEJUNAL AND GASTEOJEJUNAL ULCER 329 sis, dilatation of duodenum, and spasticity of the stomach. The accompanying tabulation shows the number of cases in which such findings were noted and their association with each other. Deformity about the stoma of a posterior gastro-enterostomy is often not readily visible. If the point of anastomosis is well up on the vertical portion of the stomach, an oblique view may show it, but it is much more commonly on the horizontal part of the stomach. Here an oblique view is of little service, and we have often found it advantageous to lift up the overhanging lower border of the stomach by manual pressure and thus expose the anastomosis. With a high anterior or posterior gastro- enterostomy a lateral view may be of value. While a gastro- enterostomy often produces a little dimpling at the point of attachment, there is ordinarily no marked irregularity. On the other hand, in approximately four-fifths of our cases of gastro- jejunal ulcer, rather striking deformity about the stoma was observed. Gastrojejunal ulcer following an anterior gastro- enterostomy sometimes produces a palpable inflammatory mass which corresponds to the visible irregularity and filling-defect about the stoma. This finding is almost pathognomonic. Since a gastro-enterostomy is often in the median line, pressure against the spine may deform this part of the stomach, and the examiner should be careful in his interpretation of plate findings. The patient's abdomen should not be pressed too tightly against the plate, and, if prone, his chest and shoulders should be supported by cushions, or a table with a deep fenestrum for the plate should be used. However, if the distortion about the stoma is marked and identical on all plates the observer is safe in saying that it is abnormal. Narrowing of the jejunum and deformity of its contour was present in more than half the cases of gastrojejunal ulcer. It involved the efferent limb, usually quite near the stoma. To^be of value, this sign must be definite and constant at the screen inspection and on all plates. A lack of free patency of the stoma was notable in several instances. The signs of this condition are both direct and in- 330 THE STOMACH AFTER OPERATION direct. Directly, the examiner can note the lessened amount of barium passing out, in contrast to the normal copious exit. If the flow is scant or wanting in spite of manipulation of the gastric contents toward the stoma, it is reasonably certain that the opening is not free. If originally made ample, contraction of the orifice, though unusual and somewhat indicative of gastro^ jejunal ulcer, is not absolutely so. We have recently noted a case in which narrowing was found at operation but without any evidence of ulcer. However, in this instance the stoma, though narrow, was not deformed. Indirectly, obstruction may be manifested by a retention from the six-hour meal, or by the large size of the stomach. Gastric hyperperistalsis, or dilatation of the duodenum or affer- ent limb of the jejunum, may also be in evidence. Of these signs the six-hour retention is most important. Occurring in a gastro-enterostomized stomach, it is highly significant of ob- structed drainage. In most of the cases of retention in associa- tion with gastrojejunal ulcer, the retention was between the stoma and pylorus. In one case the barium rest was in the immediate neighborhood of the stoma, as though held in a small pouch. This proved to be a gross ulcer with a jejunal pocket of considerable size, being exaggerated by adhesions. The unre- sected enterostomized stomach, even though large before opera- tion, tends to contract to normal or even smaller dimensions. If then it does not show diminution in size, but is still large, inter- ference with its emptying may be suspected. Another common sequence of obstruction is an exaggeration of peristalsis. An increase in the vigor and number of the waves may also result from other causes, so that this sign is merely indicative of some abnormal condition. Dilatation of the duodenum was observed in one of our cases, and this may or may not have been due to obstruction by the ulcer at the stoma. Lessened mobility of the stomach was noted in two instances, and was the result of extensive adhesions about the stoma. But this is a sign of which the observer can rarely be confident, espe- cially when dealing with a posterior gastro-enterostomy. By JEJUNAL AND GASTROJEJUNAL ULCER 331 palpation, changing tlie position of the patient, and requiring him to breathe deeply, fixation at the point of anastomosis can sometimes be fairly determined. Spasticity of the stomach as seen in one case, with extensive irregularity of the gastric borders, cannot be considered very significant, except as an indication of reflex irritation. In translating these signs into a diagnostic opinion, the examiner should be fully acquainted with the entire clinical and surgical history of the case, not for the purpose of anticipating the roentgen findings, but to prevent hasty deduction from them. The roentgen phenomena of gastrojejunal ulcer fall into two groups — those broadly denoting an abnormal condition, and those pointing directly to the seat of trouble. Six-hour reten- tion, hyperperistalsis, large size of the stomach, dilatation of the duodenum, and spasticity of the stomach, are included in the first group. They may be noted singly or in varying combina- tions. The second group, namely, deformity about the stoma, narrowing and irregularity of the jejunum, scant flow of barium through the gastro-enterostomy opening, and fixation of the stomach at the site of anastomosis, all point to the latter as the pathologic focus, and here gastrojejunal ulcer is by far the most common lesion. After resection of the stomach for cancer, similar signs may result from recurrence of the growth at the point of gastro-enterostomy; the history should aid in making the distinction. Peculiarities or errors of surgical technic may also produce some of the roentgenologic manifestations enumerated above, and in view of this possibility, the roentgen diagnosis of gastrojejunal ulcer should be guarded. However, a careful consideration of all the circumstances should decide whether or not further surgical intervention is necessary, and this is more important than an exact diagnosis. Case 33,109, male, aged 51. Stomach trouble for the last twelve years. Pain localized to pit coming on two or three hours after eating; relieved by food. Three or four spells a year lasting three or four weeks at a time. Some nausea; vomits frequently. Total acidity, 58; free HCl, 44; combined, 14. Food remnants, 1. Clinical diagnosis: 332 THE STOMACH AFTER OPERATION Fig. 268. — Case 33,109. Gastrojejunal ulcer. Irregularity of stoma and jejunum shown at s. Fig. 269. — Case 112,375. Gastrojejunal ulcer. Deformity about stoma at s Narrowed jejunum, j. JEJUNAL AND GASTEOJEJUNAL ULCER 333 Duodenal ulcer. Operative findings: January 18, 1910. Large con- tracted ulcer duodenum. Operation: Posterior gastro-enterostomy. Subsequent history: June 8, 1915. Following operation the patient was well for five years; then there was an onset of same complaint, coming with the change in the weather for several days at a time. Pre- meal distress and food-ease. Condition has progressed rapidly; dis- tress almost continuous; vomiting of retained food. Weight loss from 162 to 126. No urinary disturbance. S.B.P. 118, D.B.P. 80. No masses felt, rectal shelf free. Total acidity, 28; free HCl, 20; com- bined 8. Roentgen findings : Retention one-fourth the six-hour motor Fig. 270. — Case 96,667. Gastrojejunal ulcer. Deformity of stoma at s. Narrowed jejunum, j. Note hyperperistalsis ; peristaltic waves at p. meal. Irregularity of stoma and jejunum. Pylorus not freely patent; gastro-enterostomy only moderately so. Diagnosis: Gastrojejunal ulcer (Fig. 268). Operative findings: Very large gastrojejunal ulcer, partly in the stomach and partly in the jejunum. Pylorus adherent to abdominal wall. Linen suture found hanging in the ulcer. Opera- tion: Separation of gastro-enterostomy. Opening in stomach closed Excision of ulcer. Jejunum reunited. Gastroduodenostomy. Case 1 12,375, male, aged 42. In January, 1914, gastro-enterostomy elsewhere for duodenal ulcer, following excision of ulcer and closure of pylorus. After the operation the patient had a great deal of distress. 334 THE STOMACH AFTER OPERATION In August, 1914, he visited the Mayo CHnic, at which time an inde- terminate (post-operative) diagnosis was made. After leaving the dinic he returned to his work, but the distress became so severe that his surgeon operated again in October, 1914, and found adhesions in the neighborhood of the stoma with a mass at the gastrojejunal juncture and a linen thread hanging in it. About one week after this operation a large abscess formed in the wound, which has continued Fig. 271. Fig. 272. Fig. 273. Fig. 2 74. Figs. 271,272, 273,274. — Cases of gastrojejuna] ulcer. Stoma, s. Jejunum, j. to discharge from time to time. In probing the wound, the linen thread was removed. Roentgen findings: No retention from the six- hour meal. Filling-defect about stoma and efferent jejunum (Fig. 269). Operative findings: Gastrojejunal ulcer in which was hanging a piece of linen thread 8 inches long. Ulcer involved wall of transverse colon, but had not perforated into it. Sinuses communicating with abdominal wall. Operation: 1. Reunion pyloric end of stomach and JEJUNAL AND GASTROJEJUNAL ULCER 335 body by plastic. 2. Divulsion of stricture of the duodenum. 3. Gastro-enterostomy cut off. Restoration of jejunum. Case 96,667, male, aged 51 years. With the exception of a violent pain lasting for a few minutes some twenty years ago, followed by liG. 276, Fig. 275. Fig. 277. Figs. 275 to 278. — Cases of gastrojejunal ulcer. Stoma, s. Jejunum, j. Gastric ulcer, u. Hour-glass stomach, h. Duodenum, d. epigastric soreness and jaundice, the patient had always been well until twelve years ago, when a period of intermittent stomach trouble developed, lasting for a couple of years. These attacks were usually 336 THE STOMACH AFTER OPERATION accompanied by epigastric distress coming on two or three hours after eating, vdth. food-ease. For the last nine j'^ears, more or less constant complaint with pain two to four hours after eating and early part of night, eased b^^ soda, food, vomiting, and occasionallj^ b}^ lavage. Hemoglobin, 65 per cent. Reds, 3,540,000. Urine negative. Was- sermann negative. Total acidity, 80; free HCl, 52; combined, 28. Roentgen findings: Fairlj^ large stomach. No retention from the six- horn- motor meal. H^-perperistalsis; deformity" of the bulbus duodeni. Diagnosis: Duodenal ulcer. Operation: December 12, 1913. Per- forating duodenal ulcer. Gall-bladder and appendix negative. Pos- terior gastro-enterostomy. Subequent history: Patient returned October 5, 1914, stating that he had been comfortable for three months, then began to have occasional sharp pain and vomiting. During past three months, trouble almost constant. Roentgen findings: Large stomach with retention one-half the six-hour motor meal. Hyper- peristalsis; gastro-enterostomj'' not functionating well. Deformity of stoma (Fig. 270). Operation: October 12, 1914. Finney operation on jejunum for jejunal ulcer at old gastro-enterostomy opening, size of a quarter. Ulcer caused by old linen suture hanging in gastro- enterostomy opening. REGURGITANT VOMITING AND VICIOUS CIRCLE Persistent regui'gitant vomiting after gastro-enterostomy, the vomit ■asually containing more or less bile, is the principal symptom of what is commonly designated 'Sdcious circle." Shortly after operation there is sometimes regurgitant vomiting, "which ceases after lavage or other treatment, but a persistence of this vomiting, which rarely occm^s, is indicative of mechanically obstructive conditions requiring reintervention. Moynihan^^ classifies four varieties of misdirected current, any One of w^hich establishes the circulus vitio^us : 1. Regurgitation of duodenal contents through the pylorus. 2. Escape of fluids from the stomach into the afferent loop. 3. Escape of fluids from the afferent loop into the stomach. This is generally considered the most frequent and the most grave variety. 4. Regurgitation of the contents of the efferent loop into the stomach. REGURGITANT VOMITING AND VICIOUS CIRCLE 337 As to the causes of regurgitant vomiting, Moynihan cites the following suggestions by Chlumskij :^^ ''1. Formation of a spur. This is certainly the most fre- quent. When the anastomosis is effected, the two limbs of the loop hang downward, and a sharp kink with spur-formation re- sults at the point of junction. ''2. The jejunal displacement may cause a kink at the duo- denal-jejunal juncture, and thereby produce an acute obstruc- tion of the duodenum. ^'3. The mucous membrane of the stomach may form large pouting valves which obstruct the afferent opening. ''4. Closure of the anastomotic opening if the muco-mucous stitch is improperly applied. ''5. Compression of the efferent branch of the loop by the colon (Doyen). '^6. Stendel related a case operated upon by Czerny, in which the opening in the transverse mesocolon had narrowed and constricted the efferent loop. "7. In the original operation of Wolfler, the antiperistaltic implantation of the jejunum favored regurgitation." Moynihan himself believes that the mechanical defect con- sists mainly, if not solely, in leaving a loop of jejunum between the flexure and the anastomosis. The loop becomes distended, ''water-logged," and thus obstructive. Besides the foregoing possible and proven causes, Finsterer mentions others, including an unduly long afferent loop, which, when filled, compresses and obstructs the efferent limb. He also emphasizes still another cause, namely, herniation of the small intestine through the sht in the mesocolon, thus compressing and obstructing the afferent jejunum. He reports an instance of this in which the roentgen examination showed a long loop of the upper small bowel distended with barium to the size of a child's arm, and confirming the diagnosis of stenosis. During the past four years we have examined by theroentgen- ray 22 cases of regurgitant vomiting following gastro-enteros- tomy, all of which were reoperated. With two exceptions, the 338 THE STOMACH AFTER OPERATION original operation had been performed elsewhere. The time that had elapsed since operation ranged from one month to ten years, with an average of three years. In twelve of these cases the roentgenologist did not report any definite evidence of sec- ondary pathology. Some of the examinations were made early in this work when the examiner was satisfied with determining the patency of the stoma and pylorus, and was dubious of ob- taining any additional information. It is noteworthy also that in some cases of regurgitant vomiting a second surgical explora- tion fails to reveal an adequate cause, especially in those cases which have had a gastro-enterostomy performed for the relief of symptoms and without demonstrable pathology. Many sur- geons deem these latter cases to be particularly prone to post- operative troubles. In ten of our cases the roentgen examination elicited abnor- mal signs, which in most instances were indicative of grave dis- turbance. In the main, the signs were those of obstruction, as shown by retention from the six-hour meal, large size of the stomach, failure of the barium to pass through the stoma, and hyperperistalsis. At reoperation various conditions were found. In three instances the obstruction was due to adhesions. In one case the stricture was apparently produced by contraction of the opening through the gastrocolic omentum, and in another case the gastro-enterostomy had been made on a long loop which had kinked. Brief details of four cases follow: Case 105,429, man, aged 39 years. Chronic indigestion since the age of ten. Attacks one to two months apart, lasting up to ten days, consisting of fullness, distress, and sour eructations, coming irregularly after meals, and with irregular food relief. In later years a sore spot at the right of the ensiform was present in the attacks. Six years ago he had a gangrenous appendix removed, and was quite well for two years. Then the old trouble recurred daily until three months ago, when he had an acute attack of pain and was operated upon the next morning. A posterior gastro-enterostomy (no loop) was done for what was believed by his surgeon to be a duodenal ulcer. For eleven clays following the operation he vomited large quantities of yellowish fluid every half hour. After this the vomiting came every five to REPORT OF CASES 339 ten days, each time vomiting large amounts of duodenal content. At present he can only take about 6 ounces of food at a time; if more is taken, regurgitant vomiting follows. Roentgen findings: No reten- tion. Rather high gastro-enterostomy. The roentgenogram (Fig. 279) shows a very large amount of barium in the afferent loop of the jejunum, while very little is seen in the efferent limb. Where the mechanical conditions are normal, the reverse is true. Because of these findings, a diagnosis of vicious circle was made. Findings at operation: Large gastro-enterostomy opening; pylorus patent. Many adhesions in upper abdomen. No ulcer could be found, either in stomach or duodenum. Operation: Gastro-enterostomy cut off.' Fig. 279.— Case 105,429. Case 133,498, man, aged 51. Posterior gastro-enterostomy a month previously for duodenal ulcer with impending perforation, (This had been diagnosed roentgenologically on hyperperistalsis'and six-hour retention.) He now complains of vomiting bitter, green fluid, at times slate-colored. The vomiting occurs mostly from 9.00 p.m, to 1.00 a.m. Total acidity, 38, free, 24; combined, 14; food remnants,' filtrate 1,000 c.c. Roentgen findings: Large stomach with retention of half the six-hour motor meal. Irregular vigorous peristalsis. Nothing seen passing thi'ough stoma. Some barium passing pylorus (Fig. 280). Findings at reoperation: Stoma greatl}^ strictured, ap- 340 THE STOMACH AFTER OPERATION parently by contraction of the opening through the gastrocolic omentum. Case 37,378, man, aged 47. Gastro-enterostomy one year ago, following which he vomited incessantly for ten days. Since then he has continued to vomit frequently, often daily for several days. Re- missions at times of several days without vomiting. The vomiting occurs usually some hours after eating, and is fluid in character, food being ejected only occasionally. Gastric analysis: Total acids, 36, free, 26; combined, 10; raisin-skins. Roentgen findings: Large stom- FiG. 2.S0. — Case 133,498. Details described in text. ach. Retention of half the motor meal. No evidence of gastro- enterostomy. Deformity of the duodenal bulb. Dilatation of third portion of duodenum (Fig. 281). Findings at reoperation: The gastro-enterostomy had been made on a 4-inch loop, turned to the right. Duodenal ulcer }^ inch below the pylorus (Enterostomy — Finney) . Case 141,212, man, aged 61. The patient gave a history of having had a gastric ulcer excised nine years ago, and a gastro-enterostomy two years ago for subsequent pyloric stenosis. After the second opera- tion he did very well until six months ago, when he began to have occasional projectile vomiting. This has gradually become more marked, and for the past three weeks he has been vomiting every other LESIONS AFTER OPERATION 341 day. Weight loss marked. Gastric analysis: Total acidity, 14; all combined; food remnants (raisin-skins); filtrate 1000 c.c. Roentgen findings: Retention of three-fom'ths the motor meal (Fig. 282). No barium between stoma and pylorus. Gastro-enterostomy obstructed (Fig. 283). Findings at reoperation: Large gastric ulcer between stoma and pylorus, which had contracted until the stoma was almost closed. (Resection pyloric end; plastic enlargement of gastro-enteros- tomy. On microscopic examination of the resected tissue, cancer cells were found.) Fig. 281. — Case 37,378. Description in text. RECURRENCE AND NEW DEVELOPMENT OF LESIONS AFTER OPERATION The roentgenologic demonstration of new and recurring lesions after operation is sometimes feasible, as instanced by the following cases: Case 89,460, man, aged 64. Resection, with anterior gastro- enterostomy one year ago for extensive carcinoma of the lesser curva- ture of the stomach, perforating. The patient gained 25 poundslin weight and felt well until five months ago. He now has heavy^distress after meals and is again losing weight. Total acidity, 10; all combined. Roentgen findings: No retention. Filling-defects at site of resection (Fig. 284). Diagnosis: Recurring carcinoma; inoperable. 342 THE STOMACH AFTEE OPERATION Fig. 282. — Case 141,212. Six-hour retention in stomach. Narrowing of stoma at s. Fig. 283. — Case 141,212. Same case as in Fig. 280, after filling stomach. KEPORT OF CASES 343 Case 75,677, woman, aged 47. Resection three-fifths of stomach with anterior gastro-enterostomy for cancer of the pyloric end of .the stomach, one year ago. Gained weight and felt well until three months ago. Since then bitter regm'gitation, occasional vomiting, and loss of appetite and strength. Resistance and tenderness in right epigastrium. Roentgen findings: No retention from six-hour meal. Filling-defect at site of resection corresponding to palpable mass (Fig. 285). Diagnosis: Recurring carcinoma. No operation. Case 124,629, man, aged 44. Mikulicz-Hartman-Polya resection, three-fourths of stomach, end to side anastomosis, for cancer involving A? Fig. 284. — Case 89,460. Recurring carcinoma of the stomach after resection. all of stomach except cardiac end, nine months ago. Now complains of poor appetite, distention after meals and weight loss. Roentgen findings : No retention. Finger-print-like filling-defects extending up- ward from site of resection (Fig. 286). Diagnosis: Recurring cancer; inoperable. Case 81,588, man, aged 41. Posterior gastro-enterostomy seven months previously elsewhere, for ulcer of the lesser curvature just above the pylorus, also ulcer on the greater curvature extending into the duodenum. He had no trouble after the operation except an occasional heaviness, until three months ago, when he began to have 344 THE STOMACH AFTER OPERATION Fig. 285. — Case 75,677. Recurring gastric cancer. Fig. 286. — Case 124,629. Recurring cancer. REFERENCES 345 Fig. 287.- — Case 81,588. Cancer following ulcer. Filling defect at /. Efferent jejunum at j. Fig. 288. — This patient had had a resection of the pyloric end of the stomach four years previously for carcinoma on ulcer. The roentgenogram, which shows a filling defect on the lesser curvature above the stoma, is indicative of a recurrence. However, no corresponding mass could be felt and the patient's general condition was good. In the absence, therefore, of any clinical corroboration it was thought that possibly the filling defect was the result of the operation. A reexamination after a few weeks or months would determine the matter. 346 THE STOMACH AFTER OPERATION Fig. 289. — Patient had had a V-resection of an ulcer on the greater curv^ature, body of stomach. The roentgenogram was made four weeks after the operation. The stom- ach, especially the pyloric segment, is small and the greater curvature is irregular, prob- ably the result of the operation, and not of any new pathologj-. Fig. 290. — Gastero-enterostomy for obstructive, non-resectable cancer of the stomach. REFEEENCES 347 regurgitation of food at night. About four weeks ago he commenced to have severe epigastric pain from midnight until morning, belching of gas, and sour eructations. Roentgen findings : Gastro-enterostomy freely patent. No retention from the six-hour meal. Filling-defect lesser curvature (Fig. 287). Diagnosis: Lesion of the stomach. Findings at exploration : Inoperable carcinoma of the lesser curvature with glands of large size as high as the diaphragm. Pancreas enlarged. Fig. 291. — Case 81,479. Posterior gastro-enterostomy three years previously for gastric ulcer, lesser curvature. The roentgenogram shows extensive filling defects on both curvatures, due to the development of cancer. The jejunal loop is shown in its entirety. REFERENCES 1. Hartel, F.: "Die Gastroenterostomie im Rontgenbilde." Deutsch. Ztschr. filr Chir., 1911, cix, 317-395. 2. OuTLAND, J. H., Skinner, E. H. and Clendening, L. : ''A Study of the Mechanism of the Stomach After Gastro-enterostomy, by Means of the X-ray." Surg., Gynec. and Ohstet., 1913, xvii, 175-183. 3. Case, J. T.: ''Roentgen Studies After Gastric and Intestinal Operations." Jour. A. M. A., 1915, Ixv, 1628-1634. 4. Faulhaber, M. and v. Redwitz, E. F.: "Ueber den Einflusz der Zirkularen Magenresection auf die Sekretion und Motilitat 348 THE STOMACH ATTEE OPERATION des Magens." Med. Klinik, 1914, i, 680-684. Ahst. Fortschr. a. d. Geb. d. Rdntgenstrahle?i, 1914, xii, 469. 5. CoHX, M. : "Die Gastrostomie im Rontgenbild." Fortschr. a. d. Geh. der Rdntgenstrahlen, 1914-15, xxii, 377. 6. Pateesox, H. J.: "Jejunal and Gastrojejunal Ulcer Following Gastrojejunostomy." Annals of Surgery, 1909, 1, 367-440. 7. Mayo, W. J.: "Gastrojejunal Ulcers (Pseudo-jejunal Ulcers). Surg., Gynec. and Ohstet., 1910, x, 227-229. 8. MoTNiHAN, B. G. A. and Tatlow, E. T. : "A Case of Transgastric Excision of a Gastrojejunal Ulcer." Lancet, 1914, i, 739-740. 9. INIayo-Robsox: Trails. Roj^ Med. Chir. Soc, 1904, Ixxxvii, 339. 10. SoRESi, A. L.: "Secondarj'^ Ulcers of the Stomach and Jejunum." Annals of Surgery, 1915, Ixi, 328-333. 11. Car:max, R. D. and Balfour, D. C.: "Gastrojejunal Ulcers — Their Roentgenologic Aspects." Jour. A. M. A., 1915, Ixv, 227-232. 12. IMathieu, a. and Savigxac, R. : "Etude sur les troubles intesti- naux consecutifs a la gastro-enterostomie." Arch. d. mat. de I'app. digestif., 1913, vii, 541. 13. Liox, G. and Moreau, Ch. : "La fistule jejunocolique par ulcere peptique du jejunum a la suite de la gastroenterostomie." Rev. de chir., 1909, xxxix, 873-896. 14. Baesony, T. : "Beitrage zur Diagnostik des postoperativen jeju- nalen und Anastomosenulkus." Wiener klin. Wchnchr., 1914, ii, 1058-1062. 15. ]\IoYxiHAN, B. G. A.: "Abdominal Operations." Philadelphia, W. B. Saunders Co., 1906, 201. 16. Chltjmskij, v.: "Ueber die Gastroenterostomie." Beitrage z. Klin. Chir., 1898, xx, 231; 487. 17. FiNSTERER. H. : "Chronischer Circulus Vitiosus nach Gastro- enterostomie mit Einklemmung von Dlinndarmschlingen im IMesocolonschiitz." Beitrage z. Klin. Chir., 1912, Ixxxi, 341- 360. ^ CHx^PTER XVII GALL-STONES AND DISEASE OF THE GALL-BLADDER AND LIVER GALL-STONES The degree of precision with which gall-stones can be diag- nosticated by the roentgen-ray is a moot question. Although efforts to demonstrate biliary calculi began early in the history of roentgenology, the first trials were either unsuccessful or suc- ceeded so rarely that the method was deemed impracticable. Even as early as 1899, Carl Beck/ of New York, who was perhaps the first to report such an achievement, exhibited a roentgenogram depicting biliary and hepatic calculi. With the gradual advance of roentgenologic technic the attempt to show gall-stones was frequently renewed and was more often rewarded by positive findings. Still, the percentage of demonstrations has, in the main, been discouragingly small, and the rank and file of roentgenologists have had little cause for enthusiasm. Lately, the roentgenography of gall-stones has been given fresh impetus by such men as Pfahler, Case, Cole and George. Pfahler/ who was among the first in this country to take up the matter, concluded from his experiments on the cadaver in 1901 that the roentgen method was useless and unreliable. In 1914, however, Pfahler was able to find stones in 20 out of 27 operated cases, or 74 per cent. Nevertheless, he believes that in general one cannot count on more than 50 per cent, being demonstrable. Technically, he places the patient on the abdo- men with the plate under the gall-bladder region. The patient's arms are extended and the upper part of the body is bent strongly to the left (not rotated). The tube (6 or 7 Benoist), with compression-cylinder diaphragm, is set so that the rays will pass obliquely through the space between the last rib and the crest of the ilium toward the gall-bladder, compression being 349 350 DISEASES OF THE GALL-BLADDER AND LIVER made if desired. He prefers short exposures, but without the intensifying screen, and agrees with Rubaschow^ that several exposures are generally necessary with different tubes and dif- ferent timing. Careful oblique illumination of the finished plate is usually necessary to bring the shadows into view. Case'^ believes he is safe in the opinion that when gall-stones are present they can be demonstrated in 40 or 50 per cent, of the cases. He prefers to look for them in the course of an examina- tion of the digestive tract with the bismuth meal, rather than make a special examination. Cole^ notes that during the last few years several roentgen- ologists have detected gall-stones in about 50 per cent, of the cases examined, but that this percentage was estimated in dif- ferent ways by different men. Cole regards catharsis and fast- ing as an essential preliminary to plating. Among other details favored he mentions stereoscopic plates, and double-screened plates (two plates, back to back, with intensifying screens of different speeds, in the same holder). Superimposing finished plates and thus deepening the stone-shadows assists interpreta- tion. George and Leonard^ feel that 85 to 90 per cent, of gall- stones can be shown. They emphasize the use of an extremely small cone, but are indifferent as to the employment of intensify- ing screens. They regard preliminary catharsis with its result- ing gas as a more disturbing factor in interpreting plates than the fecal contents of the colon. CaldwelF says: "If we only make enough plates and make them well enough, we can obtain suspicious shadows in the gall- bladder region of any normal individual. The interpretation of gall-stone plates, therefore, becomes a matter involving not only skill and judgment, but temperament as well. In no other field of roentgen diagnosis is the personal equation of the observer more important. This, I believe, is the best explanation of why some observers report as high as 85 per cent, and others as low as 5 per cent, of successes in these examinations. The greatest danger of the x-rays is in faulty interpretation. These faults GALL-STONES 351 usually consist in reading into the plates something which is not there. The clinical indications of gall-stones are fairly accurate, and it is likely that stones are present in at least 50 or 60 per cent, of those cases submitted to x-ray examination. Of these perhaps as many as one-tenth give perfectly definite, reliable x-ray shadows of gall-stones. In the other nine-tenths of the cases examined, some of the x-ray plates will show hazy and suspicious shadows, many of which are due to gall-stones. If we consider all these hazy and suspicious shadows corrobora- tive evidence of gall-stones, the operation will vindicate us in the majority of the cases, and we may easily overestimate the help actually obtained from the x-ray plates. We must be very careful lest the clinical knowledge we have of the patient may lead us to accept as evidence of gall-stoaes x-ray shadows such as might be found in some of the x-ray plates of any nor- mal individual." He therefore warns against regarding as proof of gall-stones ''any x-ray shadow that does not present charac- teristics distinguishing it definitely from other shadows, and which has not the sharpness of outline commonly found in other calculi." Our own figures do not compare favorably with the larger percentages quoted above, notwithstanding the fact that abun- dant material has been at our disposal. Many of the cases gave typical histories, but even in these, although extraordinary efforts were made, we have been able to obtain diagnostic shad- ows in only a small minority. The difficulty has been, not to find shadows, for these were often present, but to find shadows that seemed definite and characteristic. The personal equation of an observer is not open to argument, and sincere endeavors to advance roentgenologic diagnosis should not be disparaged. On the other hand, a degree of conservatism is usually wholesome and corrective. Taking the more cautious estimate of 50 per cent, of successes as possibly attainable, the examiner may doubt whether a strenuous effort to find gall-stones is worth while, since if he does not succeed, the chances of their presence or absence remain practically as before. However, he is not 352 DISEASES OF THE GALL-BLADDER AND LIVER justified in taking this attitude, even though his failures far outnumber his successes. But, unless he is unusually fortunate, he should keep in mind two things: First, that though he may fail to find their shadows, stones may nevertheless be present, and a negative roentgen finding should be ignored; second, that stones are incidental and not essential to a chole- cystitis which may necessitate surgery. C. H. Mayo^ has said: ''We must remember that infection is the entity and gall-stones are secondary to it ; that although gall-stones can often be shown in a radiograph — surely a great help — the latter cannot show the severe infections, the papillary cholecystitis, soft stone or in- spissated bile. Largely to depend upon it as now developed, would be to step back twelve years in the advance of gall-bladder and gall-duct surgery and diagnosis." In this connection it may be stated that of the gall-bladders operated upon at this Clinic, 30 to 35 per cent, contain no stones. Factors affecting the demonstrability of gall-stones include their composition, size, number, and situation, their enveloping medium, the amount of obscuration by liver-tissue, the thickness of the patient, the thoroughness of his preparation and the roentgenographic technic. Pure cholesterin stones have slight density and are most difficult to show. The mixed type of stones, containing choles- terin, bilirubin and calcium salts, are most common, and their density is proportionate to the amount of contained lime. Stones made up almost wholly of lime salts cast the deepest shadow, but these are relatively rare, comprising probably less than 1 per cent, of the total. Large stones, even though poor in calcium, and numerous small stones massed together may some- times be shown (Fig. 292) . ~^ Bile has considerable absorptive power for the rays, and stones immersed in this medium are less plain in proportion to the amount of bile. It is perhaps for this reason that stones in the cystic or common duct can be shown more readily, as is claimed, than those in the gall-bladder (Figs. 293 and 294). In occasional instances, stones in the gall-bladder are less opaque GALL-STONES 353 than the surrounding bile, as can be easily shown by raying gall-bladders which contain bile and stones, after surgical re- moval (Fig. 295). lEHIQ Fig. 292. — Gall-stones from forty-eight different cases. After removal the stones were put into small pasteboard boxes and roentgenographed on a single plate. Note the variability of size and density of the shadows. The density of the liver-tissue, by obscuring the shadows of stones, is a serious obstacle to their detection, and numerous technics have been devised to minimize this difficulty. The 23 354 DISEASES OF THE GALL-BLADDER AND LIVER Fig. 293.— a, Stone in the cystic duct, b, Stone in the long pendulous gall-bladder. Fig. 294. — Arrow indicates stone in the common duct. GALL-STONES 355 thick belly of corpulent individuals, who frequently have gall- stones, is an added hindrance to satisfactory roentgenography. Technic. — While in rare instances the shadows of large cal- careous stones can be seen fluoroscopically, plating is almost invariably necessary for diagnosis. As indicated in the fore- going citations, roentgenographic methods differ. Notwith- standing the objection quoted, a preliminary clearing out of the intestinal canal has obvious advantages. Hence, we prefer to Fig. 295. — Stones in the gall-bladder. The roentgenogram was, made after the gall- bladder had been removed intact, with its contained stones and bile. The stones are seen as dark areas lying in the more opaque bile. have the patient purge himself with castor oil or a saline, and fast prior to the examination. It is our custom also to make this examination before giving an opaque meal, the shadows of which may be confusing, although we have incidentally noted stone-shadows after the barium meal had been given. For plating, various positions have been advised. To avoid as much as possible of the liver-shadow, many operators lay the patient on the belly and direct the rays through the gall-bladder region 356 DISEASES OF THE GALL-BLADDER AND LWER obliquely downward, using compression. The tube placed vertically over the plate often gives equally satisfactory defini- tion. After trying numerous different angles we are unable to say that any one position is superior. The cone undoubtedly gives sharper images. Plates should be made during suspended respiration to avoid blurring by movement. The intensifying screen also helps to avert this by shortening the exposure time. On the other hand, the intensifying screen, if it happens to be imperfect, increases the danger of artifacts. Customarily, we make a few unscreened plates also. It is essential that the tube be of moderate vacuum, inclining to softness rather than hard- ness, and overexposure should be shunned. We have occasion- ally inflated the colon before making plates, employing for the purpose a Politzer bag and rectal tube. In a few instances the air-distended hepatic flexure made a background upon which the stone-shadows stood out distinctly. Probably the most im- portant technical recommendation is the making of many plates, varying the penetration and exposure-time, for it is notorious that of two plates of apparently equal excellence, one may show distinct shadows while the other reveals no trace of them. The opinion that if shadows of stones appear they will usually be found between the eleventh and twelfth ribs or slightly below the twelfth is erroneous. In the majority of our cases, the stone-shadows were situated much lower, ranging from the level of the first lumbar vertebra to that of the fourth lumbar. The configuration of the costal arch varies to an extent that the ribs are not always satisfactory landmarks. Besides, the gall- bladder itself is subject to some variation of position. The examiner should, therefore, not limit his search for stone- shadows to the classic field, but should carefully scan the entire right abdominal region and even as low as the iliac crest. The most characteristic appearance is that produced by the grouped shadows of multiple stones, showing like a bunch of grapes. Occasionally the facets can be distinguished. These shadows are not usually as dense as those of the large olive-shaped stones, which are often single, and sometimes show concentric laminae. TECHNIC 357 Shadows of gall-stones must be differentiated from those of renal calculi. The latter are usually branched or irregular and of greater density than gall-stones, thus casting a more intense shadow (Fig. 296). Differentiation can be made by plates show- ing good detail which outline the kidney by stereo-roentgeno- grams, and by pyelography after the injection of collargol (Figs. 297, 298 and 299). Plates made from back to front show gall- stones with better definition than renal calculi, while plates made Fig. 296. — Comparison of renal and biliary calculi The kidney stones are seen above the line. from front to back bring out the kidney-stones more plainly. It is commonly stated that gall-stones lie further from the vertebrae than do renal calculi, but in both instances the rela- tion of their shadows to the spine is variable. Indeed, gall- stones may lie so near the vertebral column (Fig. 300) that slight rotation of the patient may obliterate their shadow in that of the vertebrae. Calcified lymph nodes may be mistaken for gall- stones, but the former seldom show in clusters, and are often irregularly shaped (Fig. 301). Deposits of lime salts in the ribs 358 DISEASES OF THE GALL-BLADDER AND LIVER Fig. 297. — Renal calculus excluded by pyelogram. The annular shadow of the gall-stone is pointed out bj' the arrows. Fig. 298. — Renal calculi excluded by pyelogram, p. Kidnej- outline, fc, Gall-stones at s. TECHNTC 359 Fig. 299. — Large, single gall-stone at i. Injected kidney at p. Fig. 300. — Cluster of faceted gall-stones, indicated by arrow, very near vertebral column. 360 DISEASES OF THE GALL-BLADDER AND LWER generally show irregular streaking, and are directly in line with the rib-shadow. Fecaliths and fecal matter in the intestine may exceptionally produce shadows somewhat resembling those of gall-stones, and for this reason the bowel should be thoroughly evacuated beforehand. In addition to these sources of error, inexphcable shadows (Fig. 301) are often seen which by an active exercise of the observer's imagination can be interpreted Fig. 301. — Calcified Ij-mph glands indicated by arrows. as being due to gall-stones. In everj' doubtful case a reexami- nation should be made. At^i^ical and uncertain shadows should never be considered too seriously whether clinically sub- stantiated or not. Case 133,413, female, aged 47 years. Twelve-year history. Full- ness and heaviness after meals relieved bj^ vomiting, usually induced, rarely spontaneous. Always some soreness in region of liver and as- cending colon. ]\Iuch gas. Regurgitates bitter fluid. Apples and fats cause distress. Never definite colic; never jaundiced. Total acidity 10, all combined. Roentgen findings: Shadows of multiple small stones. The low position of these shadows, in the ilio-sacro- TECHNIC 361 Fig. 301A. — Shadow in the gall-bladder region. Because of its atypical character a pyelogram was made to exclude a renal calculus. This being excluded, the ^shadow was thought to be a gall-stone. At operation it proved to be a desmoid tumor of the right rectus abdominal muscle. Fig. 302. — Case 133,413. The arrow points to the stone shadows. 362 DISEASES OF THE GALL-BLADDER AND LIVER lumbar angle, as shown in the roentgenogram, Fig. 302, is noteworthy. The case illustrates the variable position of the gall-bladder and the necessity of searching the entire right abdomen for shadows in sus- pected cases. Findings at operation: Cholecystitis with multiple small stones (Cholecystectomy). Pathologist's report: Chronic ca- tarrhal cholecystitis. Cholelithiasis. Case 140,266, female, aged 34 years. History of gastric distress and vomiting by spells, since childhood. Seven years ago, during about two months, she had attacks of severe pain at the right costal margin, and beneath shoulder-blade, lasting one or two days. For a Fig. 303. — Case 140,266. Shadow of a single gall-stbne marked by the arrow. year past she has been having epigastric pain a half to two hours after meals, with occasional vomiting. Much epigastric soreness. Total acidity 74; free 64; combined 10; filtrate 500 c.c. Roentgen findings: Shadow of a single stone slightly above and to the right of duodenal bulb (Fig. 303). This shadow was visible also during the roentgeno- scopic examination, its density being due to the fact that the stone contained considerable calcium. Findings at operation: Gall-stone obstructing neck of cystic duct (Cholecystectomy). Pathologist's report: Edematous chronic cholecystitis (old empyema with stone in cystic duct). EEPORT OF CASES 363 Case 86,771 (Roentgen-ray number 22,624), female, aged 21 years. The patient states that she has had pain and tenderness in the right abdomen for a number of years. An appendectomy three years ago gave rehef for a few months. A year and a half ago she began vomit- ing, and for seven months she has vomited after almost every meal. She first has a sense of uneasiness and epigastric fullness after the meal; then vomits in a half to one hour. The gastric contents are ejected without nausea. Every few days at irregular times the patient has rather sharp pains at the right costal margin, radiating to the back, relieved by heat and by vomiting. She has never required morphia for the pain, and has never been jaundiced. Total acidity 66, all combined. Roentgen findings: Multiple, small, characteristic, annu- lar shadows of gall-stones (Fig. 304). These were first discovered accidentally in making a roentgenogram of a duodenal tube in situ. Their visibility and the number shown were increased by inflating the colon. Findings at operation: Numerous stones in gall-bladder. Gall-bladder, liver, duodenum and pyloric end of stomach adherent in one mass with transverse colon and anterior abdominal wall (Cholecystectomy) . Case 152,564, female, aged 51 years. For fifteen years she has had attacks of pain in right hypochondrium, lasting two or three hours. At present she complains of constant pain in the right abdominal area unless she takes medicine. Icterus now and in former attacks. Total acidity 72; free 60; combined 12. Roentgen findings: Shadows of two large gall-stones (Fig. 305). Findings at operation: Two large stones in gall-bladder (Cholecystectomy). Pathologist's report: Chronic catarrhal cholecystitis with partial destruction of mucosa. Chole- lithiasis. DISEASES OF THE GALL-BLADDER In lesions of the gall-bladder without discoverable stones the roentgen-ray can only exceptionally furnish decisive evidence. The gall-bladder itself, when it contains inspissated bile, or its walls are thickened or calcified, occasionally casts a shadow if the patient is not too thick and other circumstances are favor- able (Fig. 310). Otherwise, the roentgen manifestations of cholecystitis are quite insufficient to support a diagnosis alone, although they may have some indirect and contributory value. Most of these indirect signs are obtained in the course of a 364 DISEASES OF THE GALL-BLADDER AND LIVER Fig. 304. — Case 86,771. Stone shadows marked by arrow. Fig. 305. — Case 152,564. Arrow marks shadows of stones. DISEASES OF THE GALL-BLADDER 365 routine examination of the digestive tract, and include the following : 1. Gastric spasm. 2. Six-hour residue in the stomach or duodenum. 3. Fixation of the pyloric end of the stomach, duodenum or hepatic flexure. Fig. 306. Fig. 30: Fig. 3U6. Fig. 309. Figs. 306, 307, 308, 309. — Illustrative cases of gall-stones. 4. Drawing of the stomach to the right by adhesions, or displacement to the left by an inflammatory mass about the gall-bladder. 5. Increased gastric peristalsis. 6. Demonstration of Riedel's lobe of the liver. 7. Localization of a tender point over the gall-bladder area. 366 DISEASES OF THE GALL-BLADDER AND LWER Fig. 310.— Lime-encrusted gall-bladder. Probe passed into gall-bladder through discharging sinus. Fig. 311. — Gastrospasm, localized to pyloric end of stomach, a. This type of gastrospasm is frequently associated with disease of the gall-bladder. In this instance cholecystitis was found at operation. DISEASES OF THE GALL-BLADDER 367 8. Demonstration of an organically normal stomach and duodenum, and thus excluding them as probable causes of the symptoms. As mentioned elsewhere (see "Gastrospasm"), spasms of the gastric musculature occur frequently in association with chole- lithiasis, cholecystitis and pericholecystitis — so frequently that the gall-bladder should be suspected first of all whenever spastic Fig. 312. — Spasm of the pars pylorica, a. Disease of the gall-bladder the only lesion found at operation. eccentricities of the stomach are noted (Fig. 311). The spas- modic manifestations in the stomach may be slight or extensive, ranging from a transient incisura or a temporary hour-glass to a regional spasm with considerable deformity. An especially striking type of the latter is that in which the entire pars p^^lorica is contracted to a narrow, stiffened, sometimes palpable, tube (Fig. 312). A six-hour residue in the stomach or duodenum may occur as a result of pericholecystic adhesion-bands constricting the pylorus or duodenum. Again, a gastric residue may be found. 368 DISEASES OF THE GALL-BLADDER AND LWER although rarely, in association with cholecystitis but without any organic obstruction. The pyloric end of the stomach may be fixed and its contour roughened by adhesions. The duodenum, especially the bulb, may likewise be deformed or stenosed. Adhesions may fix the hepatic flexure of the colon to the pylorus or duodenum so that they cannot be separated by manipulation. Adhesions about the gall-bladder may, though rarely, draw the., stomach to the right, and if they obstruct the duodenum, Fig. 313. — Indentation of pjdoric end of stomach at d by gall-bladder. the pars pylorica may be somewhat expanded and bulbous. On the other hand, a distended gall-bladder, or an inflammatory mass about it, may indent the pars pylorica or bulb (Fig. 313), or displace it to the left. The mass may be palpable and either mobile or adherent to the abdominal wall. Exceptionally, such m^asses may be carcinomatous. In one instance of cancer of the gall-bladder which we observed, perforation into the duo- denum had occurred and the communication was shown by the barium meal (Fig. 314). DISEASES OF THE GALL-BLADDER 369 Fig. 314. — Carcinoma pyloric end of stomach; communication between duodenum and gall-bladder. Barium in gall-bladder, G. B. Arrows point to barium in hepatic ducts. Fig. 315. — Reconstruction of common duct (Sullivan method), in common duct, partly in duodenum. 24 Rubber tube, t, partly 370 DISEASES OF THE GALL-BLADDER AND LIVER Overactive gastric peristalsis, with an increase in the number of waves, is not infrequently seen, with or without duodenal or pyloric obstruction by adhesions. Though more numerous, the waves are not deepened as a rule, and are usually more marked on the greater curvature than on the lesser. Case^ considers the presence of a Riedel's lobe of the liver, which may be demonstrable after inflation of the colon, as a valuable sign of cholecystitis. The localization of a pressure-tender point, outside the duodenal shadow, is of questionable worth, though occasionally mentioned. The most common lesions giving rise to symptoms which are often confusingly similar are gastric ulcer, duodenal ulcer, cholecystitis and appendicitis. When the roentgen findings negate the presence of a peptic ulcer, the field of reasonable consideration is narrowed to the gall-bladder and appendix. Certainly, negative roentgen findings do not exclude the pos- sibility of peptic ulcer, but they do exclude its probability, and the diagnostician usually welcomes this aid. THE LIVER Although a roentgenologic examination of the liver is not often requested by clinicians, definite and useful information can sometimes be elicited by this means. The upper border of the hepatic shadow, coinciding with the diaphragm, can be readily made out. Its lower border ordinarily shades off some- what indistinctly, but by inflating the stomach and colon it can be shown more or less plainly. Thus, it is possible to determine certain abnormalities of size, form and position. An increase of the Uver- volume, with general and symmetrical enlargement of its shadow, may be due either to hyperemia, or to an actual hypertrophy resulting from various causes, includ- ing amyloid degeneration, cancer and syphilis. The diminished shadow of an atrophic liver can be distinguished when the com- monly accompanying ascites has been relieved by paracentesis. Local deformities of the hepatic contour are sometimes THE LIVER 371 visible as a result of cancer, syphilis, abscess, or cyst. In cancer, nodulation along the diaphragmatic border is occasion- ally marked. Subdiaphragmatic abscess may be manifested by elevation and fixation of the diaphragm, with clear lung area above and normal costo-phrenic angle (Fig. 316). In some cases there may be a visible collection of gas and fluid below the diaphragm. The liver, being plastic, may sometimes mold itself into the distortions of the diaphragm occasionally pro- FiG. 316. — Subdiaphragmatic abscess. Abscess area, a; diaphragm high and fixed. duced by pleural adhesions. Jaugeas^° reports two cases in which hydatid cysts, peripherally situated, gave rise to smoothly contoured shadows resembling those of abscesses. Since it possesses a degree of mobility, the liver is subject to displace- ment both by physiologic and pathologic causes. Distention of the stomach and intestine with food or gas may displace the liver upward, or laterally to some extent. Ascites and large intraabdominal tumors also may elevate the liver, or it may be depressed by intrathoracic conditions — emphysema, pleural effusion. Transposition of the liver occurs, of course, in the 372 DISEASES OF THE GALL-BLADDER AXD LR^ER rare cases of situs inversus. Kormally in contact with the diaphragm, the hver may be ptosed. in which case the separation of the upper hepatic border from the diaphragm becomes ap- parent (Fig. 317). In marked hepatoptosis the transverse colon has been seen between the liver and the diaphragm. The normal rise and fall of the liver with expiration and inspira- FiG. 317. — Slight ptosis of liver, I. Diaphragm, d. The right lobe of the liver is well outlined because of the clear lung area above and the gas in the colon below. tion is sometimes evidently diminished or absent when fixation has resulted from inflammatory processes, either in the chest or upper abdomen. REFERENCES 1. Beck, Gael: '" On the Detection of Calculi in the Liver and Gall- bladder." Xew York Med. Jour., 1900, Ixxi, 73-77. 2. Pfahleb, G. E. : "The Roentgen-rays in the Diagnosis of Gall- stones and Cholecystitis." Jour. A. M. A., 1914, Ixii, 1304- 1306. 3. Rl"baschow, S.: "Zur Rontgenodiagnostik der Gallensteine." Fortschr. a.d. Geb. d. Roentgenstrahlen, 1914, xxi, 533-36.. REFERENCES 373 4. Case, J. T.: "Roentgenoscopy of the Liver and Biliary Passages, with Special Reference to Gall-stones." Jour. A. M. A., 1913, Ixi, 920-24. 5. Cole, L. G.: "The Roentgenographic Diagnosis of Gall-stones and Cholecystitis." Surg., Gynec. & Obstet., 1914, xviii, 218-27. Cole, L. G. and George, A. W. : "The Roentgen Diagnosis of Gall-stones by Improved Methods." Bos. Med. & Surg. Jour., 1915, clxxii, 326-330. 6. George, A. W. and Leonard, R. D.: "The Roentgen Diagnosis of Surgical Lesions of the Gastro-intestinal Tract." 1915, Colonial Medical Press, Boston, p. 140. 7. Caldwell, E. W. : "The Safe Interpretation of Roentgenograms of the Gall-bladder Region." Amer. Jour. Roent., 1915, ii, 816- 819. 8. Mayo, C. H.: "Gall-bladder Diseases." New York Med. Jour., 1916, ciii, 433-36. 9. Case, J. T.: "The X-ray Examination of the Liver and Gall- bladder." Arch. Roentgen Ray, 1913, xviii, 135-39. 10. Jaugeas: "Radioscopic Examination of the Liver." Arch. Roent- gen Ray, 1913, xviii, 48-52. CHAPTER XVIII THE SMALL INTESTINE In most instances the small intestine can be studied as a supplement to and during the examination of the stomach. Thus its disposal of the six-hour meal, some of which will usually remain in the lower ileum, can be observed, while the duodenum and upper jejunum will ordinarily be visuaUzed soon after in- gestion of the barium-water and barium-pap. Visualization can often be assisted by manual expression of the gastric con- tents. Occasionally, but not often, there is some advantage in tracing the progress of a single meal through the intestine by examination at frequent intervals. The standing position is commonly employed for screening, but the recumbent position may be of service in investigating the lower coils of the ileum which often lie behind the pubic arch when the patient is stand- ing and are thus difficult to manipulate. With the patient in the right lateral decubitus or in the prone position the duodenum is occasionally more completely filled and its condition can be more accurately determined. THE NORMAL SMALL INTESTINE The Duodenum. — Beginning at the pyloric hiatus, sweeping upward or outward, then to the right and downward, around the head of the pancreas, the duodenum presents roentgeno- logic appearances which may vary considerably within normal bounds. Somewhat resembUng a horseshoe in its course, the duodenum is divided by some anatomists into three portions, by others into four. The first segment, or pars superior, includes the bulb (cap) which is the most expanded portion of the duodenum and is of especial interest. When filled with barium it is seen in the 374 THE DUODENUM 375 anterior view as a smoothly contoured, more or less conical, or beehive-shaped, chamber, with its base at the pyloric ring (Figs. 318 and 319), The direction of its long axis depends Fig. 319. — Normal duode- nal bulb, b. Fig. 318. — Normal duodenal bulb, b. Fig. 320. — Entire duodenum well visualized. Fig. 321. — Serrated 'outline of upper jejunum, j. largely upon the form of the stomach, whether steer-horn or fish-hook. With a pronounced steer-horn type of stomach the long axis of the bulb is often quite horizontal. With the fish- 376 THE SMALL INTESTINE hook type of stomach the bulb is usually seated vertically over the p3dorus. Between these types various angles of obliquity upward and to the right are often seen. A fish-hook stomach Ijdng well to the right may also carry the base of the bulb with it and thus inchne the long axis of the bulb upward and to the left. The conical peak of the bulb as usually seen in the ante- rior view suggests a marked narrowing of the duodenum at that point, but this narrowing is only apparent and is due to the course of the duodenum which turns backward from the bulb, then outward and downward. The fact that the duo- denum is not narrowed can be shown by an oblique or lateral view. The shadow of the barium-filled bulb under normal condi- tions is more dense than the remainder of the duodenal shadow, due in part to the more anterior situation of the former, its greater size and the tendency of the opaque meal to tarry here momentarily'. Its form is fairly symmetrical, and its contour is smooth, as it contains no valvulse conniventes. Its size varies markedly; a bulb the size of a chocolate cream and one three or four times as large may each be normal. The pro- portion of length to breadth also varies; with an elongated, low-lying stomach the bulb may have the length and breadth of a finger; ordinarily the disproportion is not so great. Com- monly, the base of the bulb shows as a straight line, but if the bulb be large the base may curve slightly downward peripherally. By reason of the rapid transit of its contents, the second or descending (vertical) portion of the duodenum is not often well visuahzed. As seen from in front it may descend quite vertically or curving with a right convexity, and thus its apparent angle with the superior portion varies in acuteness. With a stomach displaced to the right, the descending portion of the duodenum may be hidden behind the bulb and antrum. When seen, its shadow is far less dense and homogeneous than that of the bulb, and the barium passing through it in small quantities makes it appear narrower than it is. THE JEJUNUM 377 The third (transverse) portion of the duodenum extends more or less horizontally from the vertical portion toward the spine, then curves upward, the latter segment being sometimes described as a fourth portion. The suspensory ligament of Treitz marks its termination and the beginning of the jejunum, the junction being sometimes visible as a flexure at that point. The valvulse conniventes, rudimentary in the lower half of the first portion and in the second portion, are well marked in the third portion, so that the shadowed barium in the latter shows a serrated appearance. The aspect of the normal duodenum is shown in Fig. 320. As to mobility, the bulb can be shifted about to some extent by palpatory manoeuvers, but the re- mainder of the duodenum is fixed and not responsive to manipulation. Peristaltic movements in the duodenum are difficult to detect. Under ordinary circumstances the bulb is seen to fill, then suddenly to overflow into the descending and transverse portions, through which the barium races quickly, and the entire duodenum is more or less completely evacuated, seemingly as though by syphonage, rather than by an active expulsive contraction of the duodenum itself. However, competent observers, including Holzknecht, have noted actual peristalsis, rhythmical in character, at minute-long intervals. The Jejunum. — Beginning at the duodenojejunal juncture, the first segment of the jejunum courses either directly toward the left hypochondrium or downward and to the left. The first loops are often seen soon after ingestion of the barium-water, especially if the exit through the pylorus is free. Issuing from the duodenum, a barium-mass is sometimes observed to dart suddenly across the abdomen to the left, where it is speedily broken up and diffused through that portion of the intestine, making its subsequent course untraceable. The barium- shadowed jejunum shows as an indefinite grayish cloud, with here and there the feathery effect of the valvulse conniventes (Fig. 321). The movements of the small intestine have been studied in 378 THE SMALL INTESTINE animals by Cannon, and in man by Hertz, Beclere and others. In cats Cannon^ has observed what he calls ''rhythmic segmen- tation," and two varieties of peristaltic movement. Rhythmic segmentation consists in a sudden division of a long food-mass into many little segments of nearly equal size; then these seg- ments are again suddenly divided, and the neighboring halves unite to make new segments, and so on. From the beginning to the end of the period of segmentation, the food changes its posi- tion in the abdomen or intestine to only a slight extent. The rapidity of the changes is remarkable, the rate of division being twenty-eight or thirty times in a minute. The peristaltic wave is seen in two forms. The first merely transports nutriment from one region to another near by. Its rate is slow, being variously estimated as 1 or 2 cm. per minute. The wave-contraction involves 4 or 5 cm. of the intestine, whereas the rhythmic segmenting contraction is hardly more than 1 cm. broad. The other form of peristaltic wave, the peristaltic rush, is swift, and may glide rapidly from one end of the canal to the other. Cannon mentions also the so-called ''pendulum movements" which have been variously described by different observers, and which he characterizes as a gentle swaying movement of the coils accompanying the rhythmic contractions. In man, Hertz^ has on numerous occasions observed well- marked segmentation, at the rate of ten divisions in a minute and a half. The shadow of the cecum began to appear, on an average, at four and three-eighths hours; hence, he computed the rate at which the intestinal contents travel as about 1 inch per minute. Faulhaber^ refers to the roentgen-kinematographic studies of Kaestle and Brugel as showing a mixing and kneading movement (segmentation) and a propulsive peristaltic m.ovement. Beclere and Meriel,^ as well as others, state that after a half hour the opaque meal is seen in the left and mid-abdomen. After two hours it predominates in the middle and lower abdomen. After four hours it occupies only a portion of the ileum and is THE ILEUM 379 already manifest in the cecum. At six hours only a little remains in the terminal ileum. At eight hours the small bowel is completely empty. The Ileum. — In the ileum the valvulae conniventes gradu- ally disappear distally until the lower segments become quite smooth. These latter lie in the lower mid-abdomen and right iliac fossa, usually contain a good portion of the meal given six hours previously, and thus can be studied during the routine examination of the stomach (Fig. 322). By manipulation and pressure, the coils, which are often massed together, can be Fig. 322. — Terminal ileum, i, as seen six hours after giving the meal. separated for scrutiny, except in enteroptotics who are likely to have the lower ileum well down behind the pubic arch. Here the recumbent position may make palpation effective. The terminal segment, which is often involved in pathologic proc- esses, deserves especial attention. In entering the ileocolic juncture it lies at varying angles from the cecum. Frequently it rises alongside the cecum and turns abruptly into the cecal notch; in other instances, the last 3 or 4 inches lie at a right angle to the long axis of the ascending colon, and exceptionally the terminal segment descends to its junction with the large bowel. Normally, as seen on the screen, the barium-filled lower coils 380 THE SMALL INTESTINE of the ileum appear to have the breadth of a finger, with an unbroken contour, and are mobile in proportion to their situa- tion and the relaxation of the abdominal wall. Peristaltic movement, with waves of slight depth succeeding each other rapidly, has been observed, but this is seldom seen during an ordinary examination. Motility of the Small Bowel.^ — An important factor in the motility of the small intestine is the rate of gastric evacuation. Other elements which influence it are the character and quan- tity of the opaque meal, and whether or not the patient has been subjected to purgation and fasting, or other unusual conditions. With the routine previously described for examination of the stomach, which includes fasting, and with average gastric motility, the ''head" of the six-hour barium meal will most often be in the ascending colon while a good portion will still be in the terminal loops of the ileum. The remainder of the small intestine will, as a rule, be empty, although there may at times be a few scattered remnants in the upper ileum. The normal limit for fairly complete evacuation of the small bowel, as defined by roentgenologists who have occupied them- selves with the matter, ranges from eight to fifteen hours after taking the meal. These figures are generally based upon a meal of barium or bismuth in fluid carbohydrate mixtures, given without previous purgation or subsequent fasting. Further, the gastric evacuation-time should be taken into account in drawing conclusions. THE ABNORMAL SMALL INTESTINE The Duodenum. — Irregularities of the duodenal contour have as their more common causes, spasm or scar-contraction from duodenal ulcer and pericholecystic adhesions. Such irregularities are more often manifested in the bulb, and are there more easily discovered (Fig. 323). The inner contour of the bulb is sometimes indented by pressure against the spine. An accessory pocket, resulting from perforating ulcer, may show as a somewhat spherical adjunct to the duodenal lumen, with THE DUODENUM 381 successive layers of barium, fluid and gas, like the accessory pocket of perforating gastric ulcer, but a localized retention within the duodenum itself or adjacent small bowel may exhibit similar phenomena. Duodenal diverticula show as a pouch- like adjunct. Among the important roentgenologic findings in the duo- denum are the evidences of obstruction, the usual cause of which is either a stenosing duodenal ulcer or the adhesion bands of a pericholecystitis. These evidences include localized and permanent narrowing of the lumen, with dilatation proximal Fig. 323. — Irregular bulb, 6, in a case of duodenal ulcer. to it, and delayed motility. Local constriction may give the duodenum an hour-glass form. As mentioned before, in the upright sagittal view the vertical portion of the duodenum often appears to be narrowed, and the bulb seems to have a conical termination; neither of these appearances should be mistaken for stenosis. The apparent size of the bulb, as well as that of the entire duodenum, depends largely upon the balance between the volume of inflow through the pylorus and the rate of duodenal evacuation, so that what seems to be a narrow duodenum as seen with the patient standing, may in fact be of normal caliber and appear thus when the patient is placed in the right lateral or prone position. Dilatation proximal to the point of stenosis is a natural 382 THE SMALL INTESTINE sequence of obstruction. Dilatation of the bulb should be judged with caution, since its size varies widely within normal limits, but extreme degrees of expansion are to be regarded with suspicion. A more dependable sign of obstruction is delayed motihty. While the normal duodenum will, as a rule, evacuate its contents practically as fast as they are received, usually within a minute, the barium will occasionally lag slightly in its transit, especially through the third portion and this is not necessarily significant. But with organic obstruction there is sometimes an evident delay at the point of stenosis, and a manifest and persistent accumulation of the barium proximal thereto. In extreme stenosis a residue from the six-hour meal may be found in the duodenum. Six-hour retention in the stomach or gastric hyper- peristalsis may also evidence duodenal obstruction, a combina- tion of residue and hyperperistalsis being strongly indicative of ulcer with obstruction. The observation of hyperperistalsis of the duodenum itself above an obstruction has been recorded. This activity has, in some instances, been described as extremely marked and of a '^writhing" character. Even duodenal antiperistalsis has been noted, but rarely. Kinking at the duodenojejunal juncture as a feature of intestinal stasis has been given considerable attention by a few roentgenologists. Acuteness of the duodenojejunal angle (kinking) with dilatation and hypomotility of the duodenum are regarded by them as important evidences of stasis. Lessened mobility or fixation of the duodenal bulb may be the result of an inflammatory process in that region, but immo- bility may be only apparent and due to rigidity of the abdomen. The Abnormal Jejunum. — Practically the sole abnormahty of the jejunum (and upper ileum) showing definite roentgeno- logic signs is obstruction. TSTien the obstruction is pronounced, these signs are quite decisive; the immense dilatation of the small bowel, dehcately ribbed by the valvulse conniventes, the delayed emptying, accumulations of barium at different points THE ABNORMAL ILEUM 383 with fluid and gas above them, and the tendency of the dilated loops to arrange themselves vertically, are characteristic. Ob- struction high up in the jejunum may result in a six-hour gastric residue. New growths (more commonly carcinomas) and adhesions from inflammatory processes are the usual causes of stenosis. Unless a tumor mass can be palpated, the nature of the obstructing lesion can hardly be predicted, nor can its exact seat usually be determined. Multiple obstructions of shght degree, as evinced by numerous collections of barium from the six-hour meal scattered irregularly through the small bowel, have been observed in tuberculous enteritis and peritonitis. Not uncommonly, however, a few small detached masses of barium will lag far behind the bulk of the meal in a normal intestine, and these should not be hastily seized upon as proof of obstruction. The Abnormal Ileum. — Since the terminal portion of the ileum can be well visualized, as a rule, it is perfectly feasible by the roentgen examination to detect abnormal variations of its position, mobility, size, contour, and motility. The most frequently noted displacem.ent of the lower ileum is ''ptosis," being rather constant in persons of the enteroptotic habitus, and these constitute a large percentage of all cases examined. The significance of such "ptosis" is variously regarded, but when it is in harmony with the general make-up of the individual, its importance should not be exaggerated. Often several loops are situated deep in the true pelvis, and from here the terminal segment makes a steep ascent to the ileocolic juncture. Displacement in any direction may be the result of pelvic tumors. With failure of the first part of the colon to orient itself (incomplete torsion), the ileocohc juncture may lie on the outer aspect of the large bowel. In the rare cases of non-rotation of the colon and situs inversus the ileum or its terminal portion will be correspondingly situated. Dilatation, consequent upon obstruction, may be demon- strable. Proximal to a severe stenosis the dilatation may be extraordinary, and the ileum may be distended to the size of 384 THE SMALL INTESTINE the colon. Definite narrowing of the ileal lumen is sometimes seen in the last few inches of its course, resulting, as a rule, from adhesion-producing pericecal inflammation. Very often, however, the contents of this part of the ileum are seen strung out irregularly when no organic constriction is present. The mobility of the ileum should be in correspondence with its accessibility to palpation and the degree of abdominal relaxa- tion. Fixation by adhesions from pathologic processes, which originate for the most part in the appendix or cecum, may be shown by immobility of the affected segment upon manipula- tion and change of the patient's position. Such adhesions may also produce localized irregularities in the contour of the gut. The term kink, which would imply a sharp angulation of the bowel, is very often applied to localized narrowing with fixation, whether or not angulation is present. What seems to be acute flexions of the bowel are frequently due merely to the plane in which the loops are viewed. The bulk of the six-hour barium meal heretofore described will, under average and normal conditions of gastro-intestinal motility, be evacuated from the ileum within six to eight hours. Any considerable delay of clearance beyond this time demands investigation. If the gastric and upper intestinal clearance has been normal, a prolonged delay in the lower ileum is indicative of obstruction. Stenosis of high grade may result in ileal reten- tion for many hours or even days. The seat of obstruction is likely to be near the cecum and the more common causes are appendiceal inflammation, cancer, and ileocecal tuberculosis. Congenital stenosis at the ileocecal valve, though rare, is a possi- bility. In addition to marked retention or delay there will nearly always be other signs of organic obstruction, such as demonstrable local narrowing, fixation at the site of stenosis, and dilatation of the proximal gut. Between the cases which are clearly normal and those with definite signs of obstruction other than prolonged delay, there are cases in which the progress of the meal is somewhat retarded, but proof of any mechanical KEFERENCES 385 obstacle is lacking. Some of the exponents of stasis consider such cases as belonging to this class. REFERENCES 1. Cannon, W. B.: "The Mechanical Factors of Digestion." 1911, Longmans, Green & Co., New York, 130-147. 2. Hertz, A. F.: "Constipation and Allied Intestinal Disorders." H. Frowde, London, 1909, 3-5. 3. Faulhaber, M.: In Rieder-Rosenthal "Lehrbuch der Ront- genkunde." J. A. Barth, Leipsig, 1913, i, 560. 4. Beclere et Meriel: "L'exploration radiologique dans les affec- tions chirurgicales cle I'estomae et de I'intestin." 25 Congres Francais de Chir., 1912, 73-74. 25 CHAPTER XIX DUODENAL ULCER Though known for a century, it is only during the past de- cade that duodenal ulcer has become firmly grounded as an anatomo-pathologic entity of great practical moment, and the frequency of its incidence has led to a rapidly increasing knowl- edge of the condition. Its importance is shown by the fact that in the Mayo Clinic alone, more than 2300 cases have been proved by operation, and a great number have been diagnosed but not operated on. In the past, ulcer of the duodenum has no doubt been con- founded with ulcer at the pyloric end of the stomach, partly because of the assumption that any ulcer found in the vicinity of the pylorus must necessarily be gastric, and partly because of the difficulty of determining the exact site of the pylorus. In 1907, W. J. Mayo^ called attention to the pyloric veins as a landmark corresponding accurately to the pyloric sphincter. More careful determination of the pyloric site has resulted in finding that the ratio of frequency between duodenal and gastric ulcer is far greater than had been supposed, being now stated as three, and even four, to one. Symptoms. — The symptom-complex in a typical case of duodenal ulcer is emphatic and convincing. The "hunger- pain," a burning or gnawing epigastric distress, coming two hours or more after meals and late at night, and quickly re- lieved by food or drink; the exaggeration of the subsequent distress by acid and fibrous foods, such as fruits and coarse vegetables; the periodicity of the attacks, lasting for weeks, with intermissions of weeks or months; the hyperacidity, sour eructations, and occasionally also hematemesis or tarry stools, all combine to form a significant clinical picture. So nearly 386 PATHOLOGY 387 characteristic is this syndrome that it has easily taken first rank in the diagnosis. Nevertheless, it is not infallible, for similar clinical histories are often elicited in cases of gastric ulcer, gastric cancer, cholecystitis and appendicitis. More- over, the history in duodenal ulcer is frequently atypical and indecisive. Errors, both of omission and commission, are an inevitable consequence of all subjective diagnoses, and the effort is constant to supplement or supplant subjective methods by more exact objective methods. In duodenal ulcer the a;-ray usually provides the desired objective data. Even when the roentgen examination does not speak independently and with certitude, it aids in excluding or confirming the simulants of duodenal ulcer, and thus furnishes adjunctive information to the clinician which may establish a decision. Efficiency in the roentgenologic diagnosis of duodenal ulcer has been developed only in recent years, and considerably after the a:-ray had become an accepted aid in the diagnosis of gastric ulcer and other lesions of the digestive tract. The anatomical differences between the stomach and duodenum, the thinness of the duodenal wall, the lack of a sphincter to prevent rapid egress of the opaque meal from the duodenum, all seemed to be insuperable obstacles to obtaining direct signs similar to those of gastric ulcer. Thus, for some time the only signs generally recognized were the secondary manifestations in the stomach, and, in the main, diagnosis by the roentgen-ray was less accurate than by the anamnesis. A more extended experience has shown, however, that besides the gastric findings, which are often sufficiently diagnostic, it is possible in most instances to obtain more direct signs of the duodenal lesion. At present, while the roentgen diagnosis is not errorless, its efficiency is fairly pro- portionate to the thoroughness of the examination, and by its objective nature is more persuasive than the clinical diagnosis. Pathology. — To roentgenologists the | pathologic anatomy of duodenal ulcer is of more than passing interest, since the location and character of the ulcer directly affect its roentgeno- logic demonstrability. Of prime importance is the fact that 388 DUODENAL ULCEK more than nine-tenths of these ulcers occur in the first inch and a half of the duodenum, and usually on the anterior wall (Fig. 324). Less than a tenth of them are more distally situ- ated, and these may be found in any part of the duodenum, even its third or fourth portion. Commonly single, the ulcer may have a companion, a ''kissing" or contact ulcer, on the opposite wall, or several ulcers variously grouped and in various stages of evolution, may be present. Macroscopically, the appear- FiG. 324. — Drawing showing small ulcer in the anterior wall of the duodenum. ance of an ulcer depends upon its age and the resulting amount of scar-tissue (Fig. 325). A recent ulcer may be so small and shallow (Fig. 326) that no marked evidence of it can be seen on the outer coat of the bowel; its presence is determined by the surgeon by palpation of the slightly thickened ulcer-area, which may also be hyperemic, or may show petechise after rubbing with the finger or with gauze. With the majority of ulcers, however, external scarring is visible, but this may occur without marked contraction or deformity. The more ancient callous PATHOLOGY 389 ulcers with extensive cicatricial contraction, cause deformity and often stenosis. While an old ulcer may show a punehed- out crater of appreciable depth, it is notable that the excavation is often superficial. Regarding this, W. J. Mayo^ says: "The mucosa of the duodenum is thin, smooth and granular, and chronic duodenal ulcers may not therefore have the character- istics we have learned to expect from experience with gastric Fig. 325. — Photograph of excised ulcer. Crater at c. Fig. 326. — Photograph of excised ulcer. Crater at c. ulcers. I haA^e excised a number of duodenal ulcers in which there was considerable scar-tissue in the submucosa and muscu- laris and marked evidence of localized peritonitis; yet the actual ulcer was a mere slit or dimple surrounded by an eroded, dis- colored patch of mucosa. This is the type of ulcer which occurs on the anterior wall unless there is a corn-like thickening over the top of the ulcer, in which case it will have the size, depth and callus characteristic of gastric ulcer." 390 DUODENAL ULCER A high percentage of ulcers penetrate to the serosa or per- forate the duodenal wall. The perforation may be sealed by the adhesion of adjacent tissues, or the ulcerative process may invade the pancreas or liver and produce an accessory pocket (pseudo-diverticulum) , similar to that of perforating gastric ulcer. An actual diverticulum, or at least a distinct pouching of the gut, is sometimes seen proximal to a stenosing ulcer. While no adhesions are found in the majority of cases of duo- denal ulcer, they are a natural consequence of perforation, occur sometimes with the chronic non-perforating type, and are seen exceptionally in association with very small ulcers. MaUgnancy developing upon a strictly duodenal ulcer is exceedingly rare, although a gastric cancer has occasionally been known to develop on a duodenal ulcer which had extended to the gastric side of the pyloric ring. Technic. — The technic of the roentgenologic examination for duodenal ulcer is practically inseparable from that of the gastric examination, for the secondary signs of duodenal ulcer are manifested chiefly in the stomach. Hence, the six-hour meal, the barium-water, and the barium-pap with roentgeno- scopy and roentgenography (page 75) are all either necessary or advantageous. In addition to the gastric examination, the principal aim is to visualize the duodenal contour adequately and satisfactorily. Often this can be attained during the routine vertical screen-examination. By manipulating the stomach, the barium-water and, though somewhat less readily, the barium- pap also, can usually be forced through the pylorus in quantity sufficient to fill the duodenal bulb. To obtain a clear view of the latter, it is most often necessary to rotate the patient slightly to the right so as to bring the shadow of the bulb away from that of the spine. Exceptionally, when the stomach is of the acute fish-hook type and the bulb lies very near the lesser curvature, rotating the patient a little to the left may show it'more clearly. We have found that examination of the patient recumbent on the screen-table has an advantage occasionally over the upright position by securing better filling of the duodenum. More TECHNIC 391 important than the position is securing relaxation of the pyloric sphincter. Adding a dram of sodium bicarbonate to the barium-water has seemed to promote this relaxation, and it is also furthered by the patient breathing deeply and relaxing all his voluntary muscles. Ordinarily, a fair view of the cap will be obtained within a very few minutes, but in some instances Fig. 329. Fig. 330. Figs. 327, 328, 329, 330. Normal stomachs and duodenal bulbs. the bulb may fill more completely after the patient has rested for a time and physiologic gastric evacuation has become more pronounced. Waiting is sometimes also necessary to eUcit the exaggerated peristalsis which is a common accompaniment of duodenal ulcer. Blocking the distal duodenum by manual pressure, or with Holzknecht's distinctor, sometimes favors 392 DUODENAL ULCER duodenal distension and hence a better delineation of its contour. In a large percentage of cases, if the examiner is experienced, the screen-examination alone will be fairly decisive as to the presence or absence of duodenal ulcer. Either a definitely deformed or a definitely normal bulbar contour will be seen, or the secondary gastric signs will affirm the diagnosis. In all doubtful cases plating is requisite. In making plates the re- cumbent position is most convenient, with the patient lying on his abdomen and rotated a trifle toward either side or in what- ever angle at which the bulb was seen most clearly on the screen. Special tables are obtainable by which the image can be seen fluoroscopically and plates made at any desired angle of pro- jection. Plates can be made at intervals, developing and ex- amining each plate as made; when any plate shows a normal bulb, or an identical deformity appears upon each of several plates, the examination may be discontinued. Or, if preferred, a series of plates may be made successively and studied to- gether. By either method it is imperative that the number o%)lates be sufficient to support a positive opinion. If economy is desired, devices can be had by which four or more exposures can be made on different parts of the same plate. Roentgen Signs. — The roentgenologic indications of duodenal ulcer may be classified as follows: A. Direct signs. 1. Deformity of the duodenal contour. B. Indirect signs. 1. Alterations of gastric tone. 2. Alterations of gastric peristalsis. 3. Alterations of gastric motility. 4. Gast1:-ospasm. 5. Tenderness localized to the duodenum. ■ Direct Signs. — 1. Deformity of the duodenal contour, more spe- cifically of its first portion, the bulbus duodeni, or cap, was first established as a practicable sign of duodenal ulcer by Lewis DIRECT SIGNS 393 Gregory Cole^ of New York, who developed the plan of "serial roentgenography," which in essence consists in making numerous roentgenograms successively and studying them in sequence. On theoretical grounds, the method did not seem to be either convenient or wholly trustworthy, and was regarded skepti- cally by many roentgen workers, including ourselves. The diffi- culty of obtaining a completely filled cap, the often insignificant anatomical changes produced by the ulcer, and the fact that bulbar distortion might be due to causes other than ulcer were urged as objections. However, more careful investigation has proved that bulbar deformity is feasible of demonstration and stands first among the roentgenologic signs in diagnostic value. The assumption that the distortion of the cap represented the organic alteration produced by the ulcer has contributed strongly to the doubt with which this sign was received, since it is known that many duodenal ulcers do not materially alter the duodenal topography. Yet ulcers of this kind often give rise to marked bulbar deformity in the roentgenogram, quite out of proportion to the organic changes found at operation. The deformity of the bulb in these cases is, we are satisfied, solely or chiefly the result of intrinsic spasm exactly similar to the incisura of gastric ulcer or the spastic distortion of the pars pylorica so often seen associated with prepyloric ulcers. On this hypothesis it is possible to understand why the distortion of the bulbar shadow is more exaggerated than the deformity seen at operation. Absence of spasm would also explain why in some cases of ulcer no irregularity of the bulb-shadow is present (Fig. 331). The bulbar deformities more or less characteristic of duodenal ulcer might thus be divided into three general classes: (1) Those due to organic distortion; (2) those due to organic changes plus spasm; (3) those which are pro- duced by spasm only. In appearance the following types are noteworthy : a) General distortion with sharply outlined projections and indentations, giving the bulb the semblance of a miniature pine-tree or a bit of branched coral. This sort of bulb almost 394 DUODENAL ULCER always means duodenal ulcer (Fig. 332). The distortion is largely due to spasm, this element being persistent and unvary- FiG. 331. — Apparently normal bulb, b. Duodenal ulcer found at operation. Fig. 332. — General distortion of bulb, b. ing. In the classic cases of this type the entire contour of the bulb is deformed; in others only one lateral border is distorted (Fig. 333). DIRECT SIGNS 395 b) Deformity of the basal border. Instances are not infre* quently encountered in which the base-hne alone of the bulb is Fig. 333. — Unilateral distortion of bulb, b. Fig. 334. — Deformity of basal border, b. irregular. Most often the distortion is seen as a shaded filling- defect, and, though definitely recognizable, may be quite small (Fig. 334). 396 DUODENAL ULCER c) The niche-type. The excavation of the ulcer is seen as a barium-filled recess projecting from the bulbar chamber. It varies from a wheat grain to larger in size, and its barium Fig. 335. — Niche-type of bulbar deformity. Niche at n. Fig. 336. — Incisura-type oi bulbar deformity. Incisura at i. content is often denser than that in the rest of the bulb (Fig. 335). The niche may or may not be accompanied by organic or spastic deformity elsewhere in the bulb. DIRECT SIGNS 397 d) The incisura-type of deformity. The incisura may be single or bilateral (hour-glass). It is usually small but sharply outlined, is evidently spastic, presumably occurs in the plane of the ulcer, and may be the sole abnormality of contour observed (Fig. 336). e) In occasional instances the bulb is represented by a very small but compact mass of barium. There is no particular irregularity of contour, but the bulbar shadow is abnormally small (Fig. 337). Sometimes this sort of bulb is produced by Fig. 337. — Diminutive balb, b. an ulcer stenosing the duodenum, so that only the proximal portion of the bulb is filled. But, unless other signs of obstruc- tion (gastric retention, antral dilatation, etc.) are also present, a diminutive cap should not be considered indicative of ulcer, since it may exist normally, or may be only partially filled and thus appear small. /) The accessory pocket of a perforating ulcer which has invaded tissues outside the duodenum, shows as a projection from the bulbar contour (Fig. 338). It may be rounded or 398 DUODENAL ULCER Fig. 338. — Accessory pocket, b, of perforating duodenal ulcer. Fig. 339. — Diverticular sac at d, in a case of duodenal ulcer. DIRECT SIGNS 399 uneven in outline, and its contents may be arranged in layers of gas, fluid and barium. Often it contains a residue from the six-hour meal. g) A diverticulum also appears as a sac-like addition to the bulb proximal to the site of the ulcer. As a consequence, the basal portion of the bulb is usually enlarged (Fig. 339). Since a diverticulum is commonly associated with a stenosing ulcer, other indications of obstruction will generally be noted also. The foregoing deformities have all been described as per- taining to the bulb, because ulcers are more commonly situated in this part of the duodenum. Ulcers seated in other segments of the duodenum doubtless produce similar deformities, but they are more difficult to recognize by the rc-ray. Distortion of the bulb is not always easy to determine. With experience the observer soon becomes famihar with the gross and typical deformities which are pathognomonic of ulcer. Likewise, when the bulb fills completely and is of normal contour, the fact is readily apparent. But to distinguish a deformed cap from one which is only partially filled is oftentimes most troublesome (Figs. 340 and 341). Cases without ulcer are frequently met with in which the bulb as seen on the screen and on plates, especially the latter, fails to show a normal contour, simply because of incomplete filling. It is somewhat characteristic of these cases that the defective or unfilled area usually shifts its situation, as shown by careful comparison of the plates or superposing them, and, as a rule, if the examination is con- tinued a normal filled bulb will finally be obtained. A bulb of apparently normal and fairly regular outhne is sometimes on closer inspection found to be eccentrically placed with respect to the pyloric canal, so that the major part of the cap-base visible lies on one or the other side of the pyloric axis. In reality only a part of the bulb is seen, and the examination must be continued until a normal bulb with a symmetrical base or a positive and unvarying deformity is shown. The significance of a deformity does not depend on its size but on its constancy. It is incumbent, therefore, on the 400 DUODENAL ULCER examiner to make his observations with extreme care lest he overlook any relatively minute irregularities of contour, but he must also make certain of their persistence. In an over- FiG. 340. — Bulb partly filled and resembling the deformed bulb of duodenal ulcer. See Fig. 341. Fig. 341. — Filled bulb of normal contour. Same case as in Fig. 340. whelming preponderance of cases, a constant bulbar deformity means duodenal ulcer. It is not absolutely diagnostic, since distortion of the duodenal shadow may also result from an DIKECT SIGNS 401 inflammatory adhesion-producing process in the right upper abdominal quadrant, notably pericholecystitis, or from cancer of the duodenum, or possibly from purely reflex spasm set up by conditions outside the duodenum. While bulbar deformity from adhesions about the gall-bladder does occur occasionally (Fig. 342) it is not a common cause of error, and we have seen cases in which the duodenum was matted in adhesions, yet the contour of its lumen was not deformed in the roentgenogram. Cancer of the duodenum is so rare that it should be thought of last of all. Fig. 342. -Hour-glass deformity of duodenum due to delicate adhesions from a peri- cholecystitis. As to the possibility of duodenal deformity by extrinsic spasm, it must be admitted that other portions of the alimentary tube are affected by reflex spasm originating from causes outside the digestive canal, and presumably the duodenum is not an exception. However, we cannot point to a specific instance in which a persistent and unchanging bulbar distortion was be- lieved to be due to this cause. Shifting and intermittence com- monly characterize extrinsic spasm, and if the duodenum were 26 402 DUODENAL ULCER thus affected, the observer would probably be unable to dis- tinguish it from incomplete filling due to a scanty flow through the pylorus, or rapid duodenal evacuation, or both. Pressure Fig. 343. — Distortion of bulb by pressure against the spine. Fig. 344. — Gastric hypertonus in a case of non-obstructive duodenal ulcer. against the spine may deform the bulbar outline, especially its inner border, but by using both screen and plate the cause should be evident (Fig. 343). The smooth, concave indentation INDIRECT SIGNS 403 of the outer border of the cap, sometimes produced by the gall- bladder, has no resemblance to the irregular deformity of ulcer. The fact has been mentioned that duodenal ulcer may exist without detectable distortion of the bulbar shadow. Such instances, however, are relatively uncommon, and the observer should consistently report them as roentgenologically negative. Indirect Signs. — 1. Alteration of gastric tone. The most common change of gastric tone, associated with duodenal ulcer, is to a hypertonus (Fig. 344). This, together with hyper- peristalsis and hypermotility, constitutes a triad of ''hypers" which was given early recognition as being rather strongly indicative of duodenal ulcer. The hypertonus may be explained upon either of two grounds: First, it may occur simply as a reflex from the irritated ulcer — a spastic increase of tone which stops short of the general reflex gastrospasm familiar as a sequence of numerous conditions outside the stomach. Second, it may result from the effort to overcome beginning stenosis of the duodenum, whether due to contraction of the ulcer-scar or duodenal spasm. A compensatory hypertonus of this sort preceding muscular hypertrophy would be a natural and first response to distal obstruction. Whatever the reason, hyper- tonus is seen with the majority of duodenal ulcers, and perhaps more frequently in this than in any other condition. True, it occurs also as a normal feature of the steer-horn stomach seen now and then in persons of the broad habitus, and is an occasional accompaniment of various pathologic conditions other than duo- denal ulcer. With markedly obstructing duodenal ulcer, if of long standing, there is a gradual failure of compensation and the stomach becomes hypotonic. If of moderate degree the effect may be chiefly noticeable in the antrum, which is larger than normal, and the examiner soon begins to regard antral dilatation as more or less significant. In the extreme degrees of hypotonus the entire stomach as well as the antrum is expanded to immense size, the condition is obviously one of dilatation rather than functional atony, and the existence of obstruction is practically certain (Fig. 345). 404 DUODENAL ULCER Fig. 345. — ]^Iarked gastric hypotonus; obstructive duodenal ulcer. Fig. 3-46. — Hj-perperistalsis; four waves running. INDIEECT SIGNS 405 2. Alterations of Gastric Peristalsis. — Hyperperistalsis is nota- ble in a large proportion of cases, perhaps 60 per cent, or more. It varies from a slight increase of wave-depth and frequency to Fig. 347. — Hyperperistalsis. See Fig. 348. Fig. 348. — Same case as in Fig. 347. In this roentgenogram, taken within a min- ute after the one shown in Fig. 347, the stomach is practically at rest. a tempestuous energy of contraction. It is most exaggerated in the obstructive cases, but it occurs also when there is no obstruction. A characteristic feature is the regular succession 406 DUODENAL ULCER and symmetrical correspondence of the Avaves on both curva- tm-es which are equally indented (Fig. 346). Three or four pairs are -seen in progress at once, whereas with the media described, only one or two pairs are seen normally. A mere exaggeration of wave-depth should not be confounded with hyperperistalsis, since an essential feature of the latter is an increase in number of the waves, although they may also show unusual vigor. Hyperperistalsis is often intermittent in character, periods of activity alternating with periods of rest (Figs. 347 and 348). Its appearance is sometimes a little delayed after the stomach is filled, but not usually beyond five or ten minutes. Of course, the phenomenon of hyper- peristalsis is not limited to duodenal ulcer. It may accom- pany lesions of the gall-bladder or appendix, or be seen normally in the hypertonic steer-horn stomach, but in any of these, as a rule, is less pronounced than in duodenal ulcer. Exaggerated peristalsis can sometimes be elicited by massage of the epigastrium in normal cases, or by palpating a tender appendix; it soon dies away when the stimulus ceases. The hyperperistalsis of duodenal ulcer requires no artificial excita- tion. Obstructing pyloric and prepyloric lesions are sometimes attended by hyperperistalsis, but this is nearly always of a disorderly character as to the depth and sequence of the waves, and these are seen chiefly on the greater curvature. Occasion- ally, however, this variety of peristaltic exaggeration accom- panies perforating duodenal ulcer. In estimating the degree of peristaltic actlAdty, it is to be remembered that peristalsis is more lively in the recumbent than in the standing posture, and that it is influenced by the character of the opaque meal. Comparisons should be made under identical circumstances. The observation of antiperistalsis with duodenal ulcer has been reported. We have noted it in one or two cases with obstruction. In the main, antiperistalsis speaks for pyloric or pre-pyloric, rather than post-pyloric. lesions. 3. Alteration of Gastric Motility. — A logical result of hyper- tonus and hyperperistalsis is hypermotihty, provided no marked INDIRECT SIGNS 407 Fig. 349. — Copious initial clearance in a ease of duodenal ulcer. Fig. 350. — Hypermotility. Advance of the six-hour meal well up to splenic flexure. 408 DUODENAL ULCER obstruction has been produced by the ulcer. Rapid clearance of the stomach is also furthered by the free patency of the pylo- rus so often observed. During screen-inspection the barium is seen passing out into the duodenum in a copious stream, not quite so voluminous as that remarked with the gaping pylorus of cancer, but larger than normal (Fig. 349). Generally speak- ing, the spontaneous initial clearance in cases of duodenal ulcer is either of this profuse type, or, with marked obstruction, ab- normally scant, and a moderate, intermittent outflow is not seen as under normal conditions. Hypermotility is also evi- denced by the position of the six-hour meal, the ''head" of which, instead of being in the cecum or ascending colon as normal, may be in the transverse or even in the descending colon (Fig. 350). Again it must be recalled that hypermotility is not peculiar to duodenal ulcer and that it is a common effect of gastric cancer, achyha and the diarrheas. If these be excluded, as can usually be done by considering the salient roentgenologic and clinical facts, a pronounced hypermotility hints strongly at the possi- bility of a non-obstructing duodenal ulcer being present. On the other hand, more than one-fourth of the ulcers are sufficiently obstructive to produce a six-hour retention in the stomach (Fig. 351). A residue in a stomach with an unbroken contour, that is to say, without any roentgen evidence of gastric ulcer or cancer, should first of all suggest duodenal obstruction, the most common cause of which is duodenal ulcer. If, in addition to the gastric retention, there is typical gastric hyper- peristalsis, the presence of a duodenal ulcer is well-nigh certain (Fig. 352). In short, we consider the combination of these two signs as being quite as diagnostic as any other evidence that can be obtained, not excepting bulbar deformity. 4. Gastrospasm. — Duodenal ulcer is frequently associated with spastic manifestations in the stomach. The spasm is rarely or never of the total or regional type. Most commonly it takes the form of an incisura or an hour-glass contraction (Fig. 353). The incisura may be extraordinarily large and deep, in which case it usually travels toward the pylorus along with INDIRECT SIGNS 409 Fig. 351. — Retention from the six-hour meal. Fig. 352. — Marked hyperperistalsis ; large stomach, otherwise normal pretention from the six-hour meal. The diagnosis of duodenal ulcer based on these signs alone was confirmed at operation. 410 DUODENAL ULCER Fig. 353. — Hour-glass stomach due to duodenal ulcer. Diagnosis, gastric ulcer. The bulb was not investigated as to deformity. At operation a duodenal ulcer was found, with stomach negative, and no hour-glass, the latter having been relaxed bj' the anesthesia. *mmt^ Fig. 354. — Gastric incisura in a case of duodenal ulcer. VALUE OF INDIRECT SIGNS 411 the deep peristaltic waves, of which it is perhaps an eccentric form. Again, the incisura is of shght or moderate depth, is seen anywhere along the greater curvature and is stationary (Fig. 354). Especially annoying is the fact that such an incisura may persist after belladonna has been given to the patient and thus arouse suspicion of a gastric ulcer. It is a vex- ing exception to the rule that spasm associated with conditions outside the stomach disappears after the administration of an antispasmodic. Other causes of gastrospasm have been discussed in the chapter on this subject. 5. Tenderness localized to the duodenum is included in many of the older lists of ulcer signs. In some cases the tenderness is rather emphatic and limited to the vicinity of the ulcer, but it may easily be confounded with a tender gall-bladder, and its diagnostic worth is trivial. Value of Indirect Signs. — The value of all these indirect signs depends considerably upon their frankness, their varying combination, and their concordance with the general aspects of the case. Hyperperistalsis associated with gastric retention and a normal gastric outline is safely diagnostic, and making multiple plates in such cases is superfluous. Hyperperistalsis alone, if pronounced, is perhaps a 60 per cent. item. Backed by a good clinical history it is worth even more, but there are instances in which this combination results from causes other than duodenal ulcer, so that it is more conservative to carry out the serial plate examination in addition. There is always this to be said of indirect signs, that where they fall short of establishing a diagnosis they contribute to diagnostic certainty, or, at all events, guide the observer in the right line of inquiry. At the risk of being tedious we must repeat the advice that the examiner acquaint himself with the clinical history in every case. This knowledge will direct his particular attention to the probable source of trouble and will restrain him from overhasty conclusions. There is no intent to suggest that the roentgen- ologist should base any diagnosis on the history only, or even chiefly — the clinician can do that. Nor should a contradict- 412 DUODENAL ULCER ing history swerve the roentgenologist when his own evidence is conclusive. But the anamnesis and cUnical data in most instances are more or less directive and eliminative, so that a correlation of all the findings is advisable, as a rule. No diag- nosis can be too strongly fortified, and any gross discordance between the findings from all sources should make the examiner cautious in his opinions. As a corollary of this, he should not pin exclusive faith to any single method of roentgen examination, but should make use of every technic that offers help, and weigh the result as a whole. Concurrence of Duodenal and Gastric Ulcer. — As mentioned elsewhere, about 15 per cent, of the cases of gastric ulcer have a duodenal ulcer also. Hence, the examiner ought not to be too easily satisfied with the demonstration of a duodenal ulcer, but should make careful observations for a possible gastric ulcer. Case 127,835, woman, aged 35 years. During the past eight or ten years she has been having attacks of epigastric pain, coming on one to three hours after meals. At first the attacks were not severe and came at long intervals, often to one year. Chronic appendix removed seven years ago; not much improvement. Two years ago she was operated upon for gall-stones, which were not found. Her surgeon told her that he ''covered in" an ulcer of the intestine. She was very much improved for six or eight months. Over a year ago she was treated by lavage and dieting for a gastric ulcer, and gained much relief. Present attack began eight weeks ago. A week ago she vomited two or three times with relief. During the past few months she has lost 10 or 15 pounds weight. Gastric analysis r Stomach empty. Hema- globin 83. Roentgen findings: Constant deformity of bulb (Fig. 355). Findings at operation: Large, contracting, scarred ulcer of duodenum just below pylorus, with adhesions to anterior abdominal wall and liver. Operation: Posterior gastro-enterostomy. Case 124,843, man, aged 30 years. Seven years ago he had a sud- den attack of very sharp and severe pain in the right hypochondrium, emesis of greenish vomit, and fever, followed by marked jaundice. For a year after this by spells he had subcostal tenderness, aggravated by jolting, together with gas, fullness and sour eructations after meals. For three or four years he had very little trouble. He then began to have attacks lasting a month, of epigastric tenderness with hunger- pain, relieved by light food and aggravated by acids, coffee, tea and KEPORT OF CASES 413 meat. Some months ago, for two weeks, he had extraordinarily black stools. For six weeks past he has had fullness for a half hour after meals, then relief for two hours, then hunger-distress. Four weeks ago he again had an acute attack of upper abdominal pain with fever, which ceased suddenly, and was not followed by jaundice. At present there is some rigidity and tenderness in the right hypochondrium. Total acidity 76; free 60; combined 16. Hemoglobin 85; leukocytes 11,000. Roentgen findings: Deformity of bulb. Diagnosis: Duodenal ulcer (Fig. 356). Findings at operation: Subacute perforating duodenal ulcer just at the pylorus. Pylorus adherent to left lobe of liver. Fig. 355.— Case 127,835. Adherent appendix. Gall-bladder negative. Operation: Posterior gastro-enterostomy. Pylorus blocked (Wilms). Ulcer covered with omentum. Appendectomy. Case 128,344, man, aged 46 years. Eight-year history of gastric attacks, coming on once or twice a year and lasting three to ten weeks. In these he has a fullness and distress two and a half hours after meals, lasting 'until the next meal or alkalies are taken. Eating soon after the pain begins increases the distress. Much night distress from 10 p.m. to 2 a.m. Very little belching or sour eructations. Total acidity 66; free 54; combined 12. Roentgen findings: Bulb deformed. Diagnosis: Duodenal ulcer (Fig. 357). Findings at operation : Large, thick, calloused ulcer of the duodenum, anterior wall, beginning just below the pylorus and extending downward 1}^ inches. Beginning obstruction. Long mesocolic band. Operation: Posterior gastro- 414 DUODENAL ULCER Fig. 356.— Case 124,843. Fig. 357.— Case 128,344. EEPORT OF CASES 415 enterostomy. Ulcer covered in with sutures. Mesocolic band divided. Case 142,380, man, aged 62 years. About three years ago he began having general abdominal pains, worse at the umbilical region, coming usually after bowels had not moved for three or four days, and relieved by catharsis. Never any trouble directly referable to the stomach. Two months ago he had an attack of pain and vomiting, after a constipated period. For two weeks he has had occasional vomiting though bowels are moving. Indefinite history also of heavy feeling at night, relieved by soda, and prevented by taking cathartics. Total acidity 70; free 60; combined 10; no food remnants. Roentgen findings: Retention of half the six-hour meal. Hyperperistalsis. Bulbar deformity. Diagnosis: Perforating duodenal ulcer (Fig. 358). Findings at operation: Large ulcer, anterior wall of duodenum, per- forating into head of pancreas, forming tumor size of a lemon. Opera- tion: Posterior gastro-enterostomy; ulcer, covered. Case 146,943, man, aged 53 years. Thirty-year history of trouble with stomach. Attacks in spring and fall, lasting three months, of cramps two or three hours after meals and at night from 12 to 1. Well between attacks. No food relief; some ease by soda; most relief by drinking water and inducing vomiting. Much sour stomach; some gas. Occasional retention vomit. Qualitative dyspepsia for fats, acids, apples, etc. Frequently tarry stools; never vomited blood. Many years ago had three attacks of severe abdominal colic requiring chloroform for relief. No jaundice, chills or fever. Weight loss, 20 pounds in one month. Total acidity 66; free 52; combined 14; no food remnants. Roentgen findings: Retention of half the six-hour barium meal. Hj^peristalsis. Irregular bulb. Diagnosis: Duodenal ulcer (Fig. 359). Findings at operation: Extensive ulceration of the duodenum. Gall-bladder negative. Operation: Posterior gastro-en- terostomy. Case 134,500, man, aged 38 years. For four years he has had at- tacks of very sour stomach coming any time in the afternoon or night and accompanied by dull epigastric pain. He forces vomiting for relief. The attacks have no relation to eating, and food does not ease although he has taken a good deal of soda. The trouble is fairly con- tinuous, although he has occasional remissions, even to one month. Three'months ago he vomited a large quantity of blood. Operation elsewhere for ruptured appendix three years ago. Weight loss, 27 pounds in two years. Total acidity 90; free 70; combined 20; food remnants. Roentgen findings: Retention of three-fourths the meal. Hyperperistalsis. Small irregular bulb. Diagnosis: Duodenal ulcer 416 DUODENAL ULCER Fig. 358.— Case 142,380. Fig. 359.— Case 146,943. REPORT OF CASES 417 (Fig. 360). Findings at operation: Multiple ulcers of duodenum, at least three being felt. Large, dilated stomach. One firm adhesion between anterior wall of stomach and gall-bladder. Operation: Posterior gastro-enterostomy. Ulcers enfolded. Case 144,333, woman, aged 33 years. For two years, following a nervous breakdown at that time, she has had severe epigastric pain, coming on immediately after eating and lasting two or three hours. Fig. 360.— Case 134,500. Some relief by soda. Always feels best with empty stomach. Con- siderable eructation of acid. For seven weeks past she has had attacks of vomiting, coming on about 1.30 a.m. and preceded by sharp pain in the epigastrium. Absolutely no abatement of symptoms in two years. On liquid diet for six weeks. Strength poor. Weight loss, 5 pounds in two years. Diffuse tenderness upper abdomen. Total acidity 40; free 22; combined 18. Roentgen 'findings : Constant spastic incisura, outer aspect of bulb near base. Diagnosis : Duodenal ulcer (Fig. 361) . (This case illustrates the fact that a small duodenal ulcer can be present 27 418 DUODENAL ULCER without showing roentgenologically unless it produces spasm.) Find- ings at operation: Definite smooth scar on duodenum, l^ inch below the pylorus, with marked stippling sign. Large stomach and dUated duo- FiG. 361.— Case 144,333. Fig. 362.— Case 111,247. denum. White gall-bladder with adhesions about it. Definite chronic appendix. Operation: Excision of ulcer of duodenum and closure as a Heineke-Mikulicz operation. Cholecystectomy. Appendec- REPORT OF CASES 419 tomy. Pathologic report : Chronic catarrhal cholecystitis (very early ''strawberry")- Duodenal ulcer. Chronic catarrhal appendicitis. Case 111,247, man, aged 25 years. Began three months ago with a sudden, sharp, sticking pain, right costal margin, causing him to double up for a few minutes. Two or three attacks daily. Never vomited or had to go to bed on account of pain. No chills, fever, or jaundice. His phj^sician gave him some pills, after taking which, the patient states, he passed gall-stones. For a month he has had a dull epigastric pain usually with empty stomach, relieved by food of any sort. No gas or sour eructations. Bowels regular; appetite fair. Sleepless and nervous. Total acidity 44; free 30; combined 14. Some tenderness and spasm, right costal margin. Roentgen findings: Diverticulum of the duodenum. Rather large low4ying stomach (Fig. 362). Findings at operation: Duodenal ulcer, 1 inch below pylorus with marked contraction, producing what appeared to be a diverticulum from lower border of duodenum, size of a tangerine. Operation: Posterior gastro-enterostomy. Ulcer area covered in with purse-strings of silk. Case 91,639, man, aged 35 years. Since the age of 13 he has had occasional epigastric pain which was always relieved by hot drinks. For eight years he has had more definite attacks, once or twice yearly, lasting one to three weeks, of gnawing epigastric pain, two or three hours after meals, relieved by food. The distress often wakes him at 2 a.m. and he takes a drink of water or soda for relief. During the attack he loses weight, but regains it between times. For two years the attacks have been accompanied by regurgitation of sour, acrid fluid. The present attack has existed for three months and vomiting is a prominent feature. The vomiting occurs four to six hours after meals, and sometimes food that had been taken twelve hours previously is vomited. He has never vomited blood. Weight loss, 23 pounds in three months. Some epigastric tenderness. Total acidity 70; free 60; combined 10, food remnants. Roentgen findings: Hyperperistal- sis. Retention of three-fourths the six-hour meal. Diagnosis: Duo- denal ulcer (Figs. 363 and 364). Findings at operation: Large indurated ulcer of duodenum, showing evidence of recent perfora- tion. Marked obstruction. Operation: Posterior gastro-enterostomy. Ulcer covered with linen. Case 158,555, man, aged 37 years. One year ago he began to have a gnawing epigastric pain, coming two hours after meals and relieved by food, so that he acquired the habit of eating five or six times daily. The pain gradually increased and he has had to give up his work. No pain at night; no nausea; no vomiting; no hematemesis; no tarry stools. 420 DUODENAL ULCER For six months, up to a month ago, the patient had a respite from his trouble and gained weight and strength. During the past month, however, there has been no freedom from pain. Weight loss, 9 pounds in one month. Considerable epigastric tenderness. Total acidity 92; free 80; combined 12. Roentgen findings: Three different exami- nations with a series of plates on each occasion failed to show either a normal filled bulb or a constantly deformed bulb. At operation, the duodenum was found to be unusually large, and this probably ac- counted for the failure to fill it and show its actual contour (Figs. 365 and 366j. Findings at operation: Ulcer anterior superior duodenal REPORT OF CASES 421 wall, just below pylorus. Obstruction first degree. Evidence of recent peritonitis. Operation: Posterior gastro-enterostomy. Ulcer enfolded. .-c5^ Fig. 365.— Case 158,555. •\ Fig. 366.— Case 158,555. Case 158,688, woman, aged 61 years. For many years she has had epigastric pain, gas, fullness, and sour eructations, usually coming directly after meals, and she feels better with an empty stomach. She has to avoid acids, apples, heavy foods and sweets. During the past 422 DUODENAL ULCER eight years, about twice a month, she has had pain under the right costal margin and in the epigastrium, often coming about 10 a.m. and lasting the remainder of the day. For three months this has been much more marked, and every night, or twice in the night, she has been awakened wath a feeling of hunger and weakness, quickly followed by terrific stabbing pain through the right costal margin to back, and lasting not more than five minutes. Stools often light. Weight loss, 16 pounds. Total acidity 50; free 40; combined 10. Hemoglobin 50. Roentgen findings: At the screen-examination an irregular bulb was seen and the case was believed to be one of duodenal ulcer. However, Fig. 367.— Case 158,688. the plates, as here illustrated (Fig. 367) showed an apparently normal bulb and a negative diagnosis was returned. Shorth' before coming to the Mayo Clinic, this patient was examined on three occasions by a roentgenologist who found a small retention from the six-hour meal but a negative stomach and duodenum. He concluded that the trouble was probably a lesion of the gall-bladder. Clinical diagnosis: Chronic cholecystitis. Gall-stones. Findings at operation : Chronic perforat- ing duodenal ulcer, anterior superior wall, beginning immediately below the pylorus. Very extensive adhesions anterior right abdomen. Gall-bladder closely adherent and cause of gall-bladder sj-mptoms. At one time evidently an acute peritonitis and leakage due to perforat- ing duodenal ulcer. Operation: Posterior gastro-enterostomy. Case 106,481, man, aged 62 years. For twenty-five years, con- REPORT OF CASES 423 tinuous, severe, burning sensation in epigastrium. Occasionally it is less severe, but he has not found relief by any measure whatever. H^ has no distinct nausea, but at times he feels as though vomiting might Fig. 368.— Case 106,481. Fig. 369.— Case 131,731. give relief. Lately the burning has become especially severe about 2 a.m. Appetite good, but he does not eat to satiation, as this is followed by distress within a half hour. Weight loss, 9 pounds. 424 DUODENAL ULCER I"iG- 374. Fig. 375. FiQS. 370, 371, 372, 373, 374, 375.— Examples of bulbar deformity in duodenal ulcer. EXAMPLES OF BULBAR DEFORMITY 425 Fig. :-!7S. Fig. 379. Fig. 380. Fig. 381. Figs. 376, 377, 378, 379, 380, 381.— Examples of bulbar deformity seen/,in duodenal ulcer. 426 DUODENAL ULCER Fig. 386. Fig. 387. Figs. 382, 383, 3 84, 385, 386, 387.— Examples of bulbar deformity in duodenal ulcer. EXAMPLES OF BULBAR DEFORMITY 427 i 4Kn Fig. 388. — Markedly deformed bulb. Fig. 389. — Lateral view showing de- Large third portion of duodenum. Opera- formed bulb in a case of duodenal tion: Duodenal ulcer; no other lesion. ulcer. Fig. 390.— Duodenal ulcer; bulbar deformity. Fig. 391. — Duodenal ulcer. Deformed bulb resembling a Maltese cross. Fig. 392. — Antero-posterior view. Bulb Fig. 393. — Same case as in Fig. 392; hidden by antrum. See Fig. 393. lateral view. Deformity of bulb. 428 DUODENAL ULCER Tenderness right costal margin. Total acidity 52; free 34; combined 18. Roentgen findings: Persistent deformity of the bulb. Diagnosis: Possible duodenal ulcer, or adhesions, or both (Fig. 368). Findings at operation: Chronic catarrhal cholecystitis. Gall-bladder very adher- ent. Liver adherent to abdominal wall. Pylorospasm. Operation: Cholecystectomy. Case 131,731, man, aged 37 years. During the past fifteen years he has had gastric distress, gas and sour eructations almost continu- ously, never being entirely free for a day, and worse in winter. The dis- comfort comes on a half hour after breakfast and becomes severe from 9.00 to 11.30 a.m. It is relieved by the noon meal and recurs at 1.00 p.m. Every morning at 3 or 4 o'clock he is awakened by it. Besides relief by food he obtains partial rehef by soda, belching, hot water, etc. Never vomits; no black stools. No weight loss. Succussion over stomach; tenderness of epigastrium. Total acidity 60; free 46; combined 14; no food remnants (twelve-hour meal). Eight-hour motor meal shows small amount of food remnants. Roentgen findings : Large hypotonic stomach. Retention of half the six-hour meaL Normal gastric and bulbar contours (Fig. 369). Negative diagnosis. Clinical diagnosis: Duodenal ulcer with obstruction. Findings at operation: Pyloric obstruction due to an extensively adherent gall- bladder, which is firmly bound to the abdominal wall. Stone % inch long in tip of appendix. Operation: Cholecystectomy. Appendec- tomy. REFERENCES 1. Mayo, W. J.: "The Contributions of Surgery to a Better Under- standing of Gastric and Duodenal Ulcer." Annals of Surgery, 1907, xlv, 810-817. 2. Mayo, W. J.: ''Chronic Duodenal Ulcer." Jour. A.M. A., 1915, Ixiv, 2036-2040. 3. Cole, L. G.: "The Diagnosis of Post-pyloric (Duodenal) Ulcer by Means of Serial Radiography." Lancet, 1914, i, 1239-1244. CHAPTER XX MISCELLANEOUS LESIONS OF THE SMALL INTESTINE Besides the bulbar sacculation or diverticulum incident to obstructive duodenal ulcer, and the accessory pocket or pseudo- diverticulum of perforating duodenal ulcer, diverticula may also occur in the neighborhood of the ampulla of Vater. These may be congenital and contain an islet of pancreatic tissue, or they may result from pressure-dilatation in late life. They are chiefly of academic interest. We have not found any roentgen observations of Meckel's diverticulum. Other than duodenal ulcer, the only important condition of the small intestine which is readily susceptible of demonstration by the x-ray is obstruction. If near either extremity of the bowel, the site of the obstruction can be shown, but not if it is seated else- where, nor can the nature of the obstruction be determined by the roentgen signs alone. Instances of obstruction from different causes are presented in the following case reports : Case 143,715, male, aged 59 years. The patient complains chiefly of numbness of the extremities and gastric distress. About eight months ago he had a rather sudden onset of numbness of the distal phalanges — ^both hands. With this was a numbness of the toes which has extended up the inner side of his legs and to his body as far as the umbilicus. For a year he has had attacks of gastric distress lasting a week or ten days, coming three hours after meals and at midnight. Relief obtained by soda and by vomiting. Some gas and sour eructa- tions. He vomits at irregular intervals, sometimes the entire meal taken six hours previously. No hematemesis or tarry stools. Some qualitative food dyspepsia for acids, apples, etc. Weight loss, 12 pounds. Anemic. Knee-jerks absent. Hemoglobin 55 per cent. Gastric analysis: Total acids, 10; all combined; no food remnants. Endamoebse histolytica in stools. Urinalysis negative. Roentgen findings: No retention from the six-hour meal. Fairly active peris- talsis. No normal bulb, but deformity inconstant at two extensive examinations (Fig. 394). Diagnosis: Indeterminate. After medical 429 430 MISCELLANEOUS LESIONS OF THE SMALL INTESTINE treatment, the patient went to his home. He returned to the CHnic about nine months after with his gastric symptoms aggravated, an icterus of seven months standing and marked weight loss. Transfu- FiG. 398. — Case 77,400. Fig. 397. — Case 77,400. sion. Exitus lethahs. At the second visit of the patient, when the x-ray might have shown the site of obstruction, no roentgen examina- tion was made. Autopsy report: Carcinoma of the duodenum which involves the head of the pancreas and partially occludes the common REPORT OF CASES 431 bile-duct. Small hypernephroma of the left adrenal. ^Moderate fatty degeneration of liver, etc. Case 139,141, woman, aged 51 years. Several years history of occasional epigastric pain, soon after meals; sometimes forced vomiting for relief. The attacks were brief and came at intervals of several months. One j^ear ago she had an unusually severe attack which necessitated morphin for relief, and again three months ago. Since then she has had much epigastric distress and pain in stomach after taking food, with burning, gas, and bitter eructations. Everj^ second day or night she vomits large quantities of food and bitter fluid. Weight loss, 30 pounds. Peristalsis well marked. Total acidity 18; free 0; combined 18; food remnants; filtrate 800 c.c. Roentgen findings: Practically entire six-hour meal retained in stomach. Large stomach and duodenum. Pyloric canal widely open. Stomach and bulb normal in outline (Fig. 395). Diagnosis: Obstruction in duodenum bej^ond the bulb. Findings at operation: Cancer of gall-bladder which had perforated against duodenum about 4}4 inches from the pylorus, causing contraction at that point and dilatation of duodenum above. Widely open pyloric ring. Huge, dilated stomach. Opera- tion : Impossible to remove cancer because of involvement of deep struc- tures, ducts, etc. Anterior gastro-enterostomy. Pathologist's report: Specimen shows carcinoma. Autopsy report: Carcinoma of gall-blad- der associated with cholelithiasis (one stone), cholangitis, etc. Case 77,400, woman, aged 36 3'ears. Trouble with stomach since girlhood, six or eight times a year. Cramps in epigastriiun, not always related to food, much gas and rumbling in abdomen, occasional vomiting. For three months past she has had a diarrhea with seven or eight watery movements daily. Severe abdominal cramps. Visible and audible peristalsis. Stool examination: Red blood corpuscles, pus; otherwise negative. Wassermann negative. Roentgen findings: One-fourth motor meal in stomach at six hours. Stomach deformed by distended loops of small bowel. Small bowel markedly dilated, containing fluid and gas. Diagnosis: Obstruction of small bowel (Fig. 396). The colon, examined by clysma, shows a redundant sig- moid; the appendix is visible. Otherwise negative (Fig. 397). Find- ings at operation: Localized hypertrophic tuberculosis involving 10 inches of the jejunum, about 6 feet from its origin. Considerable involvement of mesentery. Obstruction of the bowel is marked, the canal being cicatricial and filled with granulation tissue. Above the obstruction the bowel is enormously distended. Operation: Resec- tion 12 inches of jejunum; lateral anastomosis. A photograph of the pathologic specimen is shown in Fig. 398. 432 MISCELLANEOUS LESIONS OE THE SMALL INTESTINE Case 120,591, man, aged 60 years. Nine months ago he first noticed loss of appetite and occasional slight cramping pain in abdo- men. Later he began to have spells of vomiting, usually at night. The vomitus was light-colored and watery, as a rule, but on one occa- sion it was cherry-colored, and at another time dark and foul-smelling. Fig. 401. — Case 86,605. Fig. 403. — Case 86.605. The vomiting came at intervals of eight or ten days, was preceded by constipation, and followed by diarrhea. At present his appetite is fair and food seems to agree, but he has some epigastric discomfort. Weight loss, 30 pounds. No masses palpated; rectal shelf free. Roentgen findings: Obstruction at ileocecal valve (Fig. 399). (No examination of colon by clysma.) Findings at operation: Extensive REPORT OF CASES 433 carcinoma involving cecum, ascending colon and portion of transverse colon. Operation: Resection of 10 inches of the ileum, cecum, ascend- ing colon and one-half of the transverse colon. Lateral anastomosis. Pathologist's report: Carcinoma. No glandular involvement found. Case 85,886, man, aged 43 years. Ten months ago he had an attack of cramping pain, three or four hours after a meal, which was relieved only by induced vomiting. Six weeks later he had a similar attack and later others, at intervals of three or four weeks. For four months the trouble has been practically continuous. Pain comes an hour and a half or more after eating and is not reheved until he induces vomiting. He frequently brings up bile and large quantities of foul material. Recently he has resorted to lavage and he is some- times able to retain small amounts of fluid and soft food. Former weight 168; present 114. Gastric analysis: Total acidity 50; free 40; combined 10; food remnants. Small floating mass palpable to right of umbilicus. Roentgen findings: Although the examiner, who was at that time inexperienced, made a diagnosis of gastric cancer, the roentgenogram (Fig. 400) shows the typical signs of obstruction of the small bowel. The intestine is enormously distended and deforms the stomach by pressure. The markings of the valvulse connive ntes are clearly visible in the gas and fluid distended bowel. Findings at operation : Ring carcinoma, upper small intestine. Metastatic nodules in omentum. Operation: Enteranastomosis between distended and collapsed loop of bowel. Case 86,605, man, aged 57 years. Following an attack of diarrhea nine months ago, the patient lost appetite and began to vomit occasion- ally two or three hours p.c. The vomiting is preceded by soreness at the right costal margin. During the past week he has been worse' with epigastric distress several hours p.c, followed by vomit- ing of sour, bitter fluid. Never food-ease. Usual weight 150;Jnow 132. Total acidity 48; free 40; combined 8; food remnants; sarcines. Movable, tender mass low in the right epigastrium. Roentgen findings: Gastric retention of half the six-hour meal. Retention also in duodenum and loop of upper small bowel, which latter is high up behind stomach, and shows a collection of gas at point of obstruc- tion (Fig. 401). After filling the stomach the collection of bariiun in the small bowel was obliterated in the gastric shadow (Fig. 402) . The gas-bubble at the point of obstruction could still be seen. Findings at operation: Spool carcinoma upper jejunmn, lumen the size of a lead pencil. Operation: Resection upper jejunum, end to end anas- tomosis by suture. Jejunostomy for feeding. Pathologist's report: Carcinoma. Glands inflammatory. Pathologic specimen, Fig. 403. 28 CHAPTER XXI THE LARGE INTESTINE Technic. — In the examination of the colon either the ingested meal or the clysma, or both, may be employed. Of the two, the clysma is the more important and the more commonly used, although the meal is indicated when the determination of motility is chiefly desired and when stenotic conditions com- pletely obstruct the enema, which thus fails to show the proximal hmits of an obstruction. A convenient meal is a cereal with barium, such as is used in the examination of the stomach. When motility (stasis, etc.) is to be investigated especially, the meal should be given without previous purgation and the patient should continue his usual habits as to eating and exercise in order that the customary conditions may be maintained. Four to six hours after ingestion, with normal motility of the stomach and small bowel, the meal will begin to enter the cecum and the examina- tion may be commenced. The combined screen and plate examination is preferred, and should be repeated at set intervals until the raeal is evacuated. When the clysma is to be employed, preliminary preparation of the patient is necessary. He should take 1 or 2 ounces of castor oil on the evening prior to examination, should abstain from the evening meal, and should clear out the bowel with a plain or soapsuds enema next morning before coming for the test. He may take a light breakfast if desired. The vehicle for the opaque clysma may be fermented milk, potato-starch pap, mucilage of acacia or some similar medium, and either barium or bismuth may be used. The clysma which we' are accustomed to use is prepared by stirring 8 ounces of barium' sul- 434 TECHNIC 435 phate into 16 fluid ounces of mucilage of acacia and adding to this the contents of two or three cans of semi-condensed milk so as to make a total of 50 or 60 fluid ounces. Occasionally this mixture will be rather too thick to flow freely and may be thinned with a little water. The consistency should be that of a heavy cream. The clysma should be warmed to about body-tempera- ture for use. The enema-container, preferable of enameled ware, should be attached to a rope running over an elevated pulley, so that it may be raised and lowered as desired. The rubber inflow tube should be 8 or 10 feet long, equipped with a spring-clip cut-off, and tipped with a self -retaining syringe-noz- zle having a large opening. The air should be driven out of the tube by permitting the enema to flow for a moment before intro- ducing it into the bowel. It may be mentioned that the so-called high enema tube is quite unnecessary for filling the bowel; it sim- ply curls up in the ampulla without entering farther. -The patient, stripped to his hips, lies on his back on the screen-table. The tip of the inflow tube, anointed with vase- line, is introduced into his rectum. When all is ready, the room- lights are turned out and the spring-clip is released. As a rule, the enema rather slowly fills the ampulla, which expands to accommodate its increasing contents. Throughout the bowel the filling process is not usually seen as a steady advance of the clysma, but is rather irregular; a section of the bowel is invaded by a tongue of the oncoming stream and then filled out to its capacity, after which another tongue is pushed forward. Fre- quently there is a little delay, real or apparent, at the flexures. After a flexure is passed, the proximal portion of the bowel may fill rapidly. Complete filling will ordinarily take place in from three to ten minutes. In most instances some of the enema will pass beyond the ileocecal valve into the ileum. If the patient complains of pain at any time, the spring-clip may be closed or the container lowered until the discomfort ceases. The container at a height of 3 or 4 feet above the patient is usually practicable. While the colon is filling, the screen observation should be 436 THE LARGE INTESTINE made either continuously or at frequently repeated intervals. Palpatory manipulation is quite essential in the investigation of eccentric appearances. If the patient's abdomen be rigid, it may be relaxed by having him flex his thighs and breathe with his mouth open. The tube and screen should be shifted about so that the particular region to be inspected will be in direct line with them, thus avoiding distortion of the shadow. Turning the patient to one side will change the angle of the rays and help in the study of apparent kinks and angulations. The diaphragm should be adjusted from time to time to permit close inspection of suspicious localities. Plates, 14 by 17, are best made with the intensifying screen during suspended respiration. The lower edge of the cassette should project an inch or two below the plane of the pubic arch. The tube-distance should be from 20 to 30 inches. At least two of the plates should be made with the patient in the dorsal position, and others with the patient prone. Both screening and plating with the patient standing may occasion- ally be advantageous to show changes of position. When plates only are desired, it is more convenient to give the enema with the patient lying on either side, with his knees drawn up, rather than on his back. The old time knee-chest and Trendelenburg postures are awkward, embarrassing and unnecessary. When the examination is completed, the patient may go to a closet and empty the bowel. Haenisch^ withdraws the enema through the tube to prevent subsequent difficulty of evacuation, but in our experience very few patients have had annoyance in this respect. For several hours after a proctoscopic examina- tion, a patient may have difficulty in retaining the enema during the roentgen examination. In these instances it is better not to undertake the latter examination until the following day. THE NORMAL COLON Like normal stomachs, normal colons have by no means a constant appearance as seen in the radiologic picture. Colons POSITION 437 which functionate properly and which are proved to be without lesions by exploration often show widely diverse roentgenologic characteristics, especially to casual view. A description of the normal colon must therefore be limited to certain common types and a few fundamental points of similarity, with a liberal allowance for exceptions. Broadest at the cecum, where it is often a handsbreadth, one common type of adult colon narrows slightly but progressively to the sigmoid flexure, from which it opens into the expansible ampulla. From the ampulla descends the tapering, rectal pouch. The apparent diameters depend largely upon the degree of distention, but with a 50-ounce clysma the descending colon and sigmoid appear to be one- third to one-half the breadth of the cecum. In other cases, the disparity between the broadest and the narrowest part of the colon is much less marked, the effect perhaps of the local tone condition at the moment. Perfectly normal colons are also often seen in which the diameter is practically uniform from the cecum to the splenic flexure. Position. — Normal variance as to position is especially note- worthy. Closely fixed only at the hepatic and splenic flexures and at the rectum, the colon, between these points, has con- siderable latitude of passive movement. The position as seen at any single examination is subject to modification by the posi- tion of the patient, whether standing or reclining, the tonus of the colonic musculature, the length of colon between fixed points, and perhaps to some slight extent by the weight of the colonic content. Disparity between the heights of the splenic and hepatic flexures is usually marked. The hepatic flexure is about at the level of the first lumbar vertebra, an inch or two above the iliac crest line, while the splenic flexure is close up under the left diaphragm. Occasionally, the hepatic flexure may be at a higher or lower level, but the splenic flexure is rarely displaced except by pathologic causes. The cecum is usually in the right iliac fossa, its lower border level with the sacral promontory, but it may lie well down in the pelvis. By reason of redundancies, which are not necessarily patho- 438 THE LARGE INTESTINE logic, the transverse colon and sigmoid flexure, occasionally also the descending colon, may be so looped and placed as to give various configurations. A long, lax transverse colon may sag to the pelvis, producing imitations of various letters of the alphabet. The sigmoid flexure is especially variable in length and position. When long, it may show as a tangled festoon, or a single long loop may ascend well up out of the pelvis. The descending colon is also sometimes long and looped upon itself. In children, the colon often forms an oval, the transverse colon being high and arched, and without any clearly marked he- patic flexure. Very rarely this may be found in adults. Hertz states that although the ascending and transverse colon of the new-born is quite short, the whole length of the colon is three times the length of the infant, due to the relatively excessive length of the pelvic colon. It is almost superfluous to say that positions and configura- tions may vary at successive examinations, and the picture seen with a patient standing may be quite different from that seen when he is recumbent (Figs. 404, 405, 406, 407). Contour. — During and immediately after the administra- tion of the enema, the colon, while somewhat sinuous, usually has a relatively smooth contour, with few or no sharply marked indentations or indefinite shadings. Soon after the filling process is completed, however, with the institution of general tonic contraction, the scalloped appearance due to haustration is seen. The haustra are especially emphasized in the descending and transverse portions; later in the different segments of the bowel the haustra become more accentuated or relax slowly from time to time. A sharply angular indentation of the cecum is com- monly seen at the ileocolic juncture and there may be a corre- sponding indrawing opposite. In the rectum the valves of Houston (Heister) sometimes produce one or more acute, uni- lateral indentations. As seen with the ingested meal, the haustral sacculations of the colon are much more emphatic than with the enema, and the barium in segments between haustra may be narrowed to a thin ribbon, so that the examiner may be CAPACITY 439 inclined to suspect a stenosis. Usually the meal does not preserve its continuity unbroken, but is separated into detached portions. Fig. 406. Fig. 407. Figs. 404, 405, 406, 407.— Normal colons. Capacity. — The capacity of the adult colon depends not only upon its length, but also upon the tone of its musculature. The amount required to fill it within the hmit of comfort ranges 440 THE LARGE INTESTINE ordinarily from 40 to 60 fluid ounces. When it is hypertonic and spastic, a much smaller quantity will visualize it throughout than when it is relaxed and atonic. Mobility. — An important feature of the normal colon is its mobility by palpatory manipulation excepting at its three points of fixation, although even the hepatic flexure is ordinarily susceptible of slight shifting. The splenic flexure is not only fixed by its suspensory ligament, but is also sheltered from pal- pation bj^ the thoracic cage. The lower sigmoid, protected by the pelvis, cannot be easily shifted about. In women, gyneco- logic palpation may be of service. A tense abdominal wall greatly hinders manipulation of the colon and this feature must be duly considered. Peristalsis. — Although numerous studies of the peristaltic movements of the colon have been made, the conclusions drawn have been somewhat contradictory, and this function is not as yet well understood. One feature of peristaltic activity which, though rarely seen directly'', has been generally accepted, is a rapid propulsive movement en masse of a large portion of the colonic content, occurring at infrequent intervals. The rarity of its observation is shown by the fact that Holzknecht,^ who first noted it, saw it but twice in 1000 cases examined for five to fifteen minutes. The movement occupied only a few seconds of time, and Holzknecht was at first of the opinion that it oc- curred only about three times in twenty-four hours, although he has later come to the belief that it occurs oftener, perhaps six or eight times daily. In the cases which he saw, about one-third of the contents was suddenly driven forward a distance equal to its own length . Similar findings have been made by others and an analysis of the movement has been attempted. Jordan^ has noted that when a wave starts, the part in front loses its haustral sacculation, becoming smaller but smooth by toning up of the muscular fibers. The advancing wave consists of a very firm contraction of the circular fibers, each fiber contracting in its turn and remaining strongly constricted for many minutes after the wave has passed. The rear end of the wave is sharply PEKISTALSIS 441 conical. It is stimulated by the taking of meals, by defecation, irritation (colitis) and emotion. Schwarz'* holds that it may be excited by the discharge of a large quantity of chyme into the colon as the result of increased gastric and intestinal peristalsis. The wave is more or less perceptible subjectively. He believes that the segment in front of the wave is not contracted, but is dilated. Other than this passive movement, which has been seen infrequently, but definitely, observers have described a variety of minor peristaltic phenomena. Haustral segmentation, which Holzknecht claims has nothing to do with peristalsis except to retard it, complicates the matter. However, Rieder concluded from plate studies that there are four kinds of movements: Peristalsis, antiperistalsis, oscillating movements, and uniform tonic contractions. Schwarz,-^ examining after an ingested meal, observed a rocking back and forth, mixing movement (wiege- phanomen) and regular rapid constrictions. Interval examina- tions every three to five minutes showed alterations of contour which were greatest in the cecum and ascending colon and grew progressively less marked, distalward. The waves he saw traveled both oralward and analward from a fixed point, making a flattened depression lengthening in each direction. This peculiarity of the wave perhaps accounts for the frequent ob- servations of antiperistalsis by others. Conceding its existence, it must not be classed with gastric antiperistalsis, which latter is seen as a strictly pathologic manifestation. As to this, Schwarz^ says: '^At this point I may advert to the oft-recur- ring question as to the presence of antiperistalsis in the colon. Whether the retrograde transport results from an actual anti- peristalsis or rather from a passive backflow behind a forward advancing constriction-wave cannot be decided without further data. In my opinion the retrograde transport in the colon is most commonly the result of a passive backflow, brought about by a hindrance to the progressing mass, whether this hindrance be a strongly contracted, filled, gas-distended or organically stenosed portion of the intestine. One has only to recall how 442 THE LARGE INTESTINE in an esophageal stenosis, with waves going toward the cardia, the food-mass is forced upward. I have already pointed out that active small moA^ements can shove the intestinal content backward when there is a lessened tonus in this direction. The rocking back and forth after a clysma is apparently not due to an antiperistalsis, but a backswing from powerful, broad, for- ward-going contractures. In this I am of one view with v. Bergmann and Lenz. However, on one occasion with the enema I was able to see indubitable antiperistaltic action in the colon. Anj'^^ay, discussion as to whether there is antiperistalsis or not has no very great significance. Certain is it that retro- grade stool-movements occur in the colon, and take place normally. With this we must at present be contented." Barclay' has twice seen massive movements, but he is frankly skeptical as to the lesser waves. He saj^s: ''It is evident that the slow peristalsis which used to be described never takes place — at any rate, we never see it — and the only change we do see in the shadow is that occasionally a small bolus rolls from one saccule to another in a manner that is more suggestive of the action of gravity than of the normal passage of feces." A comparison of the observed movements of the colon with those of the small bowel shows similarities which are not sur- prising when it is recalled that these organs are not wholly independent but parts of a continuous tube. The rhythmic segmentation of the small bowel has its analogue in the haustra- tion of the colon, and both apparently have two forms of ortho- peristalsis — slow and rapid. However, in the course of a routine examination, the observer is not likely to see any peristaltic acti^dty of the colon at all comparable to that of the stomach. By close study of the screen-image or of successive plates, he may note local changes of contour, but he will seldom be able to trace the progress of any single contraction. Motility. — The normal motility of the colon as shown by the rate of progress of opaque ingesta through it is hardly subject to exact determination because of the numerous varying factors which enter into the matter. Yet an attempt at this determina- THE ABNORMAL COLON 443 tion may be of value provided the observer interprets his findings hberally and without strict adherence to set rules. Hertz^ suggests the following as an average time-table for the ''head" of the ingested meal: Cecum 4 hours Hepatic flexure 6 hours Splenic flexure 9 hours Pelvic colon (sigmoid) 12 hours From this point on, the rate of progress will depend upon the time and frequency of stooling, and as this occurs ordinarily once daily, a twenty-four hour variation is easily possible under normal conditions. Twenty-four to forty-eight hours is regarded by many roentgenologists as a fair time basis for the passage of bariumized food through the digestive tract. This would allow twenty to forty-four hours for its journey through the colon; but these figures are applicable only on the condition that the patient has not been subjected to recent drug-action and that he pursue normal and accustomed habits as to eating, drinking, exercise and stooling. Nor must absolutely complete evacuation be expected within two days or even longer. Hold- ing^ has remarked that the fecal current is like any other current; the center moves faster than the sides, and remnants of bismuth are seen for many days after the bulk of it has been expelled. After a partial evacuation, the remainder of the barium or bismuth is often seen irregularly distributed through the bowel, and these local accumulations are not necessarily indicative of obstruction distal to them, nor of functional impairment. THE ABNORMAL COLON Position. — Other than the variations of position which may occur normally, definite displacements or anomalies of situation are sometimes encountered. In association with general visceral transposition, situs transversus of the colon is occasionally seen, the cecum and ascending colon lying on the left side, the de- scending colon on the right. In one of our cases the colon 444 THE LARGE INTESTINE alone was transposed. Most radiographers indicate one side of the plate with a leaden R or h, or habitually apply the Fig. 410. Fig. 411. Figs. 408, 409, 410, 411. — Normal colons. number to a certain side. Carelessness in this respect might be a source of error where plates only are made. Arrest of developmental migration may result in a high- placed cecum, or the entire colon may still lie to the left of the POSITION 445 vertebral column — so-called non-rotation. By failure of the cecum and ascending colon to rotate on their long axes, the ileocolic juncture may be found on the outer aspect of the cecum, instead of the inner. Displacement of any part of the colon may be produced by extrinsic tumors of every sort, including those of the liver, kidney, pancreas, spleen, uterus, and adnexse, by adhesion bands, by pregnancy and by psoas abscess. Displacements Fig. 412. — Coloptosis. commonly affect only those portions of the colon which are more or less movable normally, the hepatic flexure being occasionally, and the splenic flexure rarely, impUcated. Whatever may be the final adjudication of the much mooted question of ptosis and its importance, it can hardly be doubted that this term has been abused in connection with the colon, and especially its transverse portion. With a little increase of its length, the transverse colon may easily have its middle portion down in the pelvic basin, whether its possessor be asthenic or not, and to label this condition as ptosis is certainly 446 THE LARGE INTESTINE unfair. On the other hand, there may be marked, evident and actual displacement downward of the colon, and the position of the flexures is a better criterion of this than the position of the transverse colon. The hepatic flexure may be well below the ihac crest and even the splenic flexure may be sUghtly dropped, although this is quite uncommon. In decided enteroptotics nearly the entire colon may be huddled together in the pehic basis (Fig. 412). In judging position, apparent displacement due to obliquity of the rays must be borne in mind. Contour. — Irregularities of contour — filhng-defects — may be produced by intrinsic tumors, diverticuhtis, or bands of ad- hesions. Apparent filling-defects may be caused by fecal miatter, fecaliths, gas, localized spasm, extrinsic tumors, insuflB.- cient quantity of the enema, or the pressure of adjacent bony parts such as the spine and pelvic brim. The coils of the sigmoid farthest from the screen or plate often seem vaguely shadowed. ^Movement of the patient or shght shifting of the bowel may make what seem to be fiUing- defects on the plate. Sharp angulation may be due to actual kinking; more often, however, it will be found that this appearance is due to the angle at which the loop is viewed. According to Jordan," the points of election for kinks in the colon are the hepatic flexure, the proximal portion of the transverse colon, and the sigmoid. Hertz ^^ has seen but one case of kinking with partial obstruc- tion and this was located at the splenic flexure. He also cites a case of Frank's in which a mobile left kidney adherent to the splenic flexure caused a kink of the latter. Mobility. — Abnormally increased mobility of the cecum and ascending colon has been noted in the cecum inohile et atonicum of Wilms in association with tenderness and dilatation. With increased length of any segment between suspension points, there is a corresponding increase of its mobihty. Diminished mobility even to complete fixation is a common sequence of adhesion-producing pericohc inflammations. More or less fixation of the cecum may be the result of appendicitis, PEKISTALSIS • 447 tuberculosis, pelvic conditions or malignancy. In cases of so-called Jackson's membrane, the proximal half of the trans- verse colon has been found ptosed and parallel with the ascend- ing colon and inseparable from it. Adhesions from a peri- cholecystitis or a perforating duodenal ulcer may more firmly anchor the hepatic flexure or attach it to the pyloric end of the stomach. Carcinoma of any part of the bowel, whether primarily intrinsic or extrinsic, may fix it. The sigmoid flexure may be fixed by pelvic inflammations of any sort. In regard to adhesions generally — and this applies not only to the colon but to the entire gastro-intestinal tract — it may be said that one of the hardest lessons the roentgenologist has to learn is that juxtaposition of the viscera does not necessarily mean that they are adherent to each other, but, on the contrary, are rarely so. In repeated instances, when we suspected ad- hesions, or when the diagnosis of adhesions had been made by others, surgical exploration has shown either no trace of them, or, if found, they were not where they were surmised to be. The diagnosis of adhesions or their emphasis in a roentgenologic report, is not, as a rule, highly appreciated by the surgeon or internist. Both are likely to feel that a serious pathologic process should show x-ray evidence other than adhesions, and if the roentgen examiner finds little or nothing else, he lays himself open to the criticism either of lacking thoroughness or of avoiding a specific diagnosis. Cases in which a laparotomy has been done previously, often show adhesions — so often that their roentgenologic discovery is not edifying to the surgeon. Peristalsis. — Since there is a lack of definite knowledge as to the normal peristalsis of the colon other than a general agree- ment that forward movements en masse occur at infrequent intervals, also little is known regarding peristalsis in disease. Jordan has seen increased speed of the massive movement and a greater distance traversed in diarrhea and with the enema. Case^^ noted "exaggeration of normal antiperistalsis" in car- cinoma. Schwarz has observed stenotic hyperperistalsis with carcinomatous stricture at the hepatic flexure. 448 THE LARGE INTESTINE Length and Diameter. — Increased length of the colon, the redundancy being usually most marked in the sigmoid and transverse portions, is a relatively common finding in consti- pated persons. Such redundancies are also found, however, in colons which functionate normally. Since the longitudinal muscle-fibers are largely collected into the tenia, it is obvious that the tone condition of the tenia has much to do with the length and position of the colon at a given moment. Considered in this way, it may be that so-called redundancy is often merely an expression of atony. Redundancy of the sigmoid with dilatation (megasigmoid) has been observed occasionally. In congenital idiopathic dilatation of the colon (Hirschsprung's disease) the immense dilatation throughout is strikingly shown by the x-ray. Dilatation of the cecum, ascending and trans- verse portions, with evident loss of tone, is not infrequently^ noted. Dilatation of anj^ part of the colon, proximal to a stenosis, may be evident. Hypertonic or spastic narrowing of the colon, particularly in its transverse, descending and sigmoid portions, is noted occasionally in cases of constipation, but it may accompany a colitis with frequent stools. A narrow unhaustrated colon is often seen in cases of granular or ulcerative colitis. Motility. — Hypermotility of the colon is seen typically in association with non-obstructing gastric carcinoma, in which condition the head of the meal may be in the descending colon or even the ampulla in six hours. Hypermotility with similar but usually less marked advancement is also seen in duodenal ulcer, achylia and diarrheic conditions. Hypomotilrty with decidedly slow progress of the meal through the colon, may be due either to organic obstruction or merely to functional im- pairment. Retention of all or the greater part of the meal in the colon after forty-eight hours may be regarded as possibly signifi- cant of obstruction or grave functional disturbance, but further conclusions should not be drawn from this fact alone. EEFERENCES 449 REFERENCES 1. Haenisch, G. F. : "The Roentgen Examination of the Large Intestine." Ar^ch. Roentgen Ray, 1912, xvii, 208-15. 2. HoLZKNECHT, G. : " Die normal Peristaltik des Colon." Miinchen. Med. Wchnschr., 1911, ii, 2401-3. 3. Jordan, A. C.: "The Peristalsis of the Large Intestine." Arch. Roentgen Ray, 1914, xviii, 328-9. 4. ScHWARZ, G. : "ZuY Physiologie und Pathologie der menschlichen Dickdarmbewegungen." Miinchen. Med. Wchnschr., 1911, ii, 1489-94. 5. ScHWARZ, G.: "Zm" genaueren Kentniss der grossen Kolonbewe- gungen." Miinchen. Med. Wchnschr., 1911, ii, 2060-63. 6. ScHWARZ, G.: "Klinische Roentgendiagnostik des Dickdarms." 1914, Springer, Berlin, 44 p. 7. Barclay, A. E. : "Notes on the Movements of the Large Intes- tine." Arch. Roentgen Ray, 1912, xvi, 422-24. 8. Hertz, A. F.: "Investigations of the Motor Functions of the Alimentary Canal by Means of the X-rays." Brit. Med. Jour., 1912, i, 225-29. 9. Holding, A.: "Observations of Cases of Constipation by Means of the Roentgen Rays." Am. Quart. Roentgenol., 1911, iii, 148- 51. 10. Jordan, A. C: "Radiography in Intestinal Stasis." Proc. Roy. Soc. Med., 1911 (Elect. Ther. Section), v, 9-37. 11. Hertz, A. F. : "Constipation and Allied Disorders." 1909, Frowde, London, 110. 12. Case, J. T.: " The Roentgenologic Findings in Malignant Obstruc- tion of the Colon." Lancet-Clinic, 1914, cxl, 216-19. 29 CHAPTER XXII CANCER OF THE COLON Precisely as in cancer of the stomach, the most important sign of cancer of the colon is the filling-defect — a local irregu- larity of contour produced by jutting of the growth into the intestinal lumen, by contracture of the infiltrated wall, and probably also to some extent by spasm aroused by the neoplasm. The irregularity may be rather sharply delineated, but is more often indefinitely shaded. Next in importance to the filling-defect is the presence of obstruction, the fact of which is alone highly significant, since acquired non-malignant stricture of the colon is exceedingly rare (Hertz). ^ The blocking may be evidenced by an accumu- lation and delay of the meal proximal to the stenosis, and by obstruction to the enema. It is noteworthy that the inflow of the enema is sometimes markedly or completely obstructed, when the passage of the meal is apparently hindered only slightly or not at all, and the patient gives no history of obstipation. This is probably due to a valve-like effect of the growth. Dila- tation of the bowel above the stricture is sometimes remarked. To these signs may be added the coincidence of a palpable tumor with the filling-defect or with the point of obstruction. In a few reported instances an exaggeration of peristaltic activity was noted proximal to the obstruction. Extension of the growth outside the bowel may occasionally result in evident fixation, but more often the normal mobihty of the intestine is not impaired. For eliciting signs of carcinoma, the combined screen and plate examination with the opaque enema is usually more con- venient and effective than examination with the opaque meal. 450 PSEUDO-FILLING DEFECTS 451 By the enema the entire bowel or that portion distal to a com- plete obstruction is visualized throughout at a single examination; filling-defects are more readily discovered, and the site of the ob- struction quickly determined. Where the latter is extreme, its proximal limits can be found by giving an opaque meal. A filling-defect due to carcinoma is characterized by its irregularity, its constancy upon all plates and at successive examinations, its permanence in spite of palpatory manipula- tion, and its persistence after the administration of anti- spasmodics. Its size will depend, of course, upon the extent of the growth, but in those patients whose symptoms are at all suspicious the lesion will nearly always be found of demonstrable proportions. The filling-defect may show as a concentric local narrowing of the lumen (napkin-ring carcinoma) or it may be unilateral. In some cases with marked obstruction the enema may terminate with a bluntly rounded, smooth contour at the site of the stenosis, while in others more or less tailing out may be seen. The filling defect of carcinoma is imitated by a variety of conditions. Among these are : 1. Gas. 2. Insufficient quantity of the enema. 3. Fecal matter. 4. Spasm. 5. Extrinsic tumors. 6. Pressure of bony parts. 7. Adhesions. 8. Diverticulitis, tuberculosis and other lesions of the intestine. Gas collections in the colon are relatively common and they sometimes produce filling-defects simulating those of an organic lesion. When gas accumulations are present they wiU usually be found in the proximal portion of the bowel, most often in the hepatic flexure, ascending colon or cecum. They can some- times be displaced by palpation during the screen-examination, 452 CANCER OF THE COLON may have a varying configuration upon successive plates and, as a rule, the outline of the bowel can be distinguished (Fig. 413). By failure to give a sufficient quantity of the enema the bowel may not be filled throughout, showing patches here and there resembhng filling-defects. The patches tend to shift about and are not very deceptive. By lack of thorough purgation and Fig. 413. — Gas in the colon near hepatic flexure; G, imitating the filling defect of cancer. cleansing, fecal matter may be left in the bowel and cause filling- defects. However, with the routine preparation previously described, this rarely occurs. Localized spasm of the colon may produce most vexing imi- tations of true filling-defects. Usually the affected segment is narrowed and shows fine, irregular haustra. Rarely, the spasm may completely obstruct the enema at the point in- volved. Figures 414 and 415 illustrate marked spasm of the transverse colon, a duodenal ulcer being found at operation. The sigmoid or descending colon, occasionally the transverse, PSEUDO-FILLING DEFECTS 453 Fig 414. — Obstruction of the transverse colon at (J, by ^pasm. pable mass. See Fig. 415. No corresponding pal- FiG. 415. — Same case as in Fig. 414. Colon patent after belladonna had been given. At operation a duodenal ulcer was found; colon negative. No roentgen ex- amination of the stomach and duodenum was made in this case. 454 CANCER OF THE COLON is sometimes intensely spastic and narrow, and, though filled with the enema, shows small, irregular haustration (Fig. 416). In all cases where spasm is suspected, the patient should be given belladonna to physiologic effect and the examination repeated. Extrinsic tumors by the thrust of their outline into the con- tour of the colon may rarely produce apparent filling-defects, especially in fixed portions of the bowel. As a rule, however, Fig. 416. — Marked spasticity of pelvic colon, S. such tumors do not alter the outline of the colon and their extrinsic situation is evident upon screen-examination. Pressure of the spine against the transverse colon may cause a seeming defect at this point, and a small apparent defect is often seen in the sigmoid flexure where it rises over the brim of the true pelvis, but such defects will hardly be taken seriously. Adhesions, when present, are usually about the cecum or pelvic colon. They may, but rather exceptionally, cause sharp irregular serration of the intestinal border, with more or less fixajtion, and occasionally may obstruct the bowel. REPORT OF CASES 455 Diverticulitis of the sigmoid, or other parts of the colon, by reason of the accompanying inflammatory thickening, may pro- duce obstruction and filling-defects resembling those of cancer. When the characteristic extra-lumenal, barium-filled diverticula can be discerned, the diagnosis is apparent, but sometimes the sacculations are not clearly seen as such and roentgenologic distinction from cancer is impossible. Filling-defects with or without a palpable tumor or obstruc- tion, involving the cecum and ascending colon, should not be too hastily interpreted as cancer, since these signs may be pro- duced by tuberculosis, which is a rather frequent lesion in this part of the colon. Purely roentgenologic differentiation of the two conditions cannot be made, but the clinical features may be decisive. An extensive appendiceal abscess may distort the cecum and ascending colon and be felt as a mass. Here the elementary clinical facts should at least put the examiner on his guard. Other lesions may also produce filling-defects or obstruction, or a palpable tumor, and thus show a roentgenologic similarity to cancer. Included among these are various benign tumors, polypi, syphilis, actinomycosis, and cicatricial stricture from ulcer. These lesions are all relatively infrequent. Their differentiation from cancer of the bowel would require careful weighing of all the facts, both clinical and roentgenologic. Case 86,304, female aged 53 years. For thirty years she has had hemorrhages from the bowel intermittently. These have been less frequent during the past two years. A year ago she had a dysentery with very frequent stools which at times showed bright red blood. Since then she has had diarrhea, off and on. Dm'ing the past few months she has had pain under the left costal margin in the axillary line. Her bowels are always loose, with much gas and distress. Weight loss, 45 pounds in one year. Marked prolapse of anus and internal hemorrhoids. Hemoglobin 65. Wassermann negative. Roentgen findings: Annular filhng-defect, with extreme narrowing of lumen in descending colon near splenic flexure (Fig. 417). Notwith- standing the great local narrowing, the entire bowel filled readily with the enema and without complaint on the part of the patient. Findings 456 CANCER OF THE COLON Fig. 417. — Case 86,304. Napkin-ring carcinoma of colon. Filling defect and nar- rowing, F. D. Photograph of specimen Fig. 417o. Fig. 417a. — Case 86,304. Photograph of specimen. REPORT OF CASES 457 at operation: Napkin-ring carcinoma, splenic flexure of colon, deeply situated and very adherent. Some glandular involvement. Opera- tion: Exsection (Mikulicz). Pathologist's report: Carcinoma (Photo- graph of specimen, Fig. 417a). Case 130,337, female aged 40 years. Chronic diarrhea for six years, with four to six watery stools daily, and cramping abdominal pain. With this there has been a slowly progressive weakness. Weight loss, 12 pounds. Nodular, tender mass, right abdomen, below costal margin. Free fluid in abdomen; ankles swollen. Hemoglobin 30. Stools show endameba histolytica. Roentgen findings: Gross filling- FiG. 418. Case 130,337. Carcinoma of the right half of the transverse colon. Filling defect, F. D. defect, transverse colon, near hepatic flexure, corresponding to a pal- pable mass (Fig. 418). Findings at operation: Large carcinomatous tumor of hepatic flexure, the size of a grapefruit. Second tumor, middle of transverse colon, adherent to gall-bladder. Ileum adherent to tumor. Operation: (1) Resection cecum, ascending colon, hepatic flexure and three-fifths of transverse colon. Murphy button anas- tomosis, end to side. Cholecystectomy. Pathologist's report: (1) Tumor of hepatic flexure, carcinoma. (2) Small tumor of transverse, inflammatory, (3) No glandular involvement. (4) Catarrhal cholecystitis. 458 CANCER OF THE COLON Case 157,410, male, aged 31 years. Since an attack of grippe more than two years ago he has not been entirely well. About a year ago he noticed jaundice, itching of skin and progressive weakness. Five months ago he had a chill, high fever, severe pain in lower abdomen, nausea and vomiting. He was in a hospital for three weeks, and was told that he had "peritonitis caused by rupture of the intestine." After leaving the hospital he gained in weight on a selected diet, but had a continuous dull ache and occasional sharp pain in the lower abdomen. Bowels regular, with cathartics. In the past month he has had more abdominal soreness and has grown weaker. He thinks that he may have passed very small amounts of dark blood in the stools. Weight loss, 22 pounds in five months. Firm, irregular tumor in cecal region. Lower abdomen tense and distended. Probably some ascites. Rectal shelf apparently free. Hemoglobin 35. Roentgen-ray of chest negative. No local reaction to tuberculin subcutaneously. Roentgen findings: Annular filling-defect of ascending colon corresponding to pal- pable mass (Fig. 419). Findings at exploration: Large tumor of cecum and ascending colon, adherent over large surface of parietal perito- neum. Nodules extending into peritoneum and mesentery. Specimen excised for microscopic examination. Radical operation not indicated on account of extent. Pathologist's report: Adenocarcinoma. Case 146,918, male, aged 54 years. Ten weeks ago he began to have diarrhea with four or five stools daily and colicky pain. The pain has subsided but he still has tenderness in the left lower abdomen. For a week he has been using saline enemata daily and the diarrhea has lessened, but there is still tenesmus and frequent desire to stool, with scant results. He has passed blood several times after stooling during the past two weeks. No weight loss. Hemoglobin 88. Tender movable mass, size of an egg, in left abdomen at level of iliac crest. Complete fistula in ano. Roentgen findings: The roentgenogram shows two filling-defects; one low in the descending colon, the other in the sigmoid (Fig. 420). Findings at operation: Double carcinoma; one of napkin-ring type in descending colon; the other in the sigmoid. Operation: Mikulicz. Pathologist's report: Carcinoma. Case 107,182, female, aged 44 years. Notwithstanding a good appetite and maintenance of weight the patient has not been well for a year, complaining chiefly of nervousness and insomnia. A month ago she began to have attacks of epigastric pain becoming general over the abdomen, followed by a loose watery stool and relief. She may have two or three of these attacks daily; no relation to meals. To-day, for the first time she noticed a few streaks of bright blood in the stool. Until a month ago she was always constipated; now has two passages REPORT OF CASES 459 Fig. 419. — Case 157,410. Filling defect, ascending colon, F. D. Annular carcinoma. Appendix visible, A. Fig. 420. — Case 146,918. Filling defect low in the descending colon, also in the sigmoid, F. D. 460 CANCER OF THE COLON Fig. 421.— Case 107,182. Filling defect of cecum, F. D. Carcinoma. Fig. 422.— Case 144,665. Filling defect of cancer, F..,:D. REPORT OF CASES 461 Fig. 423.— Case 80,026. Obstruction to enema at 0. Fig. 424. — Case 80,026. Roentgenogram after ingested meal. Filling defect, F. D. 462 CANCER OF THE COLON daily. At an examination two weeks ago, elsewhere, a mass was found in the right abdomen. Weight loss, 18 pounds in one and a half years. Hemoglobin 60. Tumor in cecal region, size of a goose- egg, rather fixed. Roentgen findings: Filling-defect of cecum corre- FiG. 427 Fig. 428. Figs. 425, 426, 427, 428. — Cancer of colon, producing either obstruction, O, or a filling defect, F. D., or both. sponding to a palpable mass (Fig. 421). Findings at operation: Carcinoma of ileocecal coil and ascending colon. Large tumors in mesentery of small intestine along spine. Free fluid. Liver not in- volved. Operation: Ileocolostomy. Case 144,665, female, aged 44 years. Up to ten months ago she was EEPORT OF CASES 463 in general good health, but since then she has had no appetite and has a little discomfort from gas three or four hours after meals. During the past two or three months her bowels have been loose, with three or Fig. 429. Fig. 430. Fig. 431. Fig. 432. Figs. 429, 430, 431, 432. — Cancer of colon, some showing only obstruction, O, others a filling detect F. D. four stools daily, and these have occasionally show^n small clots of dark blood. She has an indefinite ache in the lower abdomen which she thinks is of ovarian origin. General strength poor. Weight loss, 15 pounds in nine months. Hemoglobin 35. Wassermann negative. 464 CANCEE OF THE COLON Abdomen hard and resistant throughout, especially lower right, where an irregular hard mass can be felt. Pelvis negative save for small cervical polyp. Roentgen findings : Annular filling-defect with marked narrowing of lumen in right half of transverse colon, with palpable Fig. 43.5. Fig. 436. Figs. 433, 434, 435, 436. — Cancer of colon. O, obstruction. F. D., filling defect. tumor (Fig. 422). No roentgen examination of stomach requested. Findings at exploration: Tumor the size of an orange, in transverse colon, involving and penetrating posterior wall of stomach. Glands and omentum involved and adherent to abdominal wall. Tumor in liver. Lumen of bowel permits invagination of finger past tumor. REPORT OF CASES 465 Case 80,026, male aged 37 years. Five months ago he suddenly developed diarrhea with griping pain. The stools, which were four or five in number daily, contained mucus, but no blood. The diarrhea ceased after two months and was followed by constipation which has Fig. 439. Fig. 440. Figs. 437, 438, 439, 440.— Cancer of colon. O, obstruction. F. D., filling defect. Photograph of specimen in corner of roentgenogram. continued since. He is obliged to take cathartics and has gone for a week without stooling. When the bowel does not move he has general abdominal soreness. Normal weight 165; present weight 135. Defi- nite thickening felt in left iliac fossa. Proctoscopic examination 30 466 CANCER OF THE COLON negative. Cystoscopy shows edema of bladder-wall and bladder seems dragged upward. Roentgen findings: Marked obstruction to enema low in colon (Fig. 423). The ingested meal shows a filling- defect throughout a considerable extent of the descending colon and sigmoid (Fig. 424). Findings at exploration: Tumor of sigmoid, probably malignant. The growth is about 7 inches long, and is fixed to the bladder and to the pelvis in the vicinitj^ of the left ureter. Inoperable. REFERENCE 1. Hertz, A. F. : "Constipation and Allied Intestinal Disorders." H. Frowde, London, 1909, 359. CHAPTER XXIII DIVERTICULITIS According to McGrath/ Graser^ in 1899 was the first to demonstrate the association of acquired diverticula with '^iso- lated, circumscribed adhesive peritonitis" on the colon, the latter condition having been mentioned by Virchow in 1853. Although not of common occurrence as compared with other lesions of the large bowel, diverticulitis is met with sufficiently often to require its consideration in many cases with symptoms referable to the colon. Thus as early as 1907, Mayo, Wilson and Giffin^ were able to report 5 cases operated on in the Mayo Clinic and in 1912 Giffin'^ collected 27 such cases, in 17 of which there was involvement of the sigmoid. McGrath,^ in his very complete review of the pathology, has brought out the following facts: Nearly all these diver- ticula are of the ''false" type, that is to say, they are hernia of the mucosa through the muscularis, commonly at points where the latter is penetrated by vessels. They are found most fre- quently in the sigmoid. The chief causes are weakness of the muscularis with an increase of intra-intestinal pressure, such as occurs in stasis and gas formation. Diverticula vary in size from that of a pea to a hen's egg. They are usually round or ovoid, and most often sessile, though occasionally pedunculated. The opening into the bowel may be narrow and practically stenosed, or it may be almost as wide as the diverticular cavity. The sacs usually contain fecal matter and sometimes fecaliths. Histologically, the sac-wall is made up of mucosa, submucosa and serosa, the muscularis being slight or wanting. The mucosa may be slightly atrophic or even ulcerated, but the most con- stant pathologic process is the chronic, proliferative extramucosal inflammation, the "peridiverticulitis" of Wilson, with round-cell infiltration, which results in mass formation. 467 468 DWERTICULITIS Prominent features of the symptomatology, as described by Giffin, are the following: The proportion of males to females appears to be 2 or 3 to 1. An incUnation to obesity is noted almost without exception; the patients are of sound flesh with good color, and where loss of weight occurs, it is only slight. Abdominal pain, usually of considerable severity, is the rule. Often the patient is able to localize the pain to the sigmoid or descending colon. Constipation is complained of by the majority and is often of more than moderate severity. Vesical symptoms, such as urinary frequency and tenesmus, are occa- sionally noted. In every instance of diverticulitis of the sig- moid, a mass was felt in the left lower quadrant or in the pelvis. The proctoscopic examination is likely to be negative unless the tumor has intussuscepted into the rectum. Absence of blood from the stools is notable and this is explained by the fact pointed out by Wilson^ that the inflammatory process is primarily extramucosal, and the condition is really a peridiverticulitis. In the presence of these symptoms the differential diagnosis becomes a matter of importance. One condition which must be eliminated is that of left-sided appendicitis. Here the roent- genologic examination would be decisive by showing the posi- tion of the cecum. The most difficult differentiation is from carcinoma. While the symptoms are not typical of carcinoma, they do not absolutely exclude it. Indeed, Wilson^ has shown that carcinoma may develop from diverticula. The question arises as to what can be expected from the x-ray. In 1914, Abbe^ reported a case of sigmoid diverticulitis in which a roentgenologic examination had been made by Le Wald. A bismuth enema showed only a narrowing of the sigmoid. Later a bismuth meal was given and radiographs taken up to the tenth day showed the constant presence of small round spots in the vicinity of the sigmoid, long after both enema and meal had been evacuated. The shadows admitted of but one explanation, namely, bismuth fluid retained in the diverticula. Our experience with the cases hereinafter described indi- cates that, in some instances at least, the roentgen signs of REPORT OF CASES 469 diverticulitis are more or less characteristic, follows : The cases are as Case 99,640, male, aged 55. Examined January 26, 1914. Family and personal history negative. Gall-stones (passed one); severe cholecystitis and peritonitis fifteen years ago. Twelve years ago he was operated on for left inguinal hernia and hemorrhoids. Clinical history: Post-operative abscess followed previous operation with Symptoms of cystitis. The abscess developed around the ligature later, Fig. 441. — Case 99,640. Roentgenogram of bariuni-filleci colon (enema), showing marked filling defect in sigmoid with extralumenal shadows (diverticula) D, which was passed by urethra. Since then the patient has had symp- toms of bowel obstruction, the last time in December, 1913, one attack five years prior to this. There were left-sided griping and gas pains with much distention. At one time the bowels did not move for eight days; ordinarily, however, they moved regularly. Apparent lump and soreness in left iliac fossa with pressure affecting the bladder. Pencil stools before last attack. The patient returned to his home, and prior to his operation, March 17, 1914, suffered several obstructive 470 DIVERTICULITIS attacks, with flatulence, rumbling and stinging pain over the pubis and left side during bowel movement. Sensation of ''something pushing up from rectum" when in sitting posture. Some weight fluctuation Fig. 442. — Case 99,640. Longitudinal section through sigmoid, showing multiple diverticula with marked thickening of intestinal wall and narrowing of lumen. A, mucosa; B, diverticula, containing fecaliths; C, canal leading to diverticular sac. A Fig. 443. — Cross section of wall of normal sigmoid, photomicrograph, magnified four times, showing normal mucosal fold. Note that this fold does not penetrate the musculature. A, mucosa. B, mucosal fold. C, [submucosa. D, musculature. E, subperitoneal fat. F, peritoneum. but the greatest loss at any one time was 12 pounds. Urine negative. Roentgen examination: January 27, 1914, patient was examined in the routine way by barium enema. Roentgenograms showed an irregular REPORT OF CASES 471 filling-defect with marked narrowing in the sigmoid. Small barium shadows were observed outside the lumen of the bowel, an appearance quite unusual, and at that time inexplicable (Fig. 441). From the Fig. 444. — Cross section of wall of sigmoid, photomicrograph, magnified four times. Shows mucosal fold and submucosa separating the circular muscular fibers and penetrating to the longitudinal musculature. An early diverticulum of this type can hardly be demonstrated radiologically because of the absence of flask-like dilata- tion. A, mucosa. B, diverticulum. C, circular muscle fibers. D, subperitoneal fat. E, peritoneum. f" £ Fig. 445. — Cross section of wall of sigmoid, photomicrograph, magnified four times. Deep seated, late stage diverticulum with flask-like ampulla. The diver- ticulum has separated the circular fibers which are here seen compressing the neck, passed through the longitudinal bands of muscle and penetrated into the subperitoneal fat. This advanced type offers the greatest opportunity of radiologic demonstration because of its capacity and the distance from the intestinal lumen. A, mucosa of bowel. B, canal leading into diverticular cavity at C. D, musculature, E, subperitoneal fat. F, thickened peritoneum. clinical facts and the roentgen appearance, W. J. Mayo suggested to the patient that the condition might be diverticulitis. Findings at operation (March 17, 1914) : Diverticulitis of the sigmoid. Bowel 472 DIVERTICULITIS exceedingly thick and adherent to pelvic wall posteriorly; about 14 inches of bowel involved. Operation: Mikulicz. Pathologist's re- port: Tissue removed, sigmoid. Diagnosis: Diverticulitis (Fig. 442). Case 105,595, male, aged 51. Examined May 7, 1914. Family and personal history negative. Denies any previous disease. Appen- dectomy elsewhere, without any exploration. Clinical history: For ten years he has been constipated. In the past two years he has Fig. 446.— Case 105,595. Barium-filled colon (by enema) with extra lumenal shadows (diverticula) at A. noticed a sore lump in the left lower abdomen which has been asso- ciated with an increase of constipation. On two occasions this lump became swollen and very tender. In December, 1913, he had a chill with fever, and griping pain with gas, marked swelling and soreness at the spot complained of. Recent similar attack four days ago. Stools small and tapered, necessitating laxatives, but no blood or pus noted. When the lump is swollen, the patient urinates frequently with some pain. General health good. Weight loss, 5 pounds. Phj^sical examination: Tenderness and resistance in lower left abdomen. Rounded elongated mass felt by bimanual examination. Rectum seems negative aside from small hemorrhoids. Proctoscopic examina- REPORT OF CASES 473 tion : Negative. Roentgen findings : Negative save for slight enlarge- ment of cecum. At the same time small shadows were noted outside the sigmoid lumen, but their significance was not at that time appre- ciated (Fig. 446). Findings at operation: Diverticulitis of sigmoid. Operation: Mikulicz. Pathologist's report : Tissue removed, sigmoid. Diagnosis: Diverticulitis (Fig. 447). Case 107,983, male, aged 49 years. Examined June 12, 1914. Previous history unimportant. Catarrhal jaundice four years ago, with epigastric pain. He denies lues or gonorrhea. Clinical history: Present trouble began six weeks ago with gas in the lower bowel and Fig. 447. — Case 105,595, Cross section of diverticulum, photomicrograph, magni- fied four times. A, mucosa of sigmoid. B, neck of diverticulum (not well shown on account of depth at which section was cut), extending from lumen of sigmoid through circular muscular fibers to diverticular sac at C D, subperitoneal tissue. E, peritoneum. Note that mucosal lining of the diverticulum is like that of the sigmoid, and it differs in this respect from the inflammatory pockets produced by perforating ulcer of the stomach which are often, but wrongly, spoken of as diverticula. sharp, shooting pain in the left lower abdomen, passing to the hypo- gastrium, intermittent in character and relieved spontaneously or by flatus. Attacks come only if he gets a ''cold," and last four or five days; he has had three or four seizures in all. During the intervals there is some discomfort from gas, which, although there are no dis- tinct vesical symptoms, "interferes somewhat with the bladder." He has lost some weight on diet. He has been constipated and used laxatives for years. He has had occasional tenderness in the region complained of during the past six weeks. Physical examination: Mass in the sigmoid area, not now tender. Prostate slightly enlarged, otherwise negative. Small hemorrhoids. Roentgen findings (after opaque enema) : Filling-defect in upper sigmoid. Marked spasticity of transverse, descending colon and sigmoid (Fig. 448). A reray 474 DIVERTICULITIS after the administration of belladonna, was suggested but could not be obtained. This request was made because of the great amount of spasm noted, which had to be considered as a possible cause of the sig- moid deformity, although a lesion was strongly suspected. In the absence of a reray no attempt was made to carry the diagnosis further. Operation: A tumor of the sigmoid about 10 inches in length, exten- sively adherent to the lateral wall of the pelvis in the vicinity of the common iliac vein was removed (Mikulicz operation). Pathologist's report: Diverticulitis. Fig. 448.- -Case 107,983. Filling defect of sigmoid with extralumenal shadows — barium-filled diverticula — at A. Case 109,311, man, aged 54 years. Operation two years ago else- where; gastro-enterostomy for duodenal ulcer and excision of small growth from the ileum, microscopically cancer. He was completely relieved until two weeks ago when, following indiscretion in diet, he had cramping pain in the left iliac fossa, becoming generalized over the abdomen. The pain lasted about three days, and the patient has gradually grown better, though his appetite is poor, and there is some loss of weight and strength. Constipation; some mucus in stools. During the past two days he has had burning with micturition and nocturia which he never had before. Weight loss, 10 pounds. Oblong, REPORT OF CASES 475 firm, movable mass in left pelvis felt on bimanual examination. Hem- oglobin 86. Roentgen findings: Irregular obstruction of sigmoid (Fig. 449). Findings at operation: Carcinoma lower sigmoid, 10 inches above rectum, involving 4 inches of sigmoid. Obstructing tumor, probably developing on diverticula. Adhesions to bladder and left ureter. Operation: Mikulicz. Pathologist's report: (1) Diver- ticulitis. (2) Carcinoma on diverticulitis. Fig. 449. — Case 109,.311. Obstruction at O. Case 147,966, man, aged .52 years. One year ago he had a brief attack of shght pain and soreness in left iliac fossa. Three weeks ago he had cramps in the lower abdomen, followed by a little fever and some soreness in the left iliac fossa. By taking Russian oil he has fairly soft movements, but these are accompanied by pain in the left lower quadrant and some cramping in the rectum. He is afraid to eat solid food because of the increased pain when heavy fecal matter reached the sore area. He noticed a little irritation of the bladder when the present attack began. Underweight 20 pounds. Tenderness and sense of mass low in left quadrant. Roentgen findings: Diverticulitis of sigmoid (Fig. 450). Findings at operation: Tumor of the sigmoid just at the pelvic brim, about 4 inches in length, closely attached to the pelvic wall, with an abscess in the mesentery containing thick pus. Pathologist's report: Diverticulitis. 476 DIVERTICULITIS Fig. 450.— Case 147,966. Involved area at D. Fig. 451.— Case 143,262. Obstruction at O. REPORT OF CASES 477 Case 143,262, man, aged 35 years. Two years ago he had slight pain in the left abdomen radiating across navel. Recovery in two days. Since then he has been well until sixty days ago. At that time he was abroad and suffered a severe attack, lasting four weeks. The attack was accompanied by fever, and a very small amount of blood was noticed in the stool at one time. His physician could feel a tumor the size of a fist in the left lower quadrant, and made a diagnosis of diverticulitis of the sigmoid. This seemed to be confirmed by bis- muth plates of the bowel. Under treatment with castor oil and diet the swelling diminished and since returning to this country, he has felt fairly well, save for some ''weakness" in the left side. His bowels are constipated. Micturition usually normal, but there was some pain with urination during his attack. Weight loss, 5 pounds. Area of resistance in left lower quadrant; question of a mass. Roentgen find- ings: Obstruction of the sigmoid, with marked spasticity above and below the point of obstruction (Fig. 451). Findings at operation: Tumor of the sigmoid — diverticulitis? carcinoma? — perforating and adherent to parietal peritoneum at brim of pelvis. Tumor mass about 5 inches long, loosened with difficulty. Operation: Mikulicz. Pathologist's report: No diverticulitis or carcinoma found. (The specimens examined had become necrotic. C. H. Mayo considered the case one of diverticulitis.) The outstanding roentgenologic feature of the above cases is the demonstration in some of them of oval or rounded shadows projecting from or lying outside the intestinal lumen, and repre- senting the barium-filled diverticula. Such shadows in con- junction with narrowing and defective filling of the bowel would seem pathognomonic of diverticulitis. While a carcinoma might show more or less apparent pocketing, such pockets are not likely to have the rounded symmetry of diverticula. In the in- stance of carcinoma supervening upon diverticulitis, if rounded extra-lumenal shadows were present, the lesion could not be dis- tinguished from a benign diverticulitis, while if these shadows were not present the case would probably be regarded simply as one of carcinoma. The possibility should be borne in mind that by reason of a stenotic inlet, or the extremely small size of the diverticula, or because they contain fecal matter, they may fail to fill with the clysma. In this event there is seen only a filling or obstruction 478 DR'ERTICULITIS defect proportioned to the extent of inflamniatory thickening and not distinguishable roentgenologically from that of carcinoma. As to the chance of a fecaUth being seen, that would depend upon its size., density and situation. It is also quite possible that sufficient barium may enter a diverticulum containing a f ecaUth to make the sac visible. Diverticular shadows may be imitated hj phleboliths, calci- fied glands, renal and ureteral calculi, and occasionally by barium Fig. 452. — At operation a diverticulitis was found in the sigmoid, A careful examination of the transverse colon failed to discover anj' diverticula in this part of the bowel. The extralumenal shadows at B are probably due to barium in con- tracted haustra. pent up in contracted haustra. By manipulation during the screen-examination or making plates at different angles it may be possible to show that shadows of the concretions mentioned have no relation to the bowel. Plates made before giving the enema or meal would be decisive. Haustral shadows sometimes resemble those of diverticula, as shown in Fig. 452, where they appear to be detached from the lumen of the bowel. Some differential points are : REPORT OF CASES 479 1. Haustral shadows are not accompanied by a filling-defect in that portion of the bowel, while diverticular shadows may be thus accompanied. 2. Haustral shadows tend to disappear or change their situa- tion. The change may not be rapid and the screen examina- FiG. 456. Fig, 455. Figs. 453, 454, 455, 456. — Diverticulitis of pelvic colon. Involved area at D. tion should be sufficiently prolonged or plates should be made at intervals long enough to permit this change of situation. Diver- ticular shadows maintain a fixed position, and may persist after 480 DIVERTICULITIS the bowel is emptied or partially emptied. For this reason, an examination after evacuation of the colon may strengthen the diagnosis. Although Le Wald's case indicates otherwise, the liquid opaque clysma introduced under some pressure, after purgation and a cleansing enema, is probably more efficient than the meal in demonstrating surgical diverticulitis and is more convenient. Portions of the meal tend to scatter in small masses and these may be confounded with diverticula. However, there can be no objection to using both meal and enema. Since the shadows of diverticula may be overlapped by the barium in the bowel at certain angles of view, the examination should be made with the patient in various positions. Stereo- scopic ^plates may sometimes give additional assistance. REFERENCES 1. McGrath, B. F. : "Intestinal Diverticula; Their Etiology and Pathogenesis." Surg., Gynec. and Ohstet., 1912, xv, 429-444. 2. Graser, E. : "Das falsche Darmdivertikel." Arch.f. klin. Chir., 1889, lix, 638-647. Quoted by McGrath, loc. cit. 3. Mayo, W. J., Wilson, L. B. and Giffin, H. Z.: "Acquired Diverticulitis of the Large Intestine." Surg., Gynec. and Ohstet., 1907, V, 8-15. 4. GiFFiN, H. Z. : "The Diagnosis of Diverticulitis of the Large Bowel; a Clinical Review of Twenty-seven Cases." Jour. A.M.A., 1912, lix, 864-866. 5. Wilson, L.B.: "Diverticula of the Lower Bowel: Their Develop- ment and Relationship to Carcinoma." Annals of Surgery, 1911, liii, 223-231. 6. Abbe, R. : "A Case of Sigmoid Diverticulitis Simulating Malig- nancy; Demonstrated by Radiograph; Operation and Speci- men." Med. Rec, 1914, Ixxxvi, 190-191. CHAPTER XXIV TUBERCULOSIS OF THE COLON Though much less common than cancer, tuberculosis of the large bowel occurs sufficiently often to be of practical interest. Pathologically, the tuberculous lesions may be either of the ulcer- ative or hyperplastic type, or combinations of the two. Distal segments of the bowel are seldom invaded, the disease nearly always involving the proximal portion, especially the ileocecal valve, cecum and appendix, and ascending colon (Brunner^). The terminal ileum is frequently implicated. The condition is usually secondary to pulmonary tuberculosis. Appended are the histories with roentgenologic findings in four cases of cecal tuberculosis. Filling-defects or obstruction, with a corresponding palpable mass, constituted the chief findings. These, of course, are identical with the manifestations of cancer, so that strictly roentgenologic differentiation is impos- sible. However, when these signs are localized to the cecal region the examiner should at least be chary of a diagnosis of cancer without investigating the clinical history and examining the lungs by the x-ray. Case 149,397, woman, aged 52. Ten years ago she had a surgical exploration for a tumor of the right lower abdomen. She was told that it was sarcoma ; resection was not done. For a year subsequently she was treated with the x-ray. About six months after the explora- tion an abscess formed in the region of the scar and was opened. This has recurred once or twice since. She thinks the tumor has increased slowly in size, but no definite increase lately. For three months she has had diarrhea with one to four stools daily. Some irritation of bladder recently. Weight loss, 24 pounds in two years. Hemoglobin 60. Hard irregular mass in right iliac fossa. Roentgen findings: Enema obstructed in upper ascending colon, entire cecal region unfilled (Fig. 457). Findings at operation: Hyperplastic tuberculosis of cecum, forming a large tumor with a fistula, involving the entire cecum 31 481 482 TUBERCULOSIS OF THE COLON and ascending colon. Ileum involved on peritoneal and submucous coats for about 1 foot. Glands involved; some localized peritonitis in vicinity. Right Fallopian tube implicated. The growth is 4 inches in diameter and 8 inches long, filled with scar tissue. Operation: Resection of the right Fallopian tube, 12 inches of the ileum, appendix, cecum, ascending colon, hepatic flexure and part of the abdominal wall about fistula. Anastomosis with Murphy button, end to side. Pathologist's report : Tuberculosis with glandular involvement. Case 161,981, man, aged 28. Appendectomy three years ago. Fourteen months later, resection of portions of small and large bowel for "tumor and partial obstruction." Previous to the first operation Fig. 457.— Case 149,397. Cecal Fig. 458.— Case 161,981. Cecal tu- tuberculosis. Obstruction at O. berculosis. Obstruction and filling de- fect at F. D. he had three attacks of severe cramping pain in the right lower abdo- men with nausea. After the first operation he had similar attacks but less severe. After the second operation he was well for eleven months, then attacks recurred with nausea and vomiting, coming at first at intervals of one to three weeks, now almost daily. For six months he has noticed a mass in the right iliac fossa. Hacking cough for two or three years; rarely raises anything. Weight loss, 21 pounds in six months. Hemoglobin 79. Moderately movable mass in right iliac fossa. Roentgen examination of chest shows diffuse tuberculosis of both lungs. Roentgen findings: Concentric filling defect of cecum, corresponding to an obstructive mass (Fig. 458). Findings at opera- tion: Large tuberculous tumor of the cecum, involving about 1 foot of the terminal ileum. Many tuberculous areas throughout the colon, REPORT OF CASES 483 chiefly in the right half. Operation: Resection of the right half of the colon. Low ileosigmoidostomy by suture. Pathologist's report: Tuberculosis. Case 111,425, woman, aged 32 years. Shortening of round liga- ments and perineorrhaphy six weeks ago, elsewhere. At that time a growth involving the cecum was found. A year ago she had an attack of constipation and cramps, relieved by purgation but followed by low- grade fever for two weeks. Since then the constipation has been controlled by cascara and enemata. Occasional slight colic; some pain in the right upper abdomen; quite sore over cecal region. Nothing Fig. 459. Case 111,425.— Cecal tuber- culosis. Involved area, F. D. Fig. 460. Case 128,505. — Cecal tuber- cxilosis. Filling defect, F. D. abnormal in stool; no urinary symptoms. Hemoglobin 85. Tender- ness right iliac fossa. Pulmonary examination shows tubular type of breathing and delayed expiration both apices. Roentgen findings: Filling-defect of cecum with marked narrowing and irregularity (Fig. 459). Findings at operation: Tuberculosis of the cecum, involving terminal ileum and ileocecal valve. Operation: Resection 10 inches of ileum, cecum, appendix and ascending colon. End to side anasto- mosis by suture. Case 128,505, woman, aged 24 years. In good health up to three months ago when she developed soreness and tenderness in the right lower abdomen. Later her physician discovered a tumor in this region. She was explored elsewhere one month ago, and tuberculosis 484 TUBEECULOSIS OF THE COLON of the cecum was found. Since then she has been losing weight; she has had an afternoon rise of temperature and a few night sweats. The stools have been loose for several months but have never contained blood. A slight cough, but no expectoration. Former weight 124; Fig. 461. — -. FiLi. 402. Fig. 463. Figs. 461, 462, 463. — Tuberculosis of cecum. F. D., filling defect. O, obstruction. present 92; emaciated; looks anemic. Hemoglobin 75. Boggy tumor mass in right iliac fossa; not tender. Roentgen findings: Filling-defect of cecum and ascending colon (Fig. 460). Findings at REFERENCE 485 operation: Hypertrophic tuberculosis of cecum. Mass the size of two fists. Huge glands along the spine. Terminal ileum involved. Free fluid in abdominal cavity. Operation: Ileocolostomy. Attempt at resection not advisable. REFERENCE 1. Brunner, C: " Tuberculose, Aktinomycose, Syphilis des Magen- Darmkanals." Stuttgart, Enke, 1907, 49. CHAPTER XXV CHRONIC COLITIS In his monograph, Schwarz^ describes and illustrates the roentgenologic findings in a few cases each of chronic catarrhal, mucous and ulcerative colitis. One feature common to all three varieties was a local or general narrowing of the colon, which was smooth and unhaustrated. In the catarrhal type, the contracted areas changed their situation rapidly. Notwithstanding the narrowing, the enema filled the colon very quickly. Besides the wandering diffuse contractions, exaggerated peristalsis and antiperistalsis were noted, indicative of a hyperirritability. In the mucous type, with the opaque meal, the shadow of the colon was persistently narrow and had a very peculiar flecked and marbled appearance, due probably to the bismuth-holding clumps of mucus. The ulcerative type showed a narrow, stippled colon- shadow with delicate arborizations. The cases of mucous colitis and catarrhal colitis which we have examined with the ingested meal or enema either gave negative findings, or at most showed only a vacillating spasticity of the bowel which had little diagnostic import. Permanently contracted and unhaustrated areas were not noted in any instance. We have not seen barium-holding clumps or barium- ized mucous casts which might be considered pathognomonic of mucous colitis. This may have been due to the fact that they are not constant findings or that our cases were too recent. On the other hand, our cases of colitis of the granulating or ulcerating type have given consistently positive roentgen find- ings. Examination was by clysma usually. The most strik- ing roentgen characteristics noted were permanent narrowing and lack of haustration in the involved areas of the colon. These findings were logically accounted for by the organic changes 486 REPORT OF CASES 487 found at operation and at necropsy, notably the pronounced infiltration and thickening of the intestinal wall. This also explains the fact that the roentgen appearance was not altered by giving belladonna in full doses, as was tried in a few cases. Incompetence of the ileocecal valve, mentioned by Schwarz as a feature of his cases, was noted in every instance. Following are some case histories: Case 125,312, man, aged 24 years. Persistent diarrhea for twelve years. Ordinarily he has about five bowel movements daily, but Fig. 4G4.— Case 125,312. Chronic colitis. there are periods off and on, lasting several days, when he has eighteen or twenty stools daily. At these times the stool is very thin and bloody and contains mucus. No relief has been obtained from treatment with various drugs, including emetine. No loss of weight. Sugges- tion of a movable rounded mass at cecum. Proctoscopic examination: Marked granular colitis; bowel thick, very tender and bleeds easily; no ulceration found. Stool report: No parasites found. Roentgen findings : Smooth, narrow colon, devoid of haustra (Fig. 464) . Findings at operation: Much congestion of walls of colon. Prolapsed cecum. Appendix adherent to ascending colon. Operation: Appendicostomy, 488 CHRONIC COLITIS Case 146,817, man, aged 38 years. For two years he has had attacks of diarrhea lasting from two weeks to three months. The stools range in number from five to twent}^ daih\ They are of rice- water character, odorless or not offensive, with mucus and blood. During the past three months there has been much bright red blood in the stools. Occasionally he has cramps and tenesmus before the bowels move. Weight fluctuant; present loss, 26 pounds. Hemo- globin 70. Wassermann negative. Slight gurgling over cecum. Little tympanitis. No rigidity. Proctoscopic examination: No evi- dence of ulceration. Stool report: No parasites, tubercle bacilli, red Fig. 465.— Case 146,817. Chronic colitis. blood corpuscles or pus cells. Roentgen findings: Colon markedly contracted and unhaustrated throughout, indicating a chronic inflam- matory process (Fig. 465). Clinical diagnosis: Chronic colitis. Find- ings at operation: Colon contracted to about the caliber of the small intestine. Wall moderately thickened, vessels injected and the^bowel of deep reddish color. General appearance of a plastic peritonitis. Condition seemed to be present from cecum to rectum, gradually in- creasing from cecum down. Sub-acute appendix. Operation : Brown operation (ileostomy). Cecum brought up through separate incision for J colostomy later if advisable. Appendectomy' secondary. Case 107,128, man, aged 54 years. Diarrhea for eleven years. Daily average of six stools, chiefly about breakfast time. He has REPORT OF CASES 489 often noted streaks of bright blood in the stool. Some soreness in the lower abdomen, but never any distinct pain. Only slight loss of weight. Physical examination : Hemorrhoids. Mucous membrane of rectum feels granular and edematous. Hemoglobin 30. Wassermann negative. Roentgenogram of chest shows healed tuberculosis of right upper lobe. Proctoscopic examination: Dijffuse granular colitis; bowel gradually narrowed to the diameter of a twenty-five-cent piece. Stool report: Loose brown stool with mucus, red blood corpuscles and pus; no tubercle bacilli or parasites. Roentgen findings: Narrow, Fig. 466. — Case 107,128. Chronic colitis. Sausage-like colon. No haustration. smooth, sausage-like colon. Hepatic and splenic flexures ptosed (Fig. 466). Clinical diagnosis: Chronic colitis. No operation. Case 126,013, woman, aged 25 years. About eight years ago each autumn for two or three years, she had attacks of hemorrhage from the bowel. The hemorrhage occurred with nearly every defecation and continued for two weeks to two months. With the attacks there was some pain in both lower abdominal quadrants. Five years ago she passed a concavo-convex mass of material about 3 inches long which seemed to be made up of hair. Following this no hemorrhage occurred until six months ago, and again six weeks ago. Physical examination shows tenderness in left lower quadrant. No hemor- 490 CHEONIC COLITIS Fig. 467.— Case 126,013. Chronic colitis. Fig. 468.— Case 121,271. Chronic colitis. REPORT OF CASES 491 rhoicls. Roentgen examination of chest shows healed tuberculosis of right apex, and thickened pleura forming pocket over periphery of left lung. Proctoscopic examination: Generalized, chronic inflamma- FiG. 468a. Fig. 4686. Fig. 468c. tory condition of bowel as far as could be seen; bleeds easily. Stool report: Negative for tubercle bacilli; no parasites found; blood present. Roentgen findings: Smooth, narrow, unhaustrated colon, suggestive of chronic colitis (Fig. 467). Xo operation. 492 CHRONIC COLITIS Case 121,271, man, aged 48. Good health up to twenty-two years ago, then onset of diarrhea for six months, with two or three stools daily; no pus or blood. Well for a j^ear, then recurrence of the diar- rhea. For the past year he has had a daily diarrhea — about foui watery, slimy stools. Slight mid-abdominal gas pains after move- ments. Underweight 80 pounds for the past five years. Hemoglobin 80. Total gastric acidity 12; all combined. Proctoscopic examina- tion: Diffuse superficial ulceration of bowel, not typical of any especial lesion. Stool report: Loose brown stool, chiefly mucus; red blood and pus cells; cercomonades. No amebse. Roentgen findings: Colon narrow and more or less smooth throughout (Fig. 468). Clinical diagnosis: Chronic colitis. No operation. Fig. 468d. Roentgenograms of other cases of chronic ulcerative or granular colitis, confirmed at operation or necropsy, are shown in figures 468a, 4686 and 468c. Figure 468c was a case of chronic granular colitis; the peculiar appearance of the de- scending colon is due to a partial involuntary evacuation of the enema before the roentgenogram was made; figure 468d is a photograph^of a portion of the bow^el at autopsy. REFERENCE 1. ScHWARZ, G.: "Klinische Roentgendiagnostik des Dickdarms und ihre Physiologischen Grundlagen." Berlin, Springer, 1914, 100-10. CHAPTER XXVI CHRONIC INTESTINAL STASIS AND CONSTIPATION Delayed progress of food material through the alimentary- tract has been given renewed interest by the work of W. Arbuth- not Lane.^ Prior to his investigations, retarded passage of the fecal current and the symptoms arising therefrom had been broadly covered by the term "constipation," and considered chiefly as a functional disorder affecting particularly the lower bowel. But, by extending the field to include delayed transit through any part of the intestinal tract, from any cause, ad- vancing novel veiws as to etiologic relationships and surgical treatment, and inventing the term "intestinal stasis," Lane has created an apparently new and important domain. From his work and that of his followers and opponents an extensive literature has arisen. Notwithstanding this, the matter has not as yet, crystallized into a definite and accepted entity susceptible of ready and clear understanding. Einhorn^ contends that "visceroptosis giving rise to intestinal angulations (designated as kinks by Lane) and the formation of partial stenoses with delayed prochoresis," originated with F. Glenard. Einhorn states further that the theory of intestinal stasis leading to the absorption of poisons within the intestine, or auto-intoxication, was advanced long ago by Bouchard, Combe and others. However, Lane has at least developed these theories to greater lengths and logically carried them to courage- ous surgery. Lane has defined stasis as "such a delay of the contents of the intestines in some portion of the gastro-intestinal tract, but more particularly in the large bowel, as allows the absorption into the circulation of a large quantity of toxic material than can be dealt with effectually." "This delay," he states, "results from a mechanical alteration in the normal arrangement of the drainage 493 494 CHRONIC INTESTINAL STASIS AND CONSTIPATION apparatus. In early life it is produced by an abnormal disten- tion of the intestine, consequent on too frequent feeding, or by the use of articles of diet of an unsuitable nature. Later, it is brought about and accentuated by the erect posture of the trunk which is assumed from the time of getting up until going to bed." He holds that the dragging strain of the intestine upon its princi- pal points of support tends to the production of bands and kinks at these points. The bands, he states, are not inflammatory but evolutionary, that is to say, they represent a compensatory effort of nature. The points at which these bands and resulting kinks occur more commonly, he claims, are: 1. The pylorus. 2. The terminal coil of ileum. 3. The outer aspect of the cecum and ascending colon. 4. The hepatic flexure. 5. The splenic flexure. 6. The sigmoid loop. Symptoms of the auto-intoxication consequent upon stasis include: Loss of fat, impaired circulation of the blood, partial inhibition of respiration which is often entirely diaphragmatic, staining of the skin, offensive perspiration, pain and weakness in the skeletal muscles, morning headaches, and increased sus- ceptibility to infections of the gums, tubercle, rheumatoid arthri- tis, gout, etc. Lane claims, further, that as a result of enlarge- ment and abrasion at the point of stress local ulcers and cancers occur, and numerous remote lesions are set up by the systemic toxemia and irritation. This inclusive feature of Lane's con- ception of stasis makes the subject momentous. If it can be established that ulcers and cancers of the digestive tract, goiter, mammary cancer, tuberculosis, etc., are sequelae of intestinal stasis, then the diagnosis and treatment of the antecedent condition are of vast import. Lane's theory of stasis has been vigorously combated by Einhorn, Bassler,^ Hertz^ and many others. Einhorn objects to calling the digestive canal a "drainage-tube," and comparing it to a sewer system, in which any clogging must cause disaster. CHRONIC INTESTINAL STASIS AND CONSTIPATION 495 He considers intestinal stasis only another name for constipa- tion, and holds that constipation does not cause auto-intoxica- tion. He believes that if we did not need the colon we would not have it; or it would show decided signs of degeneration, which it does not, hence ileocolostomy or colectomy is not justifiable for functional disturbances. Bassler states that he has had 167 cases which had Lane kinks, but only 5 of these showed delayed prochoresis. He thinks that Lane bands are probably physio- logic, that sagging of the transverse colon does not necessarily mean stasis, and that operation should be reserved for intestinal obstruction, pure and simple. DanieP disagrees with Lane as to the origin of bands and kinks, and holds that they are due to local peritonitis resulting from bacterial activity. Hertz be- lieves that ileal stasis is a normal phenomenon resulting from the action of the ileocecal sphincter; although it may be increased by spasm of the sphincter as a result of disease in the neighbor- hood of the cecum. He states, further, that ptosis of the intes- tines does not lead to stasis, except in rare instances at the splenic flexure, a pelvic cecum or transverse colon being compatible with perfect health and normal intestinal action. He is of the opinion that in most cases of constipation a single part of the bowel is involved; and that even in the cases in which the entire colon is involved medical treatment almost invariably succeeds. Keith, "^ who does not accept Lane's theory of stasis, and denies that kinks produce delay of the food stream, thinks that he has found a possible explanation in his own observations. He has noted in the myenteric plexus (Auerbach's), or, rather, intermediate between it and the muscle-fibers, neuromuscular cells, partaking of the characters of both nerve and muscle, which he calls "nodal tissue" because of its similarity to nodal tissue in the heart. He finds that this tissue is plentiful in the neighborhood of the sphincters of the digestive tube, as well as at certain other points, and suggests that, like the nodes in the heart, each local aggregation of nodal tissue serves as a pacemaker for rhythmical contraction (peristalsis) in the zone distal to it. He does not think it over-presumptuous to suppose that irregulari- 496 CHEONIC INTESTINAL STASIS AND CONSTIPATION ties of impulse-conduction may occur in these nodal systems and cause stasis in the same way that ''heart-block" is produced. The effect of disordered conduction, he believes, is not hmited to the related sphincter, but extends to the bowel segment beyond, and that disturbance of rhythm in any one zone tends to upset the rhythm in other zones. While Keith's theory does not carry us far toward the final solution of stasis, it offers a plausible ex- planation of the manner of its production, and again brings into the foreground the musculature of the alimentary tract. Moynihan'' seems to speak wisely when he says: ''I do not hesitate to say that the whole question of stasis is one which will have to be considered by all of us and be put to the proof. It cannot be dismissed with a shrug or a sneer, for there is truth in the matter. Among much that is dross there lies a nugget of pure gold." It is quite obvious that the roentgen-ray offers a convenient means for demonstrating the evidences of stasis. Accordingly, Jordan^ who early took up the work for Lane, has\called attention to the following roentgenologic signs: 1. Dilatation and writhing peristalsis of the duodenum. He lays much emphasis upon duodenal distention, claiming that when this is present, other evidences of stasis will also be found, and that, conversely, in the absence of duodenal dilatation stasis is not likely to exist. 2. Ileal stasis, with delay of the intestinal contents in the terminal ileal coils. In some instances this may be due to drop- ping of the lower coil so that the terminal segment has a steep ascent to the ileum. In others there is obstruction by an adher- ent appendix, or by a kink. 3. Kinks. The points where Jordan finds kinks most com- monly are at the duodeno-jejunal juncture (hence the duodenal dilatation above mentioned), the terminal loop of the ileum (particularly about 4 inches from its terminus), the hepatic flexure, the splenic flexure, and the sigmoid. These kinks are evidenced by localized narrowing, fixation (as shown by lessened movement on palpation, forced respiration and change of pos- CHRONIC INTESTINAL STASIS AND CONSTIPATION 497 ture) tenderness, dilatation proximal to the stenosis and delay of the intestinal content. 4, New formed bands about the appendix, kinking and fixing it. 5. Elongation, dilatation and looping of the rectum. These findings have formed the groundwork of the roentgen- ology of stasis. To a varying extent and with additions they have been adopted by many other observers. Thus Pfahler^ has noted kinks, spasms, twists, and adhesions in A^arious parts of the bowel. He has observed obstruction at the splenic flexure by a gas-distended splenic loop. Case^° sees kinks less frequently, but often finds the distal colon to be spastic. He dwells upon incompetence of the ileocecal valve as a factor in stasis. Brown ^^ reemphasizes the relation of the enteroptic habitus to visceral ptosis and hence to stasis. Cole^^ says that the whole subject of stasis centers around the roentgenologic findings; therefore, it is essential that the roentgenologic foundation be sound, soUd and scientific. He vigorously condemns the use of roentgenograms as a weapon with which to urge surgical proced- ure for some preconceived diagnosis. The validity of the signs of stasis exploited by Jordan and his followers is not accepted by all roentgenologists. Hertz^^ asserts that intestinal stasis does not lead to duodenal kinking, dilata- tion or ulceration, and points to the fact that duodenal ulcers are associated with an unusually rapid passage of chyme out of the stomach and through the whole of the small intestine. He also says that when the stomach empties rapidly, the duodenum con- tains more barium at a given moment. Hence it appears dilated, the normal peristalsis and segmentation are rendered more clearly visible, and this accounts for so-called ''^Tithing." Segmentation in the terminal ileum is very active and this, he thinks, may be mistaken in the roentgenogram for organic nar- rowing. As to incompetency of the ileocecal valve he feels that the valve does not normally prevent regurgitation into the ileum, as he has seen this with a pressure as low as 1 foot of water. Regurgitation is not due to antiperistalsis, he claims, as a^-ray 32 498 CHRONIC INTESTINAL STASIS AND CONSTIPATION investigations have shown that antiperistalsis does not occur in man under normal conditions. Regarding stasis, Mixter^^ says: ''Since the advent of the roentgen-ray much has been learned and many mistakes have been made. It is safe to say that the old ideas of the positions of the abdominal viscera have undergone a great change in the last few years. Their positions and shapes are becoming better known, and w^hat a short time ago were considered malpositions or malformations are now known to be but slight variations from the normal, if there is any such thing as a normal arrangement. The large intestine is a marked example of this rule ; it never lies in the regular hnes and curves as shown in the diagrams of the old anatomists. There are innumerable variations, due to con- genital or acquired folds of the peritoneum, and many have too quickly decided that anything unusual must be a serious physical defect, and the cause of certain trains of symptoms. * * * Fecal stasis is recognized as an evil, and many operations have been de- signed and performed for its relief that are useless or do positive harm. * * * Ptosis does not, or should not, always mean operation. The interrelation of fecal stasis and the neuroses and auto-intoxications of all kinds are subjects that require further investigation and study, though day by day and year by year our knowledge is steadily advancing. The medical clinician, the neurologist, the psychologist, the bacteriologist must each do his part, and they should be aided, not over-shadowed, by the roentgenologist, whose mechanical findings may so often be misinterpreted." Speaking as a surgeon, Coffey ^^ offers this warning: "Roent- gen observation is of inestimable value in the study of these cases, but is, I concede, the most dangerous agent yet placed at the disposal of the unscrupulous surgeon, because it is so convinc- ing to the laity, and at the same time so meaningless when con- sidered independently of the history of the case and not properly interpreted." Hertz^^ does not seek to minimize the importance of intestinal hypomotility. On the contrary, in his book, he has admirably CHRONIC INTESTINAL STASIS AND CONSTIPATION 499 presented the whole subject of constipation from every view- point, including the roentgenologic. A summary of his observa- tions may serve to correct the spreading assumption that consti- pation is a purely mechanical matter. Admitting wide varia- tions within the normal, he says: "For practical purposes an individual may be considered constipated if his bowels are not opened at least once in every forty-eight hours. * * * Constipa- tion may be defined as a condition in which none of the residue of a meal taken eight hours after defecation, is excreted within forty hours." He divides constipated persons into two great classes: First, those in whom passage through the intestine is delayed, but defecation is normal. Second, those in whom there is no delay in arrival of fecal material at the pelvic colon, but final excretion is not adequately performed. In the first class delayed prochoresis may be due to : A. Deficient motor activity of the intestines. B. Excessive force required to carry the feces to the pelvic colon. The A group may have as causes: (1) Weakness of the in- testinal musculature, which may be constitutional or senile, or the result of chlorosis, cachexia, rickets, fevers, over-distention by gas, obesity (fatty degeneration of muscle) . (2) Deficient reflex activity of the intestine from insufficient food; insufficient chemical and mechanical excitants of intestinal activity, ex- cesive digestion and absorption of food (greedy colon) or deficient exercise. Reflex activity may be impaired also by catarrhal conditions of the mucosa, long-continued irritation by purgatives, astringents (tannin in tea and coffee) or by de- pression of the nervous system (neurasthenia, hypochondriasis). (3) Inhibition of motor activity by lead poisoning, depressing emotions, or painful abdominal viscera (ovaritis, cholecystitis, appendicitis) . (4) Spasticity of the intestinal musculature (pa- tients usually neurotic, often brain-workers). A localized spasticity of some part of the colon is often accompanied by spasm of the sphincters. The B group may result from obstruction by an excess of 500 CHRONIC INTESTINAL STASIS AND CONSTIPATION feces, or dry hard feces (insufficient supply of water, excessive loss of water by other channels, excessive absorption of water), deficient fat in the diet, obstruction by organic stricture fnearly always malignant), kinking of the intestine (of which he has noted but one instance), pressure on the intestine by tumors without, and chronic intussusception. For the second of the two great classes of constipation he pro- poses the name '' dyschezia. " The passage of feces to the distal colon may be normal or even unusually rapid, but the act of defe- cation does not empty the lower bowel as completely as it should. The causes include habitual disregard of the call to stool, weakness of the abdominal and pelvic muscles, weakness of the defecation reflex (tabes), h^^steria, hard and bulky feces, functional and organic strictures of the anal canal and sphincter, and pressure on the rectum by a pelvic tumor or retroverted uterus. Schwarz^^ distinguishes two types of chi'onic obstipation, the hypokinetic and dyskinetic. In the hypokinetic type the slow transport of the ingested meal is associated with a lessening of peristaltic action in the distal half of the colon, continuity of the fecal mass, belated gradual ejection into the end-gut, and frag- mentary emptying. Elongation of the colon is a frequent addi- tion to this syndrome. In the dyskinetic type there is a hy- perfunction of the transverse and descending colons, the fecal mass is broken up and separated, and the abnormal contraction of the mid-colon produces a retention in the cecum and ascend- ing colon. Briefly, the first type is atonic, the second is spastic. Skinner^^ notes four types of constipation which are non- organic and purely functional. These are as follows : 1. Hypermotihty of the proximal colon with increased anti- peristalsis. Six hours after the bismuth meal its shadow may reach as far as the descending colon, but at the end of twelve or twenty-four hours the opaque shadows in the cecal and hepatic areas are increased in size while there is little, if any, filling of the pelvic colon. 2. The cecal type, with slow filling of the cecum and long re- CHRONIC INTESTINAL STASIS AND CONSTIPATION 501 tention of the bismuth there, often associated with a history of recurring appendicitis in the male, and ovarian or tubal symp- toms in the female. 3. The atonic type, with ptosis of the colon, including the hepatic and splenic flexures. Bismuth residues may be found in the ileum up to twenty-eight hours after the meal and in the colon up to fourteen days. 4. Rectal constipation. The bismuth reaches the pelvic colon in the usual length of time (about twenty-four hours), but the fecal residue collects in the sigmoid and rectum from the failure of the individual to carry out a rational rectal hygiene. During the past four years we have examined several hundred cases of constipation with the opaque meal or enema or both. In many instances, notwithstanding an emphatic clinical history, the roentgen findings were trivial and valueless, or even utterly negative. In some cases the information derived from the x-ray appeared to be worth while. Although the examinations were thorough, no obstructive kinks were found, nor were any dis- covered by the surgeon in those cases which were explored. Angulations of the bowel were noted repeatedly, and in certain planes of view these sometimes seemed to be acute and potentially obstructive, but when observed from another direction the course of the bowel was seen to be curved instead of angular and no stenosis existed. The tremendous variance of opinion among observers as to the frequency of kinks indicates widely different conceptions of this condition. In several of the cases coming to operation, the surgeon found adhesions of varying extent as a result of former interventions. In one or two instances adhesions were present although no pre- vious operation had been performed. Definite roentgenologic signs of adhesions were lacking, as a rule, even when a former laparotomy had been done, and the presence of adhesions was presumable. Quite often the constipated colon, as seen with the opaque clysma showed evidences of atony (Fig. 469). The colon was broad, either in its proximal half or throughout; its outline was 502 CHRONIC INTESTINAL STASIS AND CONSTIPATION abnormally smooth, the haustra being slow to appear and only slightly marked; its length was increased by redundancy of the distal segments; its capacity was augmented so that additional quantities of the enema were required to fill it. From the roent- genologic standpoint these proofs of atony could hardly be stronger. Fig. 469. — Redundant, atonic colon. History of severe constipation. Examination by enema. No operation. On the other hand, though less often, a directly opposite con- dition was noted, namely hypertonus or spasticity (Fig. 470). The colon w^as narrow and deeply scalloped with haustra, especially beyond the hepatic flexure; it was usually short, and less than the customary amount of the enema was needed to fill it. It must be granted that neither atony nor spasticity of the colon necessarily betokens constipation, but the finding of either in association with stasis ought to have considerable bearing on the treatment. CHRONIC INTESTINAL STASIS AND CONSTIPATION 503 We have been unable to confirm any consequential relation- ship either of ptosis or the so-called insufficiency of the ileocolic valve to stasis. It might be said that the barium-meal test of motility in stasis is an elaborate method of confirming the patient's state- ment that he is constipated. However, besides this confirma- tion, which is sometimes expedient, the meal may show not Fig. 470. — Spasticity of the colon distal from the hepatic flexure. Examination by enema. Marked constipation. At operation a small, subacutely inflamed appendix was found, without adhesions. Colon negative. only the fact of delay, but the region in which the delay is greatest. As has been stated elsewhere, the meal should be given without previously purging the patient or requiring him to fast, since it is desired to show the progress of the fecal current under usual circumstances. The meal which we employ is a mixture of barium with cereal, the same as is used for testing gastric motility. It is given to the patient at 5 p.m. and the first examination is made next morning at 8 o'clock. Subse- 504 CHRONIC INTESTINAL STASIS AND CONSTIPATION quent examinations are made at intervals of twenty-four hours, or more frequently if preferred. Taking a feM" of the patients operated on as examples, the bulk of the barium meal was still in the ileum at seventeen hours in one, at twenty-five hours in another. Retention in the colon atseventy-two hours or longer was observed in several instances. Fig. 471. — Two years previouslj^ this patient had been operated upon elsewhere because of paroxysmal pain in the right lower abdominal quadrant — appendectomy, colopexy, longitudinal plication of ascending colon. Within a month the pain recurred and the stools had to be kept liquid to avoid a stoppage of the bowel movements. Roentgen examination by the ingested opaque meal showed a large delay in the right half of the colon up to 95 hours. Opera tve findings: Tremendous amount of adhesions, involving terminal ileum, cecum, ascending and right half of transverse colon, without marked obstruction, from former operation. Operation: Resection 3 inches of ileum, cecum, ascending and transverse colon. Pathologist's report: Wall of intestine exceedingly thin, with very little muscle- tissue. and in one instance a large amount of barium was still in the colon after two weeks. Retentions were noted in different parts of the colon; sometimes chiefly in the cecum (Fig. 471), some- times in the distal colon (Fig. 472), and occasionally scattered throughout. Those of our patients who were operated on were CHRONIC INTESTINAL STASIS AND CONSTIPATION 505 explored, not solely because of the roentgen findings, but because the clinical factors justified surgical intervention. Often there was a history of a previous operation. In some cases this had been done for the rehef of stasis, but without success. In view of our own rather indecisive experience and the varying experience of others with the roentgen examination for stasis, any general conclusions can be offered only with diffidence. It would seem, however, that the greatest value of the x-ray consists not in showing organic obstruction but in excluding it, and that, at Fig. 472. — Large rectal ampulla containing considerable barium at 72 hours. The patient was very constipated and because of this in association with a marked general arthritis he was sent to operation. Resection of cecum, ascending colon and right fourth of transverse colon. Neither the arthritis nor the constipation were relieved by the operation. present, clinical considerations largely must determine both diagnosis and treatment. REFERENCES 1. Lane, W. A.: ''Chronic Intestinal Stasis." Surg., Gynec. & OhsteL, 1910, xi, 495-500. 2. EiNHORN, M.: "Intestinal Stasis." Jour. A.M.A., 1914, Ixiii, nil. 506 CHRONIC INTESTINAL STASIS AND CONSTIPATION 3. Bassler, a.: ''Discussion of the Surgical Theories of Intestinal Stasis." Jour. A.M.A., 1914, Ixiii, 1469-73. 4. Hertz, A. F.: "Chronic Intestinal Stasis." Brit. Med. Jour., 1913, i, 817-21. 5. Daniel, P.: "Septic Infection Versus Chronic Intestinal Stasis; Legality of Ileocolostomy for Arthritis." Clin. Jour., 1913, xH, 305-14. 6. Keith, A.: "A New Theory of the Causation of Enterostasis." Lancet, 1915, ii, 371-75. 7. MoYNiHAN, B. G. A.: "Intestinal Stasis." Surg., Gynec. & Ohstet., 1915, XX, 154-58. 8. Jordan, A. C: "Radiography in Intestinal Stasis." Lancet, 1911, ii, 1824-28. "A Discussion on Alimentary Toxemia; Its Consequences and Treatment." Proc. Roy. Soc. of Med., 1913, vi, 311-15. "Intestinal Stasis." Practitioner, 1913, i, 441-54. "A Note on Chronic Intestinal Stasis." Clin. Jour., 1914, xliii, 159. 9. Pfahler, G. E.: "The Study of Chronic Intestinal Stasis by Means of the Roentgen rays." Surg., Gynec. & Ohstet., 1914, xix, 658-63. 10. Case, J. T. : "Basic Considerations in the Roentgen Study of Intestinal Stasis." Pennsylvania Med. Jour., 1915, xviii. "Roentgenologic Observations on the Functions of the Ileo- colic Valve." Jour. A.M.A., 1914, Ixiii, 1194-98. "A Critical Study of Intestinal Stasis, Including New Observations and Conclusions Respecting the Causes of Ileal Stasis." Surg., Gynec. & Ohstet., 1914, xix, 592-600. 11. Brown, P.: "A Roentgenological Consideration of the Relation of Individual Type to Intestinal Stasis." Bos. Med. & Surg. Jour., 1914, clxxi, 581-87. 12. Cole, L. G. : "Ileal Stasis." Canada Med. Assn. Jour., 1914, iv, 972-78. 13. Hertz, A. F.: "Chronic Intestinal Stasis." Brit. Med. Jour., 1913, i, 817-21. 14. Mixter, S. J.: "The Intestinal Tract." Jour. A.M. A., 1915, Ixv, 1607-10. 15. Coffey, R. C: "The Principles Underlying the Surgical Treat- ment of Gastro-intestinal Stasis, Due to Causes Other than Strictural or Ulcerative Conditions." Surg., Gynec. & Ohstet., 1912, XV, 365-429. 16. Hertz, A. F.: "Constipation and Allied Intestinal Disorders." London, Frowde, 1909. CHRONIC INTESTINAL STASIS AND CONSTIPATION 507 17. ScHWARz, G.: "Klinische Roentgendiagnostik des Dickdarms und ihre physiologischen Grundlagen." 1914, Springer, Ber- lin, 61-71. 18. Skinner, E. H.: "The X-ray Examination in Habitual Constipa- tion." Missouri State Jour. Med., 1913-14, x, 51-7. CHAPTER XXVII CHRONIC APPENDICITIS While, for manifest reasons, acute appendicitis seldom^comes within the purview of the roentgenologist, he has had ample material for study of the subacute and chronic varieties. At the beginning, attention was directed chiefly to the demonstration of concretions in the appendix. Later it was discovered that the opaque meal or enema sometimes entered the appendix, and efforts to distinguish between the normal and abnormal appendix were thus stimulated. Among early writers on the subject was Liertz,^ who reported a case in which the appendix was visual- ized after a bismuth meal. Liertz discussed stagnation of the bismuth in the appendix as a possible sign of appendicitis. More recent contributors to the literature include Singer and Holzknecht,- Case,^ Rieder,^ Groedel,^ George and Gerber,^ Cohn,'^ Hertz,^ Henselmann^ and Imboden.i° Singer and Holzknecht report their findings in 25 cases ex- amined fluoroscopically six hours after the meal. They beUeve that the radiology of appendicitis has striven in the wrong di- rection, namely, the demonstration of the bismuth-filled appen- dix, as this is only occasional and therefore uncertain. They dwell upon tenderness in the appendiceal region as the chief sign, and the location of the appendix is determined not so much by visualizing it as by demonstrating the position of the cecum. Used in this manner, they consider the x-ray of great value in differentiating tenderness of the appendix from tenderness of other organs in the right iliac fossa. Case was able to demonstrate the appendix in one-third of a large series of cases examined by the bismuth meal. Technically speaking, he believes that it is pathological for the contents of the 508 CHRONIC APPENDICITIS 509 colon to enter the appendix, but he does not wish to be under- stood as holding that every appendix which permits the entry of bismuth is in need of surgical attention. The appendix which remains visible for more than a day or two following the bismuth examination is, he thinks, in proportion to its poor drainage, a dangerous appendix. In those cases in which he demonstrated the appendix, 85 per cent, had definite tenderness corresponding with the shadow of the appendix. Rieder enumerates among the roentgen signs of appendicitis, the following: Stagnation of the meal in the appendix and ileo- cecal region; localized pressure-tender point; insufficiency of Bauhin's valve (mentioned by Dietlen) ; adhesions about the appendicular region; kinking or pulling up of the appendix; con- cretions in the appendix. George and Gerber have succeeded in demonstrating the appendix, either normal or pathological, in about 7 out of every 10 patients examined. They state that chronic appendicitis can be shown in two ways : first, by the ileal stasis which it produces ; and second, by actual demonstration of the kinked and adherent appendix. To be safely classed as real ileal stasis, bismuth should be present at least twenty-four hours or longer. ''From the presence of marked ileal stasis alone we cannot make a diagnosis of chronic appendicitis," they say, "but we can some- times infer it." The pathological appendix may show a bismuth mass which is sharply kinked in one or more places. It may have adhesions to itself, to the cecum, ileum or even to the sig- moid. Retrocecal appendices can sometimes be shown dis- tinctly, and will show more clearly when some of the bismuth has passed out of the. cecum. In many instances bismuth will persist in the lumen of the appendix for hours after it is out of the cecum or ascending colon. In one of their cases it persisted as late as five days. Cohn found the appendix to be an especially mobile organ. Its movements consist not only of a change of position in toto but various alterations of its configuration. It does not fill immediately upon the entrance of material from the small intes- 510 CHRONIC APPENDICITIS tine into the colon, and it can be concluded therefore, that the retrograde movements of the colon are an important factor in its filling. While the colon is full the appendix can be seen to fill and empty several times. Emptying may be retarded, and it may retain opaque matter long after the colon is evacuated. Hertz believes that the appendix can be shown in half of all persons examined. The presence of adhesions can be deter- mined. To show concretions the patient should be rayed before giving the meal. Chronic appendicitis, he insists, is one of the most common causes of enterospasm, the colon often being narrowed and spastic in places. For examination of the appendix, Imboden places the patient in a horizontal position with the tube under the table and the fluoroscopic screen on the abdomen. Means of palpation are most essential; Imboden prefers using the gloved hand and a 4- inch gauze bandage-roll. The vertical and Trendelenburg posi- tions should also be used in determining fixation. Far more ap- pendices can be visualized by the opaque meal than by the enema. Other points which he mentions are as follows: The patho- logic effects of inflammation of the appendix are peritoneal adhesions, obliteration or strictures of the lumen, and the presence of concretions. The last of these can be occasionally demonstrated by the x-ray, and the other three conditions may be sometimes inferred from the following manifestations : Drain- age, position and direction, kinks or obliteration, size, length and caliber, mobility and points of tenderness. The mere presence of some of the opaque meal in the appendix is no indication of chronic disease. Delay in emptying beyond twenty-four hours after the cecum is empty, or after vigorous catharsis, or if de- layed emptying is associated with a distinct area of tenderness, is to be regarded with suspicion. Chronic disease is not dependent upon position of the appendix but is more often found in the following positions : Posterior and external to the cecum with the distal end directed upward and meeting within the peritoneal cavity; posterior and external to the cecum and without the peri- toneal cavity, and directly behind the cecum, often just behind CHRONIC APPENDICITIS 511 the ileocolic valve. A tender area located in the course of the appendix must always be regarded as very suspicious. Recapitulating the signs of appendicitis as noted by the fore- going observers, the list comprises: 1. Shadows of concretions in the appendix. 2. Kinking. 3. Malposition. 4. Adhesions about the appendix and cecum. 5. Retention of barium in the appendix. Fig. 473. — Filling defect, F, D, corresponding to a palpable tumor, large retrocecal abscess was found. At operation a 6. Ileal stasis. 7. Insufficiency of Bauhin's valve. 8. Spasticity of the colon. 9. Pressure-tender point related to the appendix. These offer a wide selection of sign-combinations according to the preference of the examiner. Some of them are quite plausible, and with more extended observations the roentgen diagnosis of chronic appendicitis may carry conviction. At 512 CHRONIC APPENDICITIS present, however, certain reservations seem to be warranted. Fecaliths are not often sufficiently dense to be demonstrable by the x-ray, but occasionally these, as well as gall-stones and other foreign bodies will be revealed, and by using the enema or meal their intra-appendiceal situation can sometimes be determined, or their differentiation from ureteral calculi, phleboliths, or calcified glands can be thus assisted. Permanently kinked appendices. -.ro Fig. 474. — Cecum narrowed and irregular by filling defects, F, D. To the outer side of the contracted cecum is the shadow of a fecalith, S, immediately above it is a small collection of barium. At operation the concretion was found to be the size of a pecan nut and Isang at the bottom ol a discharging sinus, which communicated with a post- appendiceal abscess. may perhaps be pathologic; likewise permanent malpositions, especially the retrocecal, suggest pathology. In this connection, however, Cohn's statement that the appendix tends to change its position and configuration must be considered. Definite fixa- tion of the appendix or of the cecum can, of course, be attributed to inflammatory adhesions ; but findings in this respect are often illusive. Whenever barium or bismuth enters the appendix, the length of time it may be retained there, within normal limits, is CHRONIC APPENDICITIS 513 problematic; Cohn asserts that the appendix fills and empties in- termittently as long as the meal remains in the cecum. Mere visualization of the appendix is not evidence of appendicitis; since chronic appendicitis tends to an obliteration of the lumen, failure to visualize the appendix should be the more suggestive. Just when chronic appendicitis can be inferred from the presence of ileal stasis is not stated by the authors cited, and ileal stasis un- doubtedly has other causes also. Insufficiency of the ileocolic Fig. 475. — Cecum, C, distorted by adhesions from a chronic appendicitis. valve, as demonstrated by the enema, has been meaningless in our experience. Spasticity of the colon has other causes besides appendicitis. Pressure-pain points over the visualized appendix or in close relation to the visualized cecum, are more significant than the clinical sign of tenderness at the McBurney point. Without this tenderness all the other signs enumerated lose much of their persuasiveness. Many patients sent for roentgen examination have symptoms suggesting a lesion either of the stomach, duodenum, gall- 514 CHRONIC APPENDICITIS Fig. 476. — Cecum displaced upward and to the left by an old abscess of the appendix. f Fig. 477. — Barium-filled appendix, A, tender to palpation and not freely movable. At operation the appendix was found to be large and adherent. A Meckel's diverti- culum, three inches long, situated two feet above the ileo-cecal valve, was also found. CHRONIC APPENDICITIS 515 bladder or appendix, but with suspicion equally divided. When by the roentgen examination the stomach and duodenum can Fig. 478. — Barium-filled appendix, A. Fecal concretions were found in the appendix at operation. Fig. 479. — Barium-filled appendix marked by arrow. Concretions found at operation. reasonably be excluded, the x-ray has given its most valuable service and should not as yet be expected to go much further. 516 CHRONIC APPENDICITIS In fortunate instances the ray may positively convict the gall- bladder; or the combined clinical and roentgen findings may favor either the gall-bladder or the appendix, but at present often only surgical exploration can decide between them justly. Fig. 4S2. Figs. 480, 481, 482, 483.— Visualized appendices. No operation. On the whole, the value of the roentgen signs of appendicitis appears to depend not only upon the intensity of the examiner's endeavor, but also, to some extent, upon the degree of his en- CHRONIC APPENDICITIS 517 thusiasm. Inasmuch as few normal appendices have been found by surgeons or pathologists, the diagnosis of appendicitis upon any grounds whatever is not at all hazardous, but the novice should make sure that the appendix has not pre- viously been removed, lest he mistake barium in the ileum for a shadowed appendix and draw his conclusions accordingly. Our own observations have included cases of retrocecal ab- scess, probably of appendiceal origin (Fig. 473), fistulous abscess Fig. 484. — Chronic appendicitis found at operation. examination. No evidence in the Roentgen with shadowed concretion (Fig. 474), distortion of the cecum by adhesions from a chronic appendicitis (Fig. 475), and displace- ment of the cecum upward and to the left as a result of an old abscess of the appendix (Fig. 476). While the roentgen evidence in these cases was strongly indicative of a lesion, it was not alone decisive as to the nature of the process, except in the case with a fecal concretion. Spasticity of the distal colon, in cases which ta operation proved to be chronic appendicitis, was noted suffi- 518 CHRONIC APPENDICITIS ciently often to occasion remark, but, while interesting, this could not be considered diagnostic. In a small percentage of the co- lons examined, the appendix was visualized by the enema. Some of these cases went to operation and a chronic appendicitis was found (Fig. 477); in two instances the appendix contained fecaliths, but the roentgenogram did not show their presence (Figs. 478 and 479). Unoperated cases with a visualized appen- FiG. 485. — Chronic appendicitis found at operation. Roentgen examination negative. dix are illustrated in Figs. 480, 481, 482 and 483. In scores of patients operated on for chronic appendicitis the roentgen ex- amination of the colon was negative (Figs. 484 and 485). REFERENCES 1. LiERTZ, R. : "Die radiographische Darstellung des Wurmfort- satzes." Deutsch. Med. Wchnschr., 1910, ii, 1269-70. 2. Singer, G. and Holzknecht, G.: " Radiologische Anhaltspunkte zur Diagnose der chronischen Appendizitis." Munch. Med. Wchnschr., 1913, ii, 2659-2664. REFERENCES 519 3. Case, J. T.: "Roentgen Examination of the Appendix." New York Med. Jour., 1914, c, 161-67. 4. RiEDER, H.: "Zur Rontgenuntersuchung cles Wurmfortsatzes, besonders bei Appendizitis." Munch. Med. Wchnschr., 1914, ii, 1492-94. 5. Groedel, F. jM. : ''Die rontgenologische Darstellung des Proc- essus vermiformis." Munch. Med. Wchnschr., 1913, i, 744-45. 6. George, A. W. and Gerber, I.: ''The Value of the Rontgen Method in the Study of Chronic Appendicitis and Inflamma- tory Conditions, Both Congenital and Acquired, about the Cecum and Terminal Ileum." Surg., Gynec. & Obstet., 1913, xvii, 418-27. 7. CoHN, M.: "DerWurmfortsatz iniRontgenbilde." Deutsch.Med. Wchnschr., 1913, i, 606-08. 8. Hertz, A. F. : "X-ray Diagnosis of Gastro-intestinal Conditions, with Especial Reference to Appendicitis." Arch. Roentgen Ray, 1914, xix, 249-55. 9. Henselmann, a.: "Kleine rontgenologische A^orrichtung zur Erzeugung von Wurmfortsatzbildern." Berl. klvn. Wchnchr., 1914, ii, 1517-18. 10. Imboden, H. yi. : ''Roentgen Diagnosis of Lesions of the Vermiform Appendix." Amer. Jour. Roent., 1915, ii, 581-91. CHAPTER XXA III MISCELLANEOUS LESIONS AND CONDITIONS OF THE COLON Polyposis. — Relatively few cases of extensive polyposis of the colon have been recorded. Doering^ in 1907, collected 52 cases, including 2 of his own. Recently Soper- has collected 8 addi- tional cases and reports 1 personally observed. Soper' s case was examined bv the x-rav after colectomv. Idiu no mention is Fig. 486. — Polj-posis of the colon. made of a roentgen examination in any of the other cases avail- able for reference. Of the recent cases seen in the Mayo Clinic, one was submitted to roentgen inspection. The patient, a man aged 30. had had diarrhea for a year, with abdominal pain and distress. A tender, freely movable, sausage-shaped mass could he palpated in the epigastrium. The proctoscopic examination revealed a general- ized mucosal inflammation, becoming granular higher up. The stools contained pus and red blood cells, but no parasites. 520 ANOMALIES OF MIGRATION AND ROTATION 521 The two roentgenograms herewith show the condition as seen by the x-ray. The first examination (Fig. 486) showed appar- ent obstruction in the pelvic colon. At the second examination the entire colon was filled but was irregularly mottled through- out, and this was doubtless due to the multiple papillomatous growths (Fig. 487) . .^ At operation the colon, from the hepatic flexure on, showed marked thickening of its walls, and the vessels were injected. An ileostomy was made. Four and a half months later, the Fig. 487. — Polyposis of the colon. patient having gained weight and strength, a second operation w^as performed. This time a colectomy, complete save for about 12 inches of sigmoid and rectum, was done. The exsected bowel was found to contain multiple polyps, beginning in the ascending colon and extending to the middle of the sigmoid. Figure 488 is the photograph of a specimen from the colon in a similar case of polyposis. Anomalies of Migration and Rotation. — ConnelP points out that in its normal development the ileocecal juncture migrates 522 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON from below upward and to the left to form the splenic flexure, crosses the abdomen to the hepatic flexure where it rotates on its long axis, descends, and is fixed in its usual location in the right iliac fossa. This complicated embryological maneuver is gener- ally spoken of as ''rotation of the cecum," but Connell shows that it comprises three distinct elements, viz., migration, rota- tion, and fixation. By migration, he means the journey of the Fig. 488. — Photograph of specimen from colon. Polyposis. ileocecal juncture up the left side, across, and down the right side of the abdominal cavity. Rotation should be confined to the actual axial rotation of the ileocecal juncture through an angle of 180 degrees. Fixation means the blending of the pos- terior colonic peritoneum with the prerenal parietal peritoneum. Migration, he states, may be incomplete or delayed. The commonest arrest of migration occcurs at some point between ANOMALIES OF MIGRATION AND ROTATION 523 the hepatic flexure and the usual location of the cecum in the right iliac fossa. It may occur at the hepatic flexure, or distal to it, either before or after fixation. If before fixation, the cecum may fall back to the left iliac fossa. This is unusual, but may account for cases of left-sided appendicitis in which the viscera are not transposed. With delayed migration the cecum may be in its normal position, but adventitious bands or membranes may suggest that fixation began before migration was complete. Fig. 489. — High cecum. Possible arrest of migration. No operation. Non-rotation may occur with incomplete migration before the development of the hepatic flexure, or, less frequently, it may persist after formation of the hepatic flexure and ascending colon. In these instances the terminal ileum enters the cecum from be- hind or from the right side. With excessive rotation, which may be even as much as 270 degrees, the ileum enters the cecum in front. Fixation may be absent, or excessive, or improper surfaces may be fused. The cecum mobile is due to an absence of fixa- tion. Connell suggests that the Lane kink may be the result 524 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON of anomalous fixation, while Jackson's pericolic membrane may be due to anomalous fixation, excessive rotation, or delayed migration. Apart from the question of Lane's kink and Jackson's mem- brane, we have encountered occasional instances of incomplete migration. Now and then we have noted a high placed cecum with a very short ascending colon, due perhaps to incomplete migration (Figs. 489 and 490j. Less often, the arrest of migra- FiG. 490. — High placecLlcecum. Possible arrest ofmigration. No operation. tion is strikingly evident, as in Fig. 49 L In Fig. 492 the cecum is fixed at the site ordinarily occupied by the hepatic flexure. Cecum Mobile. — In 1908, AVilms^ announced his theory that in many cases of so-called chronic appendicitis the real cause of the pain and tenderness at McBurney's point was a long, mov- able cecum. The pain, he suggested, was produced by twisting and stretching of the nerves in the mesentery, and this accounted for the failure of appendicectomy to relieve the symptoms. Wilms, therefore, advised fixation of the cecum also, and reported satisfactory results in about 40 cases. Since his contribution, CECUM MOBILE 525 cecum mobile has been frequently discussed by others, being either^indorsed or disputed as a disease-entity. Case^ states that it is easily recognizable roentgenologically. Associated with abnormal mobility, varying degrees of dilatation and elonga- tion, there is stasis in the cecum long after the remainder of the colon has been emptied. Great tenderness is often elicited by palpation over the cecal shadow. He goes on to say that this dilated, "elongated cecum is not always mobile, being often asso- FiG. 491. — Non-migration of colon. Plate made twenty-four hours after in-gested meal (Dr. J. H. Selby). The colon is almost completely visualized and lies entirely to the left of the spine. The arrows indicate the flexures. Confirmed by operation. ciated with adhesions. Hausmann'^ discusses the subject ex- haustively, and gives the roentgenograms of several cases, show- ing extraordinary mobility of the cecum. Beclere and MerieF say that abnormal mobility of the cecum, which has been called cecum mobile by analogy to abnormal displacement of the kidney, is not really a morbid condition. It is compatible with perfect health, and appears only to be a mechanical condition capable in association with other causes, of favoring the develop- 526 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON merit of certain functional troubles. While its radiologic study- is of interest, they say, the findings obtained are never sufficient to recommend operative intervention. Schwarz^ mentions a case in which he could demonstrate that the cecum, with its ab- normally wide and therefore readily filled appendix, moved about 5 cm. toward the median line when the patient was placed in the lateral position. He considers this to be what Wilms would call cecum mobile. Fig. 492. — Cecum fixed high up in right abdomen, due probably to incomplete migra- tion. No operation. Jackson's Membrane. — Jackson,^ in 1909, described a series of cases in which the proximal portion of the colon was closely invested with a delicate, transparent, vascular membrane or veil, somewhat resembling the arachnoid, or a thin pterygium. Usually the cecum was not involved, and the membrane ex- tended from the cecum toward or up to the hepatic flexure; in one instance it passed across to the transverse colon which was drawn down parallel with the ascending colon. In advanced TRANSPOSITION 527 and characteristic cases it seems to bind the colon close to the abdominal wall, producing marked angulations of the colon, or a practical stricture of its lumen. The clinical sydrome includes pain referred to the whole right abdomen, general right-sided tenderness, though frequently more marked at McBurney's point and just below the ribs, constipation, mucus in the stools, gas distention, loss of weight, gastric fermentation, and neurasthenia. Often appendicectomy or cholecystotomy has been done with- out relief. In a few instances Jackson has removed the mem- brane by careful dissection, with good results. Skinner ^'^ has discussed the roentgen manifestations of Jack- son's membrane, both in theory and practice. He states that there are two favorite sites upon the ascending colon for pericolic bands: First, just below the hepatic flexure, on the ascending colon. This almost seems to be an accentuation of the normal mesenteric attachment. It produces a filling-defect in the form of a circular constriction of the colon, which causes a partial damming back of the colonic contents, with tenderness along this portion of the colon. Second, a frequent pericolic band seems to constrict the ascending colon upon a level with the ileocecal valve, producing a transverse, linear filUng-defect, and this is usually accompanied by ileal adhesions causing stasis. He also shows the roentgenogram of a case of pericolitis dextra, in which the cecum lies in the true pelvis and is loaded with bis- muth; the ascending colon is narrow, spastic and poorly filled; the hepatic flexure is high, and stringy mucous shadows are seen in the transverse colon. Skinner is careful to point out numer- ous possible sources of error in interpretation, especially spasm, and says: ''The disposition to take roentgenograms of the ab- dominal viscera at their face value is extremely dangerous, as there is probably nothing which lends itself so easily to interpre- tations of thought." Transposition. — Transposition of the colon is an interesting feature of the rare cases of situs viscerum inversus totalis, and a few cases have been reported by roentgen observers. Transpo- 528 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON sition of the colon may exist also without transposition of the other viscera (Fig. 492a). Intussusception. — Two cases of intussusception in which a roentgen examination was made have been noted in the literature. One case reported by Lehmann^^ was that of an eighteen-year- old patient. Upon introducing the enema it flowed without in- terruption to about the middle of the transverse colon. Here it Fig. 492a. — Transposition of the colon, wliich is otherwise normal. Confirmed by care- ful screen examination. The stomach was not transposed, nor was the heart. was definitely obstructed, and, after a little, the stream sent out a projection about 1 cm. broad along the upper and lower borders of the transverse, beyond the obstruction, and between these projections was an area of lessened density occupied by the invaginated small bowel. The invagination corresponded ex- actly to the roentgen findings. HIRSCHSPRUNG S DISEASE 529 The other case, recorded by Groedel,^^ was of a boy 7 years of age. With the enema the colon was visuahzed through- out and there was a slight retrograde filling of the ileum, but nothing distinctive was seen. Two days later an opaque meal was given. Eight hours afterward some of it had passed into the colon, but the terminal ileum was markedly dilated, and Groedel considered the picture typical of ileocecal stenosis. At operation 15 cm. of the bowel was found to be invaginated. Fig. 493. -Megasigmoid. The sigmoid was found at operation to be thin-walled and enormously distended. Hirschsprung's Disease (Megacolon) and Megasigmoid. — Congenital idiopathic dilatation of the colon is easily shown by the x-ray, and several observations have been published. A typical case is that reported by Linde and Kleiner. ^^ The child, a girl 3H years of age, was extremely constipated from birth, and had never had a bowel movement without an enema. The abdomen was protuberant. The roentgenogram of the enema-filled bowel shows the entire colon to be excessively broad and capacious and with very little haustration. Elonga- tion with dilatation of the sigmoid (megasigmoid) appears to_^be more frequent than the complete dilatation of Hirschsprung 31 530 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON (Beclere and Meriel).^^ Figure 493 is the roentgenogram of a case. Incompetence of The Ileocecal Valve. — Insufficiency of Bauhin's valve, permitting a retrogression of the cecal contents into the small intestine, has been given considerable attention from the roentgenologic viewpoint by Case,^^ Dietlen,^^ Groedel^^ and others. Case, who began his observations in 1910, has found the valve to be incompetent in about one-sixth of all cases examined with the enema. He uses an enema, made up with either barium or bismuth, which is warmed to a temperature of 100°F., and the container is held not higher than 2 feet above the patient. For the most part, the patients examined were suffering from gastro- intestinal symptoms and complained of constipation. In many cases he has also observed a reflux of ingested bismuth from the colon into the ileum. Case believes that incompetence of the valve is a significant abnormality, and that it is a common cause of ileal stasis. Dietlen avows his belief that, while the valve is incompetent in infants, it is normally competent in children and adults. He has been able to demonstrate insufficiency, usually by the enema but occasionally by the ingested meal, in a number of cases. Few of these patients were operated upon, but there were clinical or roentgenologic signs of various pathologic conditions such as chronic appendicitis, dilatation of the cecum, colitis, extrinsic tumors, perityphlitis with adhesions, obstipation and perichole- cystitis. In one or two of his cases the colon was presumably normal. In studying the ileocolic valve, Groedel uses 1 liter of an enema containing 300 gm. each of barium sulphate and bolus alba. After introducing the enema the patient is allowed to empty the bowel partially by natural defecation without un- usual effort. After this, if a large portion of the small bowel is retrogradely filled, a pathologic condition of Bauhin's valve may be assumed. In the majority of cases, he states, the cause is either a chronic catarrhal affection of the cecum, or a chronic INCOMPETENCE OF THE ILEOCECAL VALVE 531 perityphlitic process. Other causes include anatomic anomalies, nervous disturbances, dilatation of the ascending colon, ulcers and tumors of the valve-ring, cecum or cecal region. Singer and Holzknecht^^ noted incompetence of the valve in numerous cases of obstipation, and this occurred whether the cecum was dilated or not. The theory that the ileocolic valve is normally competent is supported by some of the anatomic and experimental studies which have been made. The work of Keith^^ has been adduced in corroboration. A recent monograph by Rutherford-" also substantiates this view. Contrary opinions regarding the competence of the valve and the significance of the incompetence shown by the x-ray have been advanced by numerous authorities. Some of these are frankly cited by Dietlen and Case. Relative to the matter of giving nutrient enemata, it has been shown that, at least in cer- tain cases, the valve permits the entry of an enema into the ileum. Senn^^ found by experiment that air at a pressure of Y4, to ly^ pounds would overcome the resistance of the valve, and thinks that this incompetency is caused by a lateral and longi- tudinal distention of the cecum which mechanically separates the margins of the valve. Hertz^^ declares unequivocally that the ileocecal sphincter does not prevent regurgitation into the ileum, as, in common with other observers, he has seen a bis- muth suspension pass into the ileum when run into the colon at a pressure as low as 1 foot of water. There can be no doubt, he says, that the function of the valve sphincter is, as Keith origi- nally suggested, to prevent the contents of the ileum passing too rapidly into the cecum. In our own work, with the enema given in the manner de- scribed, the clysma enters the ileum in the great majority of cases — probably three-fourths of them. The patients examined are of the character usually sent for the roentgen test ; most of them have gastro-intestinal symptoms of some sort, and many are constipated, but there is also a considerable number whose symptoms are found at operation to be due to various abdominal 532 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON lesions not involving the bowel, which is normal. The incompe- tence is of all degrees, ranging from a trivial backflow through the valve to an extensive filling. of the lower ileum (Figs. 494, Fig. 496. Fig. 497. Figs. 494, 495, 496, 497. — Barium in ileum from enema. 495, 496 and 497). Absolutely no relation has been noted be- tween this insufficiency and pathologic conditions,^ either in general or in particular. ENTEROLITHS 533 In the course of abdominal operations for various conditions, the late Dr. E. H. Beckman (Mayo Clinic) carefully examined the ileo-cecal region in a number of cases which had shown in- competence of the valve with the opaque enema, but he found no anatomic abnormality to account for it. It is doubtful whether an enema, put into the bowel under unphysiologic conditions, and necessitating at least a slight degree of hydrostatic pressure, would be a fair test of the physiologic competence of the valve. A regurgitation of the in- gested meal into the ileum, after once passing the valve, would Fig. 498. — Barium-coated scybalse in lower bowel resembling concretions. theoretically have greater import. But whether this indi- cates merely an unimportant perversion or laxity of function, or is significant of serious pathology, with possibilities in the way of differential diagnosis, remains to be determined. Enteroliths. — Besides the occasional presence of fecal con- cretions in the appendix, as mentioned under the latter subject, enteroliths of larger dimensions are sometimes discovered in the 534 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON intestine. Pfahler and Stamm-^ report a case in which the x-ray examination revealed an abnormal mass, IM inches in diameter, of slight opacity, occupying the pelvic, then the iliac region. Injection of the colon with an opaque enema showed definitely that the mass was in the cecum; it could be moved about within the cecum and ascending colon. It was partially dissolved by glycerin enemata, passed into the rectum, and was there broken up with the finger and removed. It proved to be a fecahth consisting mainly of magnesium phosphate. In Fig. 498 the barium-covered scybalae resemble concretions. Foreign Bodies. — The approximate localization of foreign bodies in the intestine is sometimes a matter of importance. For example, when anastomosis has been made with a Murphy button and the exit of the button is delayed, it is desirable to know w^hether it has passed into the colon or not. This can be done conveniently by giving an opaque clj^sma and noting whether or not the shadow of the button is enveloped in that of the enema. ^The method is applicable, of course, in the case of any opaque foreign body. Figures 499 and 500 illustrate a case in which a dental plate in the transverse colon was localized by an enema. Fistulae. — Following operations on the intestine or as a re- sult of disease, external fistulse sometimes develop, and it may be desirable to know the exact part of the bowel in which the fistulse originate, as w^ell as the extent of their ramifications. Ordinarily this can be learned by injecting the fistula with a bismuth-petrolatum paste. The paste may enter the bowel in sufficient quantity to \dsualize a segment of it, and thus show the point of communication (Fig. 501); if not, the colon may also be filled with an opaque enema. In occasional instances it may be doubtful whether or not a suppurating sinus following an abdominal operation has any connection with the bowel. In such cases we have made effect- ive use of a procedure suggested by E. S. Judd. The sinus is thoroughly injected with the paste, the external opening is sealed with gauze and adhesive plaster, and a roentgenogram is made. FISTULA 535 Fig. 499. — Dental plate, P, in bowel. Location uncertain. Fig. 500.-— Same case as in 499, twenty-four hours later. The enema locates the plate, P, in the transverse colon. Subsequently, the plate was passed in the stool. 536 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON Fig. 501." — Fecal fistula injected with thick barium-pap, showing its ramifications and point of communication with the colon. Fig. 501a. BECTTJM 537 A second roentgenogram is taken twenty-four hours later, after purging the patient ^"ith oil. If the second plate indicates a diminution of the paste, as shown by changes in the sinus-shadow, it is safe to assume that a fistulous connection with the bowel exists; otherwise not. Fig. 501 o illustrates an interesting post-operative condition. Following an operation on the left kidney fifteen years ago the patient developed a suppurating sinus which has continued ever since. An attempt to close it by operation ten years ago failed. Both these operations were done elsewhere. Another attempt was made here in Xovember, 1916. During this latter operation a small amount of a solution of methylene blue was injected iato the fistula, and some of it im mediately appeared in the patient's mouth. Because of insuperable difficulties the operation was abandoned and treatment with Beck's paste was directed. After the first injection of the paste, the patient was sent for roentgen examination. The roentgenogram ^Fig. oOla) shows the extensive suius ramifications. Some of the paste has entered the colon and the stomach is completely filled by it. Rectum. — Direct inspection of the rectum through the proc- toscope is. im.der ordinary circumstances, so far superior to other methods of examination that the aid of the x-ray is rarely called for. Occasionally, however, in the case of a rectal cancer, more expUcit information is desired as to the upper limit of involvement, and this is obtainable by the roentgen examina- tion. An instance is shown in Fig. 502. We have had an in- teresting case in which a fecahth obstructing the upper rectum was first detected by the x-ray (Fig. 503), no digital examina- tion having been made. The Colon after Operation. — When there are clinical indica- tions of acute intestinal obstruction following laparotomy, the question arises as to the fact of obstruction and its probable site, and exceptionally a roentgen examination may be permissible. In some of these instances Case-- has found it unnecessary to administer any opaque material, roentgen observations being 538 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON Fig. 502. — Cancer of upper rectum. Filling defect, F. D. Fig. 503. — Large fecalith, F, in rectum. Patient aged two years. THE COLON AFTER OPERATION 539 made possible by the gas-distention of the intestine. With acute colonic obstruction the haustral markings and the distri- bution of the gas were sufficient to identify the colon, while in acute obstruction of the small bowel its serrated contour and the parallel arrangement of its coils were equally characteristic. When circumstances allow the administration of a barium meal or enema the diagnosis can be made with greater certainty. Recurring cancer of the colon, after resection of the original growth, can, of course, be shown by the x-ray. Numerous Fig. 504. — Colon after ileosigmoidostomy. short-circuiting operations such as ileo-sigmoidostomy and ceco-sigmoidostomy are being performed, not only for the pallia- tion of otherwise inoperable conditions, but also for stasis. After any of these the functional results can be studied by the x-ray, frequently with profit and always with interest. Roent- gen observers agree without exception that after any anastomo- sis which leaves a blind sac of the colon proximal to the point of 540 MISCELLANEOUS LESIONS AND CONDITIONS OF COLON juncture, the sac tends to fill by a retrograde movement of the ingested meal, which may remain there for long periods. Among the interesting post-operative cases which we have examined was a patient who had a five-year history of abdominal discomfort and gas-distention. Four years ago her appendix was removed, without relief. Sixteen months ago an ileo- sigmoidostomy was done, but the results were disappointing. At this clinic the right half of the colon was resected and some improvement in the patient's condition resulted, but she still has some of her original symptoms. The roentgenogram (Fig. 504) shows the barium-filled colon, prior to the last operation. The enema divided at the point of anastomosis ; part of it entering the ileum, the loops of w^hich can be seen, and the other stream passed up through the sigmoid and descending colon. The two streams met at the hepatic flexure. REFERENCES 1. DoERiNG, H. : "Die Polyposis intestini und ihre Beziehung zur carcinomatosen Degeneration." Arch. f. klin. Chir., 1907, Ixxxiii, 194-227. 2. SopER, H. W. : "Polyposis of the Colon." Amer. Jour. Med. Sci., 1916, di, 405-09. 3. CoNNELL, F. G. : "Etiology of Lane's Kink, Jackson's Membrane and Cecum Mobile." Surg., Gynec. & Ohstet., 1913, xvi, 353- 59. 4. Wilms: "Das Coecum mobile als Ursache mancher Falle von sogenannter chronischer Appendicitis." Deutsch. Med. Wchn- schr., 1908, ii, 1756-58. 5. Case, J. T.: "X-ray Studies of the Ileocecal Region and the Appendix." Am. Quart. Roentgenol., 1912-13, iv, 77-109. 6. Hahsmann, T. : "Die verschiedenen Formen des Coecum mobile." Mitt. a.d. Grenzgeb. d. Med. u. Chir., 1913, xxvi, 596-616. 7. Beclere and Meriel: "L' exploration radiologique dans les affections chirurgicales de I'estomac et de I'intestin." Cong. Francais de Chir., 1912, xxv, 81. 8. ScHWARZ, G. : "The Movable Cecum: Its Demonstration by the Roentgen-rays." Arch. Diagnosis, 1910, iii, 242-44. 9. Jackson, J. N.: "Membranous Pericolitis." Surg., Gynec. & Ohstet, 1909, ix, 278-87. REFERENCES 541 10. Skinner, E. H.: "The Interpretation of Pericolic Membranes."' Am. Jour. Roentgenol, 1913-14, i, 474-86. 11. Lehmann, C: "Ein Fall von Invaginatio ileocoecalis im Rontgen- bilde." Fortschr. a.d. Geb. d. Rontgenstrahlen, 1914, xxi, 561- 62. 12. Groedel, F. M.: "Die Invaginatio ileocoecalis im Rontgenbild." Fortschr. a.d. Geb. d. Rontgenstrahlen, 1914-15, xxii, 206-08. 13. Linde, J. I. and Kleiner, S. B. : "A Case of Congenital Idiopathic Dilatation of the Colon (Hirschsprung's Disease)." Arch. PediaL, 1915, xxxii, 278-81. 14. Beclere and Mertel: Loc. cit., p. 91. 15. Case, J. T. : " Roentgenologic Observations on the Function of the Ileocolic Valve." Jour. A.M. A., 1914, Ixiii, 1194-98. "X- ray Observations on Colonic Peristalsis and Antiperistalsis, with Special Reference to the Function of the Ileocolic Valve." Med. Rec, 1914, Ixxxv, 415-26. 16. DiETLEN, H.: "Die Insuffizienz der Valvula ileocoecalis im Ront- genbild." Fortschr. a.d. Geb. d. Rontgenstrahlen, 1914, xxi, 23- 30. 17. Groedel, F. M.: "Die Insuffizienz der Valvula ileocoecalis im Rontgenbild." Fortschr. a.d. Geb. der Rontgenstrahlen, 1913, XX, 162-72. 18. Singer, G. and Holzknecht, G.: "Ueber objektive Befunde bei der spastischen Obstipation." Miinch. Med. Wchnschr., 1911. ii, 2537-39. 19. Keith, A.: Anatomical Society of Great Britain and Ireland, November, 1903, 7-20. 20. Rutherford, A. H. : "The Ileocecal Valve." New York, Hoeber, 1914, 61. 21. Senn, N.: "Experimental Surgery." Chicago, Keener, 1889, 491. 22. Hertz, A. F. : "Chronic Intestinal Stasis." Brit. Med. Jour., 1913, i, 817-21. 23. Ppahler, G. E. and Stamm, C. J.: "Diagnosis of Enteroliths by Means of Rontgen-rays." Surg., Gynec. & Obstet., 1915, xxi, 14-17. 24. Case, J. T.: "Roentgen Studies after Gastric and Intestinal Operations." Jour. A.M.A., 1915, Ixv, 1628-34. BIBLIOGRAPHIC INDEX Abbe, 468, 480 Adami and NichoUs, 122, 151 Alwens and Husler, 313, 317 Andral, 220, 239 Arnsperger, 302, 312 Auerbach, 495 Baetjer and Friedenwald, 113, 119 Balfour, 327 Balfour and Carman, 348 Barclay, 50, 70, 74, 94, 111, 118, 119, 137, 152, 294, 442, 449 Barclay and Ramsbottom, 293, 294, 311 Barret and Leven, 317, 318 Barsony, 328, 348 Basch, 242, 249 Bassler, 45, 73, 108, 109, 114, 119, 309, 312, 494, 495, 506 Beaumont, 106, 118 Beck, 349, 372 Becker, 302, 312 Beckman, 533 B^cl^re, 328, 378 B^clere and Meriel, 309, 312, 378, 385, 525, 530, 540, 541 Bergeim, Rehfuss and Hawk, 151, 152 Bergmann and Lenz, 442 Birch-Hirschfeld, 222, 239 Blake and Cannon, 321 Boas, 109 Boas and Ewald, 108 Bouchard, 493 Brinton, 214, 218 Brown, 488, 497, 506 Brugel and Kaestle, 378 Brugsch and Schneider, 220, 239 Brunner, 223, 240, 481, 485 Burchard, 292, 311 Buttei-worth, 292, 311 Cannon and Blake, 321 Carman, 243, 327 Carman and Balfour, 348 Carman and Moore, 213 Carman and Myer, 44, 73 Case, 320, 321, 322, 347, 349, 350, 370, 373, 447, 449, 497, 506, 508, 519, 525, 530, 531, 537, 540, 541 Chlumskij, 337, 348 Christie, 222, 223, 240 Clairmont and Haudek, 292, 311 Clendening, Outland and Skinner, 320, 347 Coffey, 498, 506 Cohn, 325, 348, 508, 509, 512, 513, 519 Cohnheim, 109 Cole, 31, 33, 103, 113, 118, 119, 349, 350, 373, 393, 428, 497, 506 Cole and George, 373 Combe, 493 Connell, 521, 522, 523, 540 Coolidge, 22 Cornil, 222, 239 Cronin, 220, 222, 239 Crump, 45, 73 Czerny, 337 Daniel, 495, 506 Dietlen, 509, 530, 531, 541 Dodd and Harmer, 150, 152 Doering, 520, 540 Downes and LeWald, 221, 239 Doyen, 337 Dunn and Howell, 315, 318 EiNHORN, 110, 119, 222, 239, 493, 494, 505 Ewald, 97, 108, 118, 148, 222 Ewald and Boas, 108 Ewald and Sievers, 108, 118 Caldwell, 350, 373 Falconer, 299, 311 CampbeU, 241, 249 Faroy, 222, 240 Cannon, 91, 101, 105, 107, 118, 135, Faulhaberm, 378, 385 143, 151, 152, 309, 378, 385 Faulhaberm and Redwitz, 322, 347 543 544 BIBLIOGRAPHIC INDEX Fenwick, 220, 239 Finney, 340 Finsterer, 337, 348 Flesch and Peteri, 313, 317 Frank, 446 Franke, 292, 311 Friedenwald and Baetjer, 113, 119 George, 349 George and Cole, 373 George and Gerber, 113, 114, 119, 508, 509, 519 George and Leonard, 350, 373 Gerber and George, 113, 114, 119, 508, 509, 519 Glenard, 307, 493 Graham, 172, 213 Graham and Thompson, 218 Graser, 467, 480 Gray, 118 Gray and Nesselrode, 241, 249 Griffin, 301, 312, 467, 468, 480 Griffin, Mayo and Wilson, 467, 480 Groedel, 102, 111, 112, 118, 119, 132, 151, 308, 312, 508, 519, 529, 530, 541 Haenisch, 436, 449 Harmer and Dodd, 150, 152 Hartel, 319, 320, 347 Hartman, Mikulicz and Polya, 343 Haudek, 28, 30, 33, 81, 114, 115, 116, 117, 120, 138, 139, 143, 147, 152, 252, 266, 291 Haudek and Clairmont, 292, 311 Hausmann, 525, 540 Hawk, Rehfuss and Bergeim, 151, 152 Hayes, 116, 120 Heichelheim, 108, 118 Heister, 438 Hemeke and Mikulicz, 418 Hemmeter, 250, 291 Henselmann, 508, 519 Hertz, 308, 312, 378, 385, 438, 443, 446, 449, 450, 466, 494, 495, 497, 499, 506, 508, 510, 519, 531, 541 Hess and Hildebrand, 302, 312 Hildebrand and Hess, 302, 312 Hirsch, 41, 73 Holding, 443, 449 HoUtsch, 222, 240 Holland, 293, 294, 311 Holzknecht, 48, 74, 86, 90, 101, 103, 117, 142, 144, 377, 440, 441, 449 Holzknecht and Kaufman, 100, 118 Holzknecht and Luger, 160, 170 Holzknecht and Robinsohn, 138 Holzknecht and Sgalitzer, 143, 152 Holzknecht and Singer, 508, 518, 531, 541 Houston, 438 Howell and Dunn, 315, 318 Husler and Alwens, 313, 317 Hiittenbach, 292, 295, 311 Imboden, 508, 510, 519 Jackson, 526, 527, 540 Jaugeas, 371, 373 Johnson, 316, 318 Jonas, 138, 152 Jordan, 440, 446, 447, 449, 496, 497, 506 Judd, 534 Kaestle, 99, 102, 106, 112, 118, 119, 134, 137, 151, 152, 308, 312 Kaestle and Brugel, 378 Kaestle, Rieder and Rosenthal, 101, 103, 118 Kampmann, 292, 311 Kaufman and Holzknecht, 100, 118 Keith, 495, 496, 506, 531, 541 Kemp, 108, 118 Ivienbock, 302, 312 Ivleiner and Linde, 529, 541 Klemperer, 108, 119 Koniger, 302, 312 Ladd, 313, 318 La Fetra, 315, 318 Lane, 307, 493, 494, 495, 496, 505 Lehmann, 528, 541 Lenz and Bergmann, 442 Leonard and George, 350, 373 Leube, 108 Leube and Riegel, 108 Leven and Barret, 317, 318 LeWald, 315, 316, 318, 468, 480 LeWald and Downes, 221, 239 LeWald and Pisek, 314, 318 LeWald and Satterlee, 112, 119, 143, 152 BIBLIOGRAPHIC INDEX 545 LeWald and Smith, 317, 318 Liertz, 508, 518 Linde and Kleiner, 529, 541 Lion and Moreau, 328, 348 Lipsitz and Neilson, 143, 152 Luger and Holzknecht, 160, 170 Lyle, 215, 218 Mathieu and Savignac, 327, 348 Mayo (C. H.), 299, 311, 352, 373, 477 Mayo (W. J.), 35, 201, 213, 327, 348, 386, 389, 428, 471 Mayo, Wilson and Griffin, 467, 480 Mayo-Robson, 327, 348 McDowell and Wilson, 251, 291 McGlannan, 215, 218 McGrath, 467, 480 McNeil, 221, 239 M6riel and Beclere, 309, 312, 378, 385, 525, 530, 540, 541 Meyers, 222, 240 MikuUcz, 457, 458, 472, 473, 474, 475, 477 Mikulicz, Hartman and Polya, 343 Mikulicz and Hemeke, 418 Mills, 222, 223, 240 Mixter, 498, 506 Moore, 292, 311 Moore and Carman, 213 Moreau and Lion, 328, 348 Morgan, 222, 223, 240 Moynihan, 336, 337, 348, 496, 506 Moynihan and Tatlow, 327, 328, 348 Muhlmann, 222, 223, 240 Myer, 118, 220, 222, 239, 242, 244, 249 Myer and Carman, 44, 73 Nassetti, 241, 249 Neilson and Lipsitz, 143, 152 Nesselrode and Gray, 241, 249 Neumann, 220, 239 Nicholls and Adami, 122, 151 OuTLAND, Skinner and Clendening, 320, 347 Paterson, 326, 348 Peteri and Flesch, 313, 317 Petit, 33 Pfahler, 349, 372, 497, 506 Pfahler and Stamm, 534, 541 Pisek and LeWald, 314, 318 Plummer, 33 Polya, Mikulicz and Hartman, 343 Portis, 30, 33 Ramsbottom and Barclay, 293, 294, 311 Redwitz and Faulhaberm, 322, 347 Rehfuss, Bergeim and Hawk, 151, 152 Reiche, 250, 252, 291 Reuben, 315, 318 Rhein and Sailer, 302, 312 Richter, 315, 318 Rieder, 111, 112, 113, 115, 119, 250, 441, 508, 509, 519 Rieder, Kaestle and Rosenthal, 101, 103, 118 Rieder and Rosenthal, 102, 118, 119, 151, 312, 385 Riegel, 108, 109, 113, 114, 148 Riegel and Leube, 108 Robinsohn and Holzknecht, 138 Robson, 327, 348 Rosenthal, Kaestle, Rieder, 101, 103, 118 Rosenthal and Rieder, 102, 118, 119, 151, 312, 385 Rowden, 328 Rubaschow, 350, 372 Rudniew, 220 Rutherford, 531, 541 Ruysch, 241 Sahli, 143 Sailer and Rhein, 302, 312 Salomon, 139 Satterlee and LeWald, 112, 119, 143, 152 Savignac and Mathieu, 327, 348 Schlesinger, 92, 93, 94, 118, 131, 151, 309, 312 Schneider and Brugsch, 220, 239 Schwarz, 100, 118, 292, 311, 441, 447, 449, 486, 487, 492, 500, 507, 526, 540 Selby, 525 Senn, 531, 541 Sever, 314, 318 Sgalitzer and Holzknecht, 143, 152 Sherren, 241, 249 Sievers and Ewald, 108, 118 Singer and Holzknecht, 508, 518, 531, 541 Skinner, 500, 507, 527, 541 546 BIBLIOGRAPHIC INDEX Skinner, Outland and Clendening, 320, Thompson and Graham, 218 347 Smith and LeWald, 317, 318 Soper, 520, 540 Soresi, 327, 348 Stamm and Pfahler, 534, 541 Stendel, 337 Stewart, 73, 74 Stiller, 82, 83, 86, 95, 117, 310, 312 Stockton, 309, 312 Sullivan, 369 Treitz, 377 Tuohy, 220, 229, 239 ViRCHOw, 467 Wade, 241, 249 Willox, 314, 318 Wilms, 413, 446, 524, 526, 540 Wilson, 468, 480 Wilson, Mayo and Griffin, 467, 480 Wilson and McDowell, 251, 291 Tatlow and Moynihan, 327, 328, 348 Wolfler, 337 Thompson, 214 Wulach, 111 INDEX OF SUBJECTS Abdominal wall, relation of, to normal stomach, 86 Abscess, fistulous appendiceal, 517 retrocecal, 517 subdiaphragmatic, appearance, 371 Adenoma, papillary, of stomach, 242 Aerophagy in infancy, 317 Air as medium, 26 Anesthesia, general, effect on gastro- spasm, 166 Antiperistalsis in abnormal stomach, 138 in gastric cancer, 189 ulcer, 267 in normal colon, 441 Antrum cardiacum, 79 pylori, 80 Apoplectic habitus, 83 Apparatus, roentgen-ray, 17 Appendicitis, chronic, 508 enterospasm from, 510 position of appendix in, 510 roentgenologic signs, 509, 511 Appendix, fistulous abscess of, 517 mobility of, 509 position of, in chronic appendicitis, 510 technic of examination, 510 Asthenia universalis congenita, 82 Atonic stomach, 94 Atropin sulphate test for indirect gas- trospasm, 164 Auto-intoxication from chronic in- testinal stasis, symptoms, 494 Barium cornstarch pap as medium, 76 sulphate as medium, 25, 75 Barium-acacia mixture as medium, 41 Bariumized gruel as medium, 42 Bassler's mixed-meal method of testing gastric motility, 114 Bauhin's valve, insufficiency of, 530 Belladonna test for indirect gastrospasm, 164 Benign tumors of stomach, case re- ports, 245-249 Bile, effect of, on appearance of gall- stones, 352 Bismuth oxychlorid as medium, 25 subcarbonate as medium, 25 subnitrate as medium, 25 Bismuth-acacia mixture as medium, 41 Blood-changes from roentgen ray, 30 Boas and Ew aid's test-breakfast, 108 Boas test for pyloric stenosis. 109 Calculi, renal, demonstrated by pyelogram, 357, 358 gall-stones and, differentiation of shadows from, 357 Cancer of colon, 450 case-reports, 455-466 demonstration of signs of, 450 filling-defects in, 450 conditions simulating, 451 from adhesions, 454 from diverticulitis, 455 from extrinsic tumors, 454 from gas collections, 451 from insufficient enema, 452 from localized spasm, 452 from pressure of spine, 454 interpretation, 455 obstruction in, 450 of stomach. See Gastric cancer. Carcinomatous gastric ulcer, 269 roentgen characteristics, 196 Cardiospasm, case reports, 58-62 demonstration of, method, 44 with sausage-skins, 45 differential diagnosis, 51 roentgen-ray characteristics, 50 Case observations, records of, 32 Cecum, fixation of, 523 migration of, 522 incomplete, 524 mobile, 524 et atonicum, 446 [547 548 INDEX OF SUBJECTS Cecum, rotation of, 522 Children, stomach in. See Stomach in infancy. Cholecystitis, Riedel's lobe in, 370 Cholesterin gall-stones, appearance, 352 Cicatricial stricture of esophagus, cases, 68-70 observation of, 65 Cirrhosis of stomach, 214 case reports, 217 characteristics, 214 clinical summary, 215 roentgenologic manifestations, 215 Coil, roentgen-ray, 17 Cole's gastric cycles, 103 Colitis, chronic, 486 case reports, 487-492 Colon, abnormal, 443 peristalsis in, 447 variations of position, 443 adhesions of, 447 after operation, roentgenology of, 537 anomalies of migration and rotation, 521 cancer of. See Cancer of colon. causes of displacement of, 445 congenital idiopathic dilatation of, 529 dilatation, 448 diminished mobility of, 446 filhng-defects in, causes, 446 gas in, simulating filling-defects in gastric cancer, 180 hypermotility of, 448 constipation from, 500 hyperperistalsis in, 447 hypomotility, 448 increased mobility of, 446 intussusception of, 528 irregularities of contour, 446 miscellaneous lesions of, 520 narrow, 448 non-rotation of, 445 normal, 436 antiperistalsis in, 441 capacity, 439 haustral segmentation in, 441 mobility, 440 motility, 442 peristalsis in, 440 position, 437 Colon, normal, variations in contour, 438 in position, 437 peristalsis in, exaggerated, 447 polyposis of, 520 ptosis of, 445 redundant, 448 situs transversus of, 443 transposition of, 527 tuberculosis of, 481 case reports, 481-485 Constipation, 493 adhesions in, 501 atonic type, 501 cecal type, 501 from hypermotility of colon, 500 Hertz's classification, 499, 500 definition, 490 hypertonic, 502 rectal type, 501 Skinner's types of, 500 spastic, 502 Coolidge roentgen-ray tube, 22 Cornstarch pap, as vehicle, prepara- tion of, 27 Cysts, dermoid, of stomach, 241 of liver, hydatid, appearance, 37 1 Dermoid cyst of stomach, 241 Developers, roentgen-ray, 22 Diaphragm, elevation of, 302 Diaphragmatic hernia, 301 case report, 304-307 paradoxic respiratory phenomenon in, 304 Dilatation of colon, congenital idio- pathic, 529 of esophagus, observation, 50 of ileum, 383 Diverticula, false, 467 of duodenum, 381 of stomach, 297 case-report, 301 Diverticulitis, 467 case reports, 469-477 differential diagnosis, 468 in cancer of colon, filling defects from, 455 pathology, 467 shadows in, 477 shadows in, conditions imitating, 478 haustral, 478 INDEX OF SUBJECTS 549 Diverticulitis, shadows in, rounded, 477 symptomatolog}', 4G8 Diverticulum of esophagus, cases, 63-65 classification, 62 observation of, 62 Duodenal, contour, irregularities of, causes, 380 Duodenal xilcer, 386 adhesions with, 390 alterations of gastric motility in, 406 of gastric tone in, 403 association ■with gastric ulcer, 268 bulbar deformity in, 396 accessory pocket in, 397 at basal border, 395 diverticulum in, 399 niche-tj'pe, 396 smaU, 397 with general distortion, 393 incisura type, 397 significance, 399 callous, 388 case reports, 412 common location, 388 concurrence with gastric ulcer, 412 deformity of duodenal contour in, 392 gastric hypermotility in, 406 hyperperistalsis in, 405 hypertonus in, 403 hypotonus in, 403 peristalsis in, 405 gastrospasm in, 408 hunger-pains of, 386 incisura in, 408 kissing, 388 macroscopic appearance, 388 old, 389 pathologic anatomy, 387 patholog}', 387 perforating, 390 roentgenologic signs, 392 direct, 392 indirect, 403 value, 411 scarring in, 388 sjTnptom-complex, 386 technic of roentgenologic examina- tion. 390 tenderness in. 411 Duodenum, abnormal, 380 delayed motility in, 382 diverticula of, 381 evidences of obstruction in, 381 hyperperistalsis of, 382 lessened mobility of, 382 normal, 374 anatomic divisions, 374 descending portion, 376 pars superior of, 374 peristaLsis in, 377 transverse portion, 377 Dj'schezia, 500 ExEMA, opaque, 27 medixims for, 27 Enterohths, 533 Enteroptotic habitus, 82 Enterospasm from chronic appendicitis, 510 Enterostomy, stomach after, 320 Epicardia, examination of, position of patient, 43 Esophagus, anatomic memoranda, 46 cicatricial strictures of, cases, 68-70 observation, 65 deformitj- of contour, observation of, 48 dilatation of, observation, 50 displacement, causes, 48 diverticulum of, cases, 63-65 classification, 62 observation of, 62 examination of, supplementary stom- ach examination with, 45 fistula of, 71 foreign bodies in, locahzation of, 71 interpretation of findings in, 46 miscellaneous lesions of, 71 movements, 47 normal, appearance, 47 obser\^ation of peristalsis in, 47 of obstruction in, 49 paralysis of, 71 pathologic appearance, 48 piles of, 73 polyps in, 73 roentgenographj- of, 44 media, 44 position of patient, 42, 43, 44 variations in technic, 44 550 INDEX OF SUBJECTS Esophagus, roentgenoscopy of, 39 barium-acacia mixture for, 41 bariumized gruel in, 42 bisniuth-acacia in, 41 position of patient, 39, 40 technic, 39 spasm of, 70 Eventration, 302 Ewald and Boas' test-breakfast, 108 Ewald's test-meal, 108 Fibromatosis of stomach, 214 case reports, 217 characteristics, 214 clinical summary, 215 roentgenologic manifestations, 215 Fibrosis of stomach, 214 case reports, 217 characteristics, 214 clinical summary, 215 roentgenologic manifestations, 215 Filling-defects in abnormal stomach, 126 in cancer of colon, 450 conditions simulating, 451 in gastric cancer, 173 at pars media, 178 pylorica, 178 determining permanence, 176 food masses simulating, 180 from faulty media, 179 gas in colon simulating, 180 hair-ball simulating, 180 imprisoned secretion simulating, 180 perigastric adhesions simulating, 184 retraction of belly-wall simulat- ing, 181 spasm of gastric musculature simulating, 183 spinal deformities simulating, 181 true and simulated, differentia- tion, 184 variations, 175 in stomach from causes other than cancer, 179 from extrinsic tumors, 185 from pressure against spine, 181 spastic, antispasmodic treatment, 184 Fish-hook stomach, 79, 87 acute, in gastric ulcer, 266 Fistulse, intestinal, 534 of esophagus, 71 Fixation of cecum, 523 Fluoroscopy. See also Roentgenoscopy. Food masses simulating filling-defects in gastric cancer, 180 Foot-switch for roentgenoscopy, 19 Foreign bodies in esophagus, localiza- tion of, 71 in stomach, 297 intestinal, 534 Fornix of stomach, 79 Fundus of stomach, 79 Gall-bladder diseases, 363 gastric disorders simulating, 370 symptoms in, 367 gastrospasm in, 159, 367 hyperperistalsis in, 370 indirect signs in, 363 relation of gastric disorders to, "367 six-hour residue in, 367 gall-stones in, appearance, 352 Gall-stones, calcified lymph-nodes and, differentiation, 357 case reports, 360-363 cholesterin, appearance, 352 effect of lime salts on appearance, 352 of liver-tissue on appearance, 353 factors affecting demonstrability, 352 faults in roentgenology of, 351 in gall-bladder, appearance, 352 mixed type, appearance, 352 percentage of incidence, 352 position of shadows from, 356 renal calculi and, differentiation of shadows from, 357 roentgenology in, 349 sources of error in demonstration, 360 technic of demonstration, 355 Gas as medium, 26 in colon simulating filling-defects in gastric cancer, 180 Gas-bubble in abnormal stomach, 133 in normal stomach, 99 Gastric cancer, 171 absence of peristalsis in, 189 alteration of pyloric function in, 186 INDEX OF SUBJECTS 551 Gastric cancer, altered capacity of stom- ach in, 191 motilitj' of stomach in, 189 size of stomach in, 191 antiperistalsis in, 189 broad incisura of, 191 case reports, 205-213 clinical data in, 172 colloid, 194 degenerative, 194 diagnosis, 171 early, 203 diffuse, 214 displacement of stomach in, 191 early, 202 evidences of inoperability in, 201 exaggerated peristalsis in, 189 filling-defects in, 173 at pars media, 178 pylorica, 178 determining permanence, 176 food masses simulating, 180 gas in colon simulating, 180 hair-ball simulating, 180 imprisoned secretion simulating, 180 perigastric adhesions simulating, 184 retraction of belly-wall simulat- ing, 181 spasm of gastric musculature simulating, 183 spinal deformities simulating, 181 true and simulated, differentia- tion, 184 variations, 175 forms, 192 fungous, 192 characteristic appearance, 194 gaping of pylorus in, 186 gastriculcer and, differentiation, 268 gastrospasm in, 157 persistent local, 191 hour-glass stomach in, 179 hypermotility in, 189 hypomotility in, 190 infiltrative, 192 latent, 202 lessened flexibility of stomach in, 190 Gastric cancer, lessened motility of stomach in, 190 metastasis, roentgen diagnosis, 201 mucoid, 194 roentgen characteristics, 196 operability, 198 pathology, 192 perversions of peristalsis in, 189 proliferative, 192 pyloric obstruction in, 188 roentgenologic manifestations, 172 scirrhous, 192 roentgen characteristics, 194 syphilis of stomach and, differentia- tion, 224 weak peristalsis in, 189 cycles of Cole, 103 disorders, relation of, to gall-bladder diseases, 367 simulating gall-bladder diseases, 370 hypermotiUty in duodenal ulcer, 406 hyperperistalsis in duodenal ulcer, 405 hypertonus in duodenal ulcer, 403 hypotonus in duodenal ulcer, 403 motility, alterations of, in duodenal ulcer, 406 neoplasms, benign, 172 peristalsis, alterations of, in duodenal ulcer, 405 retention in pyloric ulcer, 156 syphilis, 219 ulcer, 250 abnormalities of peristalsis in, 266 accessory pocket in, 256 acute fish-hook stomach in, 266 adhesion-band in, 259 antiperistalsis in, 267 association with duodenal ulcer, 268 carcinomatous, 252, 269 case reports, 271-291 classes of, 251 concurrence with duodenal ulcer, 412 contributory signs, 257 diagnosis, 250 differentiation of gastrospasm in, 261 diffuse gastrospasm in, 156 forms of gastrospasm in, 261 552 INDEX OF SUBJECTS Gastric ulcer, gastric cancer and, differ- entiation, 268 gastrospasm from, forms, 154 hour-glass stomach in, organic, 263 hj-potonus in, 264, 267 incisura in, 257-261 lessened mobiUt}' in, 267 niche in, 252 penetrating, 251 niche of, 124, 125 perforating, 251 accessor}- pocket, 124 residue in stomach in, 264 roentgenologic signs, 252 shallow, 251 spasmodic hour-glass stomach in, 261 manifestations, 257 syphihtic, 220 annular, 221 tender point in, 267 value of sign-groups in, 268 Gastritis, syphilitic, 220 Gastro-enterostomy, regurgitant vomit- ing after, case reports, 338-341 causes, 337 roentgenology- in, 336 stomach after, classes, 320 roentgenology of, 320 "s-icious circle after, case reports, 33S- 341 causes, 336 Gastro-intestinal tract, roentgenoscopy of, 29 Gastrojejiinal lolcer, postoperative, 326 case reports, 331-336 etiology, 327 grouping of roentgen phenomena in, 331 lessened mobility of stomach in, 330 obstructive sj-mptoms in, 330 six-hour retention in, 330 S3-mptoms, 327 Gastrojejunostomy, stomach after, roentgenology of, 321 Gastropex3', stomach after roentgen- ology of, 325 Gastroptosis, 307-311 clinical conception, 308 status of, 309 Gastroptosis, pyloroptosis as sign of 132 Gastrospasm, 153 case reports, 168-170 differentiation, 162 in gastric ulcer, 261 diffuse, in gastric ulcer, 156 effect of general anesthesia on, 166 etiolog}', 162 extrinsic, 158 forms of, in gastric ulcer, 261 from deformity of gastric outhne, 163 from disease conditions, 163 from gastric ulcer, forms, 154 hour-glass stomach in, 154 in cancer of stomach, 157 in duodenal ulcer, 408 in gaU-bladder disease, 159, 367 in pyloric ulcer, 156 incisura in, 154 indirect, atropin sulphate test for, 164 belladonna test for, 164 causes, 164 intrinsic, 158 manifestations, 162 persistent local, in gastric cancer, 191 total, 160 types, 154 with incisura, 154 Gastrostomy, stomach after, roent- genology of, 325 Habitus, apoplectic, 83 broad, 83 enteroptotic, 82 normal, S3 relation of, to position of stomach, 82-86 Hair-ball of stomach, 292 case-reports, 296, 297 etiology, 294 symptoms, 295 simulating filHng-defect in gastric cancer, 180 Haudek's double-meal method of test- ing gastric motility, 114 hubhohe, 81 Haustral segmentation in normal colon, 441 Hernia, diaphragmatic, 301 case report, 304-307 INDEX OF SUBJECTS 553 Hernia, diaphragmatic, paradoxic re- spiratory phenomenon in, 304 mucosae of stomach, 299 Hertz's classification of constipation, 499, 500 definition of constipation, 490 Hirschsprung's disease, 529 Hour-glass stomach, 121 causes, 122 congenital, 122 gastrospasm in, 154 in gastric cancer, 179 organic, in gastric ulcer, 263 simulation of, 124 spasmodic, in gastric ulcer, 261 varieties, 122, 123 Hubhohe, Haudek's, 81 Hunger-pains of duodenal ulcer, 386 Hydatid cysts of liver, appearance, 371 Hypermotility, gastric, in duodenal ulcer, 406 in abnormal stomach, 139 in gastric cancer, 189 of colon, 448 constipation from, 500 zone of, in abnormal stomach, 148 Hyperperistalsis in abnormal stomach, 135 in colon, 447 in duodenum, 382 in gall-bladder diseases, 370 Hypertonic stomach, 92 in duodenal ulcer, 403 Hypomotility in abnormal stomach, 143 in colon, 448 in gastric cancer, 190 zone of, in abnormal stomach, 148 Hypotonic stomach, 93 in duodenal ulcer, 403 Hypotonus in gastric ulcer, 264, 267 Ileocecal valve, incompetence of, 530 Ileum, abnormal, 383 dilatation of, 383 immobility of, 384 kinks of, 384 normal, 379 peristalsis in, 380 terminal segment, 379 obstruction in, causes, 384 ptosis of, 383 Incisura angularis, 79 broad, of gastric cancer, 191 cardiaca, 79 gastrospasm with, 154 in duodenal ulcer, 408 in gastric-ulcer, 257-261 Infants, stomach in. See Stomach in infancy. Intensifying screens for roentgen- ography, 22 Interrupter, roentgen-ray, 17 Interrupterless transformer, roentgen- ray, 18 Intestine, fistulse of, 534 foreign bodies in, 534 large, technic of roentgenologic ex- amination, 434-436 small, 374 abnormal, 380 miscellaneous lesions of, 429 case reports, 429-433 normal, 374 motility, 380 time for complete evacuation, 380 Intussusception of colon, 528 Iron, magnetic oxide, as medium, 25 Jackson's membrane, 526 Jejunal ulcer, postoperative, 326. See also Gastrojejunal ulcer, 'postoperative. Jejunum, abnormal, 382 normal, 377 course of first segment, 377 pendulum movements in, 378 peristalsis in, 378 rhythmic segmentation in, 378 obstruction in, causes, 382, 383 Keith's nodal tissue, 495 Kinematography, roentgen, 32 Kinks, Lane's, 494 Kontrastin as medium, 25 Lane's definition of chronic intestinal stasis, 493 kinks, 494 points of occurrence, 494 Leather-bottle stomach, 13S, 214 case reports, 217 characteristics, 214 clinical summary, 215 roentgenologic manifestations, 215 554 INDEX OF SUBJECTS Leube-Riegel test-dinner, 108 Leube's test-meal, 108 Linitis plastica, 214 case reports, 217 characteristics, 214 clinical summary, 215 roentgenologic manifestations, 215 Liver, 370 cancer of, appearance, 371 displacement, causes, 371 examination of, 370 hydatid cysts of, appearance, 371 increase of volume, causes, 370 local deformities, 370 roentgenology of, 370 Liver-tissue, effect of, on appearance of gall-stones, 353 Lymph-nodes, calcified gall-stones and, differentiation, 357 Magenblase, 79 Mediums for visualization, 25 Megacolon, 529 Megasigmoid, 529 Membrane, Jackson's, 526 Migration of cecum, 522 incomplete, 524 Mobility, lessened, in gastric ulcer, 267 Niche in gastric ulcer, 252 Nodal tissue, Keith's, 495 ^k Obstipation, chronic, dyskinetic, 500 hypokinetic, 500 Opaque enema, 27 mediums for, 27 meal, Rieder's for testing gastric motility. 111 salts as media, 25 quantities used, 28 for tests of gastric motility, 110 Operator, protective measures for, 30 Orthotonic stomach, 92 Oxide of iron, magnetic, as medium, 25 of thorium as medium, 25 of zirconium as medium, 25 Oxychlorid of bismuth as medium, 25 Palpation before roentgenoscopy, 30 Papillary adenoma of stomach, 242 Paralysis of esophagus, 71 Pars cardiaca, 79 Pars intermedia, 79 media, 79 filling-defects at, in gastric cancer, 178 pylorica, 80 filling-defects at, in gastric cancer, 178 Patient, preparation of, 24, 30 for examination of stomach, 75 protective measures for, 31 Pendulum movements in normal jeju- num, 378 Peridiverticulitis, 467 Perigastric adhesions simulating filling- defects in gastric cancer, 184 Peristalsis, abnormahties of, in gastric ulcer, 266 absent, in gastric cancer, 189 exaggerated, in gastric cancer, 189 in abnormal stomach, 134 absence of, 135 in colon, exaggerated, 447 in duodenal ulcer, 403 in normal colon, 440 duodenum, 377 ileum, 380 jejunum, 378 stomach, 100 delayed, 105 varieties, 102 lack of, in infancy, 313 of esophagus, observation of, 47 perversions of, in gastric cancer, 189 weak, in gastric cancer, 189 Permanent record, 33 Piles, esophageal, 73 Plates, roentgen-ray, 22 Pocket, accessory, in gastric ulcer, 256 in stomach, 299 Polyposis of colon, 520 of esophagus, 73 of stomach, 241, 243 Preparation of patients, 30 for examination of stomach, 75 Protective measures for operator, 30 for patient, 31 Ptosis of colon, 445 of ileum, 383 Pyloric ring, 80 ulcer, gastric retention in, 156 gastrospasm in, 156 INDEX OF SUBJECTS 555 Pyloroplasty, stomach after, roentgen- ology of, 321, 325 Pyloroptosis as sign of gastroptosis, 132 Pylorospasm, gastric retention from, 142 Pylorus after operation, roentgenology of, 321 alteration of function, in gastric can- cer, 186 congenital stenosis in infancy, 315 gaping, in gastric cancer, 186 obstruction at, in gastric cancer, 188 positions of, in abnormal stomach, 131 stenosis of, Boas' test for, 109 Radiography, serial, 31 Recapitulation records, 33 Records of case observations, 32 permanent, 33 recapitulation, 33 Rectum, roentgenology of, 537 References to literature, 33, 73, 117, 151, 213, 218, 239, 291, 311, 317, 347, 373, 385, 428, 449, 480, 485, 492, 505, 518, 540 Retrocecal abscess, 517 Rhythmic segmentation in normal jeju- num, 378 Riedel's lobe in cholecj^stitis, 370 Rieder's opaque meal for testing gastric motility, 111 Riegel test-dinner, 108 Ring, pyloric, 80 Roentgen ray, kinematography, 32 and stomach tube findings in gastric motility, comparison, 148 apparatus, 17 blood-changes from, 30 coil, 17 developers, 22 interrupter, 17 plates, 22 steriUty from, 30 table, 20 transformer, 18 interrupterless, 17, 18 tubes, 21 Coolidge, 22 Roentgenogram, exposure necessary for, 23 Roentgenography, diagnosis by, haz- ards of, 36 Roentgenography, intensifying screens for, 22 when preferable, 31 diagnosis by, essentials for, 38 differential diagnosis in, 35 findings by, correlation with clinical findings, 37 interpretation of findings in, 34 re-examination in, 35 Roentgenoscopy, foot switch for, 19 of gastro-intestinal tract, 29 palpation before, 30 preparation of observer's eyes for, 29 protective measures for operator, 30 room-light for, 30 tube stand for, 20 vertical screen apparatus for, 18 when preferable, 31 Room-light for roentgenoscopy, 30 Rotation of cecum, 522 Sahli's capsules for differentiating causes of gastric retention, 143 opaque capsules for determining secretion in fasting stomach, 99 Salts, opaque, as media, 25 Sausage-skins for demonstrating cardio- spasm, 45 Schlesinger's classification of stomach tonus, 92 Schwarz's fibrodermic capsules for determining digestive power of stom- ach, 100 Screen apparatus, vertical, for roent- genoscopy, 18 examination. See Roentgenoscopy. intensifying, for roentgenography, 22 Serial radiography, 31 Six-hour meal for visualization, 28 advantages, 29 in examination of stomach, 75 zones of motility based on, in ab- normal stomach, 146 Skinner's types of constipation, 500 Spasm of esophagus, 70 Spasmodic hour-glass stomach in gas- tric ulcer, 261 Spinal deformities simulating filling- defects in gastric cancer, 181 Stasis, chronic intestinal, 493 556 INDEX OF SUBJECTS Stasis, chronic intestinal, auto-intoxica- tion from, symptoms, 494 Lane's definition, 493 roentgenologic signs in, 496 Steer-horn stomach, 79, 87 Stenosis of pylorus, congenital, in in- fancy, 315 Sterility from roentgen-ray, 30 Stomach, abnormal 121 absence of peristalsis in, 135 alterations in size, 132 of tone, 129 altered mobility, 132 position, 131 antiperistalsis in, 138 causes of retention in, 142 changes of contour, 124 disordered motOitj'- in, 139 filling-defects in, 126 gas-bubble in, 133 gastrospasm from, 163 hypermotility in, 139 hyperperistalsis in, 135 hypertonic, 129 hypomotihtj^ in, 143 hypotonic, 131 incisura in, 126, 129 lessened flexibility of, 133 motUitj', comparison of roentgenray and stomach tube findings, 148 six-hour meal test for, 148 motor-meal in, 140 peristalsis in, 134 positions of pylorus in, 131 retention in, 141 double-meal method in, 144 from pylorospasm, 142 incidence, 150 Sahh's capsules for determining cause of retention in, 143 secretion in, 134 significance of retention in, 145 six-hour residue in, 141 variations in form, 121 zone of hypermotUity in, 148 of hypomotility in, 148 zones of motility based on six-hour meal, 146 accessory pocket in, 299 after enterostomj^, roentgenology of, 319 Stomach after gastro-enterostomj^, classes, 320 roentgenology of, 320 after gastrojejunostomy, roentgen- ology of, 321 after gastropexy, roentgenology of, 325 after gastrostomy^, roentgenology of, 325 after operation, roentgenology of, 319 after pyloroplasty, roentgenology of, 321, 325 altered capacity of, in gastric cancer, 191 size of, in gastric cancer, 191 anatomic parts, 78 antrum pylori of, 80 ascending arm of, 81 atonic, 94 benign tumor-producing lesions, 241 tumors of, case reports, 245-249 body of, 79 cancer of. See Gastric cancer. carcinomatous ulcer of, roentgen characteristics, 196 cirrhosis of, 214 case reports, 217 characteristics, 214 clinical summary, 215 roentgenologic manifestations, 215 dermoid cyst of, 241 descending arm of, 80 digestive power of, Schwarz's fibro- dermic capsules for determining, 100 displacement of, in gastric cancer, 191 diverticula of, 297 case report, 301 examination of, 75 preparation of patient, 75 supplementary to examination of esophagus, 45 technic, 75 fasting, Sahli's opaque capsules for determining, secretion, 99 fibromatosis of, 214 case reports, 217 characteristics, 214 cUnical summary, 215 roentgenologic manifestations, 215 fibrosis of, 214 case reports, 217 characteristics, 214 INDEX OF SUBJECTS 557 Stomach, fibrosis of, clinical summary, 215 roentgenologic manifestations, 215 filling-defects in, from causes other than cancer, 179 from extrinsic tumors, 185 from faulty media, 179 from pressure against spine, 181 spastic, antispasmodic treatment, 184 fish-hook, 79 acute, in gastric ulcer, 266 fixing supports of, 97 flexibility of, lessened, in gastric cancer, 190 foreign bodies in, 297 fornix of, 79 fundus of, 79 gastrospasm from deformity of out- line, 163 hair-ball of, 292 case-reports, 296, 297 etiology, 294 symptoms, 295 hernia mucosae of, 299 hour-glass, 121 causes, 122 congenital, 122 gastrospasm in, 154 in gastric cancer, 179 organic, in gastric ulcer, 263 simulation of, 124 spasmodic, in gastric ulcer, 261 varieties, 122, 123 hypertonic, 92 hypotonic, 93 in infancy, forms, 314 lack of peristalsis in, 313 normal, 313 position, 314 incisura angularis of, 79 cardiaca of, 79 leather-bottle, 133, 214 case reports, 217 characteristics, 214 clinical summary, 215 roentgenologic manifestations, 215 lengthened, 309 mobility, lessened, in postoperative gastrojejunal ulcer, 330 lessened, in gastric cancer, 190 Stomach, altered motility of, in gastric cancer, 189 tests, 110 Bassler'smixed-mealmethod, 114 Haudek's double-meal method, 114 opaque salts for, 110 vehicles for. 111 normal, contour, 97 effect of tone of musculature on, 86 emptying time, 112 fasting, secretion in, 99 fish-hook, 87 flexibihty, 99 forms of, 87 gas-bubble in, 99 hypermotility in, 117 mobility, 97 motility, 106, 116 motor function, 106, 107 peristalsis in, 100 delayed, 105 varieties, 102 position, 95 relation of abdominal wall to, 86 retention of food by, 109 roentgen-ray appearance, 82 size, 96 steer-horn, 87 variations of motility in, 107 zone of motility in, 147 organic deformity of lumenal con- tour, significance, 153 orthotonic, 92 papillary adenoma of, 242 pars cardiaca, of, 79 intermedia of, 79 media of, 79 pylorica of, 80 polyposis, 241, 243 position of, relation to habitus, 82-86 post-operative complications in, roent- genology of, 326 recurrence of lesions after operation on, 341-347 residue in, in gastric ulcer, 264 roentgen anatomy of, 77 roentgenography of, 77 roentgenoscopy of, 75 sleeve resection, roentgenology after, 322 558 INDEX OF SUBJECTS Stomach, steer-horn, 79 syphihs of, 219 case reports, 224 cirrhotic, 221 gastric cancer and, differentiation, 224 gummata in, 221 infiltrative, 221 microscopic examination in, 219 roentgenologic manifestations, 224 symptoms, 221, 223 tertiary, 220 tumor-producing, 221 varieties, 220 Wassermann test in, 219 test for normal tone, 94 tone, 92 alteration of, in duodenal ulcer, 403 trichobezoar of, 292 ulcer of. See Gastric ulcer. water-trap, 143 retention in, 112 Stomach-tube and roentgen-ray findings in gastric motility, comparison, 148 Strictures, cicatricial, of esophagus, cases, 68-70 observation of, 65 Subcarbonate of bismuth as medium, 25 Subdiaphragmatic abscess, appearance, 371 Subnitrate of bismuth as medium, 25 Sulphate of barium as medium, 25 Syphihs of stomach, 219 case reports, 224-239 cirrhotic, 221 gastric cancer and, differentiation, 224-239 gummata in, 221 infiltrative, 221 microscopic examination in, 219 roentgenologic manifestations, 224 symptoms, 221, 223 tertiary, 220 tumor-producing, 221 varieties, 220 Wassermann test in, 219 Syphilitic gastric ulcer, 220 gastritis, 220 Table, roentgen ray, 20 Technic, general, 24 Test-breakfast, Ewald-Boas, 108 Test-dinner, Leube-Riegel, 108 Test-meals, 108 Thorium oxid as medium, 25 Transformer, interrupterless, for roent- gen ray, 17, 18 roentgen ray, 18 Transposition of colon, 527 Trichobezoar of stomach, 292 Tuberculosis of colon, 481 case reports, 481-485 Tubes, roentgen ray, 21 Coolidge, 22 Tube-stand for roentgenoscopy, 20 Tumors, extrinsic, in cancer of colon, filling-defects from, 454 of stomach, benign, case reports, 245-249 Ulcer, carcinomatous, of stomach, roentgen characteristics, 196 duodenal. See Duodenal ulcer. gastric. See Gastric ulcer. gastrojejunal, postoperative, 326. See also Gastrojejunal ulcer, post- operative. jejunal, postoperative, 326. See also Gastrojejunal ulcer, postoperative. of stomach. See Gastric ulcer. Vehicles for visuaHzation, 26 Vertical screen apparatus for fluoro- scopic examinations, 18 Vicious circle after gastro-enterostomy, case reports, 338-341 causes, 336-338 roentgenology in, 336-338 Visualization media, 25 six-hour meal for, 28 advantages, 29 vehicles for, 26 Vomiting, regurgitant, after gastro-enter- ostomy, case reports, 338-341 causes, 337 roentgenology in, 336-338 Wassermann test in syphilis of stomach, 219 Water-trap stomach, 143 retention in, 112 X-RAY. See also Roentgen ray. Zirconium oxid as medium, 25 SAUNDERS' BOOKS — on Practice, Pharmacy, Materia Medica, Thera> peutics. Pharmacology, and the Allied Sciences W. B. SAUNDERS COMPANY WEST WASHINGTON SQUARE PHILADELPHIA 9, HENRIETTA STREET, COVENT GARDEN, LONDON Carman €? Miller*s X-ray Diagnosis Rontgenology of the Qastro=intestinaI Tract. By Russell D. Carman, M. D., Head of Section on Rontgenology, and Albert Mil- ler, A. B., M. D;, Second Assistant in Section on Rontgenology, Division of Medicine in The Mayo Clinic, Rochester, Minnesota. Octavo of 550 pages, with 504 illustrations. [Published May, 1917. Cloth, $6.00 net; Half Morocco, ^7.50 net. COMPREHENSIVE IN DETAIL This work takes up the diagnosis of disease of the alimentary tract, following its course from the esophagus to the rectum. You are told what apparatus is needed, and exactly how to use it, with formulas for the barium meal and enema. You are given the Rontgen appearance of the normal organ under discussion, what appearances signify abnormality, and exactly how to detect abnormality. Then you get the Rontgenologic symptoms of every disease of the organ, followed by several actual examples of each to show individual variaf-ons, and an exten- sive bibliography on every topic. A few of the important topics treated are early cancer, diverticula, gastroptosis, "himger-pain" in duodenal ulcer, Lane's kinks. SAUNDERS' BOOKS ON A NEW CLINICAL PUBLICATION The Medical Clinics of North America Issued serially, one octavo of 225 pages, illustrated, every other month. Sold only by the Clinic Year (July to May), six volumes. Cloth, $14.00 net; Paper, $10.00 net. In The Medical Clinics of North America subscribers will receive a postgraduate course of unusual scope, giving them the clinical teaching of the great medical centers of the country. Each number will be a hand- some octavo volume devoted exclusively to the work of ane medical center. The Baltimore Number (Johns Hopkins Hospital) : Dr. Theodore C. Janeway Dr. Herman C. Mosenthal Dr. Louis Hamman Dr. Lewellys F. Barker Dr. Thomas R. Brown Dr. Thomas B. Futcher The Philadelphia Number (University of Pennsylvania and Jefferson Medical College): Dr. Alfred Stengel Dr. Thomas McCrae Dr. Theo. H. Weisenburg Dr. Joseph Sailer Dr. Hobart A. Hare Dr. Judson Daland Dr. A. A. Stevens Dr. Elmer H. Funk Dr. Henry K. Pancoast Dr. John H. Musser, Jr. Dr. Martin E. Rehfuss Dr. Jay Frank Schamberg Dr. O. H. P. Pepper Dr. Ross V. Patterson Dr. David Riesman Dr. John A. Kokner The New York Number (Columbia, Bellevue, Cornell and Post-Graduate Schools; Presbyterian, St. Luke's, Post-Graduate, New York, Mt. Sinai, and Bellevue Hospitals): Dr. W. T. Longcope Dr. Arthur F. Chase Dr. Emmanuel Libman Dr. Homer Swift Dr. Ed. Quintard Dr. Harlow Brooks Dr. Henry R. Geyelin Dr. Ludwig Kast Dr. Malcolm Goodridge Dr. Samuel W. Lambert Dr. Louis A. Conner Dr. Alfred Hess Dr. L. F. Frissell Dr. W. R. Williams Dr. Frederick Tihiey Dr. W. A. Bastedo Dr. Marcus A. Rothchild The Boston Number will include Harvard, Massachusetts General Hos- pital, Boston City Hospital, and Peter Bent Brigham Hospital. The Chicago Number will include the institutions familiar to our sub- scribers through the Chicago Clinics. Goepp's Medical State Boards Fourth Edition published March, 1917 State Board Questions and Answers. By R. Max Goepp, M. D., Professor of Clinical Medicine, Philadelphia Polyclinic. Octavo of 723 pages. Cloth, $4.25 net. This book will help you to pass any State Board Examination, those for army and na^T appointments, intern- ships, etc. Also a quick reference work. For instance: You want to know the technic of the Wassermaim- Noguchi Reaction, or of the "606" treatment of syphilis. The complete inde.x gives you the page, and in an in-stant you have before you definite, concise descriptions. " Nothing has been printed which is so admirably adapted as a guide and self -quiz for those intending to take the State Board Examinations." — Pennsylvania Medical Journal. DIAGNOSIS AND TREATMENT Cabot's Works on Diagfnosis Differential Diagnosis. Presented through an Analysis of Cases. By Richard C. Cabot, M. D., Assistant Professor of Clinical Medi- cine, Harvard Medical School, Boston. Each volume an octavo of about 750 pages, illustrated. Per volume : Cloth, f6.oo net. Dr. Cabot's work takes up diagnosis from the point of view of \he presenting symptovi — the symptom in any disease which holds the foreground in the clinical picture : the principal complaint. It groups diseases under these symptoms, and points the way to proper reasoning in coming to a correct diagnosis. It works backward from each leading symptom to the actual organic cause of the symptom. This the author does by means of case-teaching. The syfuptom- groups in Volume I (Third Edition— January, 1915) are: Headache, gen- eral abdominal pain, epigastric pain, right hypochondriac pain, left hypochondriac pain, right iliac pain, left iliac pain, axillary pain, pain in arms, pain in legs and feet, fevers, chills, coma, convulsions, weakness, cough, vomiting, hematuria, dyspnea, jaundice, and nervous- ness — 21 symptoms and 385 cases. Volume II (December, 1914) : Abdominal and other tumors, vertigo, diarrhea, dyspepsia, hematemesis, enlarged glands, blood in stools, swelling of face, hemoptysis, edema of legs, frequent micturition and polyuria, fainting, hoarseness, pallor, swelling of arm, delirium, pal- pitation and arhythmia, tremor, ascites and abdominal enlargement — a total of 19 symptoms and 317 instructive cases. Morrow's Diagnostic and Therapeutic Technic Diagnostic and Therapeutic Technic. By Albert S. Morrow, M. D., CHnical Professor of Surgery, New York Polyclinic. Octavo of 834 pages, with 860 original line drawings. Cloth, $5.50 net. SECOND EDITION Dr. Morrow's new work is decidedly a work for you — the physician engaged :n general practice. It is a work you need because it tells you just how to perform ctiose procedures required of you every day, and it tells you and shows you by clear, new line-drawings, in a way never before approached. It is not a book on drug therapy ; it deals alone with physical or mechanical diagnostic and thera- peutic measures. The information it gives is such as you need to know every day — transfusion and infusion, hypodermic medication, Bier's hyperemia, explora- tory punctures, aspirations, anesthesia, etc. Then follow descriptions of those measures employed in the diagnosis and treatment of diseases of special regions or organs: proctoclysis, cystoscopy, etc. Journal American Medical Association "The procedures described are those which practitioners may at some time be called on to perform.'" Published January, 1915 SAUNDERS' BOOKS ON Musser and Kelly on Treatment Practical Treatment. By io8 eminent specialists. Volumes I, II, and III, edited by John H. Musser, M. D., and A. O. J. Kelly, M. D. Each an octavo of 950 pages, illustrated. Cloth, ;$6.oo net; Half Mo- rocco, ^6.50 net. Volume IV, edited by John H. Musser, Jr., M. D., and Thomas C. Kelly, M. D. Octavo of 990 pages, illustrated. Cloth, ;g7.00net; Half Morocco, $8.50 net. PubUshed May, 1917. Subscription. VOLUME IV— All the New Treatments— JUST OUT With Musser and Kelly's Treatment within arm's reach you have at your instant command the combined experience and teachings of 108 leading internists and specialists of America and England. In many cases you get the actual pre- scrzp f ions used hy these authorities. The past few years have seen radical de- velopments in medicine ; it is these new developments that constitute the subject- matter of Volume IV. Bacteriology, the endocrine glands, serum therapy, syn- thetic chemistry, new surgical and non-medical treatments — these are only a few of the subjects covered. Remember, Musser and Kelly's Treatment covers the entire field. It is a Treatment that will give you more service — better service — han any other. Thomson's Clinical Medicine Clinical Medicine. By William Hanna Thomson, M. D., LL. D., formerly Professor of the Practice of Medicine and of Diseases of the Nervous System, New York University Medical College. Octavo of 675 pages. Cloth, ;^5.oo net; Half Morocco, ^6.50 net. TWO PRINTINGS IN FOUR MONTHS This new work represents over a half centttry of active practice and teach- i7ig. It deals with bedside medicine — the applicatio7i of medical knowledge for the relief of the sick. First the meaning of common and important symptoms is stated definitely ; then follows a chapter on the use of remedies and a classifi- cation of them ; next the section on infections, and last a section on diseases of par- ticular organs and tissues. It is medical knowledge applied — from cover to cover. An important chapter is that on the mechanism of surface chill and "catching cold," going very clearly into the etiologic factors, and outlining the treatment. The chapter on remedies takes up non-medicinal and medicinal remedies and vaccine and serum thera^py. In the chapter on the ductless glands the subject of inter7ial secretions is \exy clearly presented, giving you the latest advances. The infectious diseases are taken up in Part II, while Part III deals with diseases of ipecial organs or tissues, every disease being fully presented from the clinical side. Treatment, naturally, is very full. Published Ju^i^, 1^14 PRACTICE OF MEDICINE Ward's Bedside Hematolog'y Bedside Hematology. By Gordon R. Ward, M.D., Fellow ol the Royal Society of Medicine, London, England. Octavo of 394 pages, illustrated. Published April, 1914. Cloth, ^3.50 net. INCLUDING VACCINES AND SERUMS Dr. Ward's work gives you the exact technic for obtaining the blood for ex- amination, the making of smears, the blood-count, finding coagulation time, etc, Then it takes up each disease, giving you the synonyms, definition, nature, gen- eral pathology, etiology, bearings of age and sex, the onset, symptomatology (dis- cussing each symptom in detail), course of the disease, clinical varieties, compli- cations, diagnosis, and treatment (drug, diet, rest, vaccines and sertans, etc.). Faught*s Blood-Pressure Blood = Pressure from the Clinical Standpoint. By Francis A. Faught, M. D., formerly Instructor :n Medicine, Medico-Chirurgical College of Philadelphia. Octavo of475 pages, illustrated. Cloth, ^3.25 net. SECOND EDITION— published November. 1916 Dr. Faught' s book is designed for practical help at the bedside. Besides the actual technic of using the sphygmomanometer in diagnosing disease, Dr. Faught has included a brief general discussion of the process of circulation. The practical application of sphygmomanometric findings within recent years make it imperative for every medical man to have close at hand an up-to-date work on this subject. Smith's What to Eat and Why What to Eat and Why. By G. Carroll Smith, M.D., Boston. I2mO of 377 pages. Cloth, $2.75 net. Published September, 1915 SECOND EDITION With this book you no longer need send your patients to a specialist to be dieted — you will be able to prescribe the suitable diet yourself just as you do other forms of therapy. Dr. Smith gives the "why" of each statement he makes. It is this knowing why which gives you confidence in the book, which makes you feel that Dr. Smith knows. Pennsylvania Medical Journal "All through this book Dr. Smith has added to his dietetic hints a great many valuable ones oi a general nature, which will appeal to the general practitioner SAUNDERS' BOOKS ON Kolmer's Specific Therapy Infection, Immunity, and Specific Therapy. By John A. Kolmer, M, D., Dr. p. H., Assistant Professor of Experimental Pathology, Uni- versity of Pennsylvania. Octavo of 900 pages, with 143 original illus- trations, 43 in colors, drawn by Erwin F. Faber. New (2d) Edition ready August. 1917. ORIGINAL ILLUSTRATIONS Dr. Kolmer's book gives you a full account of infection and immunity, and the application of this knowledge in the specific dia,gnosis, prevention, and treat- ment of disease. The section devoted to immunologic techtiic gives you every de- tail, from the care of the centrifuge and making a simple pipet to the actual pro- duction of serums and vaccines. Under specific therapy you get methods of making autogenous vaccines and their actual use in diagnosis and treatment. The directions for injecting vaccines, serums, salvarsan, etc.- — with the exact dosage — are here given so clearly that you will be able to use these means of treatment in your daily practice. You also get full directions for making the clinical diagnostic reactions — the various tuberculin tests, luetin, mallein, and similar reactions, all illus- trated with colored plates. The final section is devoted to laboratory experiments. Anders £^ Boston's Medical Diag'nosis (Published July, 1914) A Text-Book of Medical Diagnosis. By James M. Anders, M. D., Ph.D., LL.D., Professor of Medicine, and L. Napoleon Boston, M.D., Professor of Physical Diagnosis, Medico-Chirurgical College, Graduate School of Medicine, University of Pennsylvania. Octavo of 1 248 pages, with 466 illustrations. Cloth, |6.oo net ; Half Morocco, ;^7.50 net. SECOND EDITION This new edition is designed expressly for the general practitioner. The methods given are practical and especially adapted for quick reference. The diagnostic methods are presented in a forceful, definite way by men who have had wide experience at the bedside and in the clinical laboratory. The Medical Record " The association in its authorship of a celebrated clinician and a well-known laboratory worker is most fortunate. It must long occupy a pre-eminent position." THE PRACTICE OF MEDICINE Anders' Practice of Medicine A Text=Book of the Practice of Medicine. By James M. Anders, M. D., Ph. D., LL. D., Professor of Medicine, University of Pennsylvania. Handsome octavo, 1336 pages, fully illustrated. Cloth, $5.50 net; Half Morocco, ^7.00 net. Published September, 1915 TWELFTH EDITION The success of this work is no doubt due to the extensive consideration given to Diagnosis and Treatment, under Differential Diagnosis the points of distinction of simulating diseases being presented in tabular form. In this new edition Dr. Anders has included all the most important advances in medicine, keeping the book within bounds by a judicious elimination of obsolete matter. A great many articles have also been rewritten. Wm. E. Quine, M. D., Professor of Medicine and Clinical Medicine, College of Physicians and Surgeons, Chicago. " I consider Anders' Practice one of the best single-volume works before the profession at this time, and one of the best text-books for medical students." DaCosta's Physical Dia^^nosis Physical Diagnosis. By John C. DaCosta, Jr., M. D., Associate Professor of Medicine, Jefferson Medical College, Philadelphia. Octavo of 589 pages, with 243 original illustrations. Cloth, $3.50 net THIRD EDITION— published November, 1915 Dr. DaCosta' s work is a thoroughly new and original one. Every methodi given has been carefully tested and proved of value by the author himself. Normal physical signs are explained in detail in order to aid the diagnostician in determining the abnormal. Both direct and differential diagnosis are emphasized. The cardinal methods of examination are supplemented by full descriptions of technic and the clinical utility of certain instrumental means of research. Dr. Henry L. Eisner, Professor of Medicine at Syracuse University. " I have reviewed this book, and am thoroughly convinced that it is one of the best ever written on this subject. In every way I find it a superior production." SAUNDERS' BOOKS ON Norris ^ Landis* Physical Diagnosis Phy.sical Diagnosis. Part I : By George William Norris, A. B., M. D., Associate in Medicine at the University of Pennsylvania ; Part II : By H. R. M. Landis, A. B., M. D., Director of Clinical and Sociological Department of the Phipps Institute, Philadelphia. Octavo of 8oo pages, with 325 illustrations, mostly original. STRONG ON INTERPRETATION This work presents an admirable combination of the theory and applications of physical diagnosis. It is complete down to the last detail. The first part takes up the methods in themselves. Inspection, palpation, percussion, and ausculta- tion are completely covered in the examination both of the lungs and of the heart. The latter is ampHfied by a chapter on the electrocardiograph by Dr. Edward B. Krumbhaar. The second part takes up the particular diseases of the bronchii, of the lungs, of the pleura, diaphragm, pericardium, heart and aorta, and shows you exactly how to determine the diagnosis by the symptoms and findings. You get here the application of the four methods to your daily clinical work. r riedenwald and Ruhrah on Diet Diet in Health and Disease. By Julius Friedenwald, M. D., Professor of Diseases of the Stomach, and John Ruhrah, M. D., Pro- fessor of Diseases of Children, College of Physicians and Surgeons, Baltimore. Octavo of 857 pages. Published juiy, 1913. Cloth, ^4.00 net. FOURTH EDITION This new edition has been carefully revised, making it still more useful than the two xditions previously e.xhausted. The articles on milk and alcohol have been rewritten, additions made to those on tuberculosis, the salt-free diet, and rectal feeding, and several tables added, including Winton's, showing the composition of diabetic foods. •George Dock, M. D. Professor of Theory a?id Practice and of Clinical Medicine, Tulane University. " It seems to me that you have prepared the most valuable work of the kind now available, I am especially glad to see the long list of analyses of different kinds of foods." Carter's Diet Lists Diet Lists of the Presbyterian Hospital of New York City. Compiled, with notes, by Herbert S. Carter, M. D. i2mo of 129 pages. Pubii;i2cd :.:c:;-, 1913 Cloth, $1.00 net. Here Dr. Cnrter has cimpilrd nil the diet lists for the various diseases and for conva- lescence as prescribed at the Presbyterian Hospital. Recipes are also included. PRACTICE OF MEDICINE Kemp on Stomach, Intestines, and Pancreas Diseases of the Stomach, Intestines, and Pancreas. By Robert Coleman Kemp, M. D., Professor of Gastro-intestinal Diseases at the New York School of Clinical Medicine. Octavo of 1096 pages, with 428 illustrations. Cloth, $7.00 net ; Half Morocco, $8.50 net, NEW (3d) EDITION— published April. 1917 The new edition of Dr. Kemp's successful work appears after a most search- ing revision. Several new subjects have been introduced, notably chapters on Colon Bacillus Iiifectio?i and on Diseases of the Pattcreas, the latter article being really an exhaustive monograph, covering over one hundred pages. The section on Duodenal Ulcer has been entirely rewritten. Visceral Displacements are given special consideration, in every case giving definite indications for surgical inter- vention when deemed advisable. There are also important chapters on the Intes- tinal Complications of Typhoid Fever and on Diverticulitis. ' The Therapeutic Gazette "The therapeutic advice which is given is excellent. Methods of physical and clinical examinadon are adequately and correctly described." Gant on Diarrheas Diarrheal, Inflammatory, Obstructive, and Parasitic Diseases of the Qa5tro=intestinal Tract. By Samuel G. Gant, M. D., LL.D., Professor of Diseases of Sigmoid Flexure, Colon, Rectum, and Anus, New York Post-graduate Medical School and Hospital. Octavo of 604 pages, 181 illustrations. Cloth, ^6.00 net; Half Morocco, ^^7. 50 net. ILLUSTRATED This new work is particularly full on the two practical phases of the subject — diagnosis and treatment. For instance : While the essential diagnostic points are given under each disease, a fuller description of diagnostic methods is given in a special chapter. The differential diagnosis of diarrheas of local and those of sys- temic disturbances is strongly brought out. There is a special chapter on ner- vous diarrheas and those originating from gastrogenic and e7iterogenic dyspepsias. You get methods of simultaneously controlling associated constipation and diar- rhea. You get a complete formulary. The limitations of drugs are pointed out, and the indications and techtiic of all surgical procedures given. June, 1915 Gant on Constipation and Obstruction This Avork is medical, non-medical (mechanical), and surgical, the latter really being a complete work on rectocolonic surgery. Second Edition October, 1916 Octavo of 575 pages, with 250 illustrations. By SAMUEL G. Gant, M. D. Cloth, ^6.00 net. SAUNDERS' BOOKS ON Sollmann*s Pharmacology A Manual of Pharmacology : Its Applications to Therapeutics AND Toxicology. By Torald Sollmann, M. D., Professor of Pharma- cology and Materia Medica in the School of Medicine of Western Re- serve University, Cleveland. Octavo of 901 pages, illustrated. Cloth, ^4.50 net. Published February, 1917 JUST OUT— BASED ON THE 1916 U. S. PHARMACOPOEIA lyt A jaij A f ^ This is the text or reference volume. Two sizes of type are used. The broad conceptions, the generalizations, and those detailed discussions of great and practical value to practitioner and student are set in the large type. The mass of minute details is set in the smaller type, with frequent side headings to facilitate quick reference. Throughout the work the relation of pharmacology to the practice of medicine is forcibly emphasized. The really important drugs — those drugs that you actually use in your practice — are discussed extensively, while those used less frequently are dismissed with less con- sideration. All the new remedies are included, with detailed instructions for their use : Vaccines, serums, salvarsan, neosalvarsan, pituitary extract, emetin — all those new remedies of the Pharmacopoeia being so extensively discussed and em- ployed. Every worthwhile development in the field of pharmacology is included. LABOR.AXORY GUIDES. '^^^ exercises in this Laboratory Grade present no difficulty in technic, and re- quire little help from the instructor. They teach you how to teach yourself. Special stress is laid on facts with direct practical bearing. The experiments on animals are arranged in groups to illustrate various types or phenomena, to bring out the similarities and differences of the response of organs to pharmacologic agents, rather than to individual drugs. This arrangement articulates better with the student's experience in physiology and pathology. A Labomiory Guide in Pharmacology. By Torald Sollmann, M. D. Octavo of 355 pages, illustrated. Cloth, $2.50 net. Amy's Pharmacy Principles of Pharmacy. By Henry V. Arny, Ph. D., Professor of Chemistry, New York College of Pharmacy. Octavo of 1056 pages, with 246 illustrations. Cloth, $5.50 net; Half Morocco, $7.00 net. SECOND EDITION— published March, 1917 Professor Arny divides his book into seven parts: The first part deals with phar- maceutic processes, a striking feature being the clear discussion of the arithmetic of pharmacy; the second, with galenic preparations of the Pharmacopoeia and those unofficial preparations of proved value; the third, with the inorganic chemicals, including the theories of chemistry; the fourth discusses the organic chemicals; the fifth is devoted to chemical testing, presenting a systematic grouping of all the tests of the Pharmacopoeia ; the sixth discusses the prescription from the time it is written until it is dispensed; the seventh is devoted to laboratory work, with exercises in equation writitig and chemical arithmetic . George Reimann, Ph. G., Secretary New York State Board of Pharmacy " I would say that the book is certainly a great help to the student, and I think it ought to be in the hands of every person who is contemplating the study of pharmacy." THERAPEUTICS AND EXERCISE Bastedo's Materia Medica Pharmacology, Therapeutics, Prescription Writing Materia Medica, Pharmacology, Therapeutics, and Prescription Writing. By W. A. Bastedo, Ph. D., M. D., Associate in Pharma- cology and Therapeutics at Columbia University, New York. Octavo of 602 pages, illustrated. New (2d) Edition ready soon THREE PRINTINGS IN SIX MONTHS Dr. Bastedo's discussion of his subject is very complete. As an illustration, take the pharmacologic action of the drug. It gives you the antiseptic action, the local action on the skin, mucous membranes, and the alimentary tract ; where the drug is obsorbed, if at all — and how rapidly. It gives you the systemic action on the circulatory organs, respiratory organs, nervous system, and sense organs. It tells you how the drug is changed in the body. It gives you the route of elimination and in what form. It gives you the action on the kidneys, bladder, urethra, skin, bowels, lungs, and mammary glands during elimination. It gives you the after- effects. It gives you the unexpected — the unusual — effects. It gives you the tolerance — habit formation. Could any discussion be more complete, more thorough ? Boston Medical and Surgical Journal " Its aim throughout is therapeutic and practical, rather than theoretic and pharmacologic. The text is illustrated with sixty well-chosen plates and cuts. It should prove a useful con- tribution to the text-book literature on these subjects." McKenzie on Exercise in Education and Medicine Exercise in Education and Medicine. By R. Tait IMcKenzie, B. A. M. D., Professor of Physical Education and Director of the Department, University of Pennsylvania. Octavo of 585 pages, with 478 original illustrations. Cloth, $4.00 net. SECOND EDITION— published June. 1915 D. A. Sargeant. M. D., Director of Hetnenway Gymnasium, Harvard Uni'^ersity. "It cannot fail to be helpful to practitioners in medicine. The classification of athletic games and exercises in tabular form for different ages, sexes, and occupations is the work of an expert. It should be in the hands of every physical educator and medical practitioner." Bonney's Tuberculosis second Edition Tuberculosis. By Sherman G. Bonney, M. D., Professor of Medi- cine, Denver and Gross College of Medicine. Octavo of 955 pages, with 243 illustrations. Cloth, $7.00 net ; Half Morocco, ^8.50 net. Maryland Medical Journal " Dr. Bonney's book is one of the best and most exact works on tuberculosis, in all its aspects, that has yet been published." Published May, 1910 12 SAUNDERS' BOOKS ON Garrison's History of Medicine History of Medicine^ With Medical Chronology, Bibliographic Data, and Test Questions. By Fielding H. Garrison, M. D., Prin- cipal Assistant Librarian, Surgeon-General's Office, Washington, D. C. Cloth, ^6.00 net; Half Morocco, ^7.50 net. Published December, 1913 REPRINTED IN THREE MONTHS— THE BAEDEKER OF MEDICAL HISTORlf The work begins with ancient and primitive medicine, and carries you in a most interesting and instructive way on through Egyptian medicine, Sumerian and Oriental medicine, Greek medicine, the Byzantine period ; the Mohammedan and Jewish periods, the Medieval period, the period of the Renaissance, the Re- vival of learning and the Reformation ; the Seventeenth Century (the age of indi- vidual scientific endeavor), the Eighteenth Century (the aye of theories and systems), the Nineteenth Century (the beginning of organized advancement of science), the Twentieth Century (the beginning of organized preventive medicine). You get all the important facts in medical history; a biographic dictionary; an album of 7nedical portraits; and a complete jnedical chronology. Stevens* Therapeutics Fifth Edition, September, 1909 A Text-Book of Modern Materia Medica and Therapeutics. By A. A. Stevens, A. M., M. D., Lecturer on Physical Diagnosis in the University of Pennsylvania. Octavo of 675 pages. Cloth, ^3.50 net. Dr. Stevens' Therapeutics is one of the most successful works on the subject ever published. In this new edition the work has undergone a very thorough revision, and now represents the very latest advances. The Medical Record, New York " Among the numerous treatises on this most important branch of medical practice, this by Dr. Stevens has ranked with the best." Butler's Materia Medica sixth Edition A Text-Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph. G., M. D., Professor and Head of the Department of Therapeutics and Professor of Preventive and Clinical Medicine, Chicago College of Medicine and Surgery, Medical Department Valpariso University. Octavo of 702 pages, illustrated. Cloth, ^4.00 net; Half Morocco, ^5.50 net. Published June, i908 For this sixth edition Dr. Butler has entirely remodeled his work, a great part having been rewritten. All obsolete matter has been eliminated, and special attention has been given to the toxicologic and therapeutic effects of the newer compounds. Medical Record, New York ■' Nothing has been omitted by the author which, in his judgment, would add to the completeness of the text." THERAPEUTICS AND MATERIA MEDICA 13 Tousey's Medical Electricity R6ntg(en Rays, &nd Radium Medi<:al Electricity, Rontgen Rays, and Radium. By Sinclair TousEY, M. D., Consulting Surgeon to St. Bartholomew's Hospital, New York. Octavo of 1219 pages, with 801 illu.strations, ig in colors. Cloth, $7.50 net; Half Morocco, ;$9.oo net. PubUshed February, 1915 SECOND EDITION, RESET The revision for this edition was extremely heavy ; new matter has increased the size of the book by some loo pages. About 50 new ilkistrations have been added. The new matter added includes : Diathermy, sinusoidal currents, radiography with intensifying screens, rontgenotherapy, the Coolidge and similar Rontgen tubes and the author's method of dosage, and radium therapy are noted. The booli has been enriched by including several of Machado's tabular classifications of electric methods, effects, and uses. Throughout the entire work everything concerning electricity, x-rays, and radium in medicine, as well as phototherapy, is explained in detail — nothing is omitted. It tells you how to equip your office, and, more than that, how to use your apparatus, explaining away all difficulties. It tells you just how to apply these measures in the treatment of disease. The chapters on dental radiography are particularly valuable to those interested in dental work. Deaderick C^ Thompson's Endemic Diseases of South Endemic Diseases of the Southern States. By William H. Deaderick, M. D., Member American Society of Tropical Medicine ; and LoYD Thompson, M. D., Charter Member American Association of Immunologists. Octavo of 546 pages, illustrated. Cloth, ;^5.oo net; Half Morocco, 36.50 net. Published March, 1516 THE ONLY WORK OF ITS KIND This work records the experiences of two active practitioners and teachers right in the field arid thoroughly familiar with these diseases. Those diseases of special importance are given unusual consideration. Pellagra, for instance, is given eight chapters for its full consideration, while hookworm disease covers nine chapters and malaria eight. You get the etiology, pathology, clinical history, diagnosis, prognosis, prophylaxis, and treatment of each disease, presented from every angle, always bearing in mind the practical aim of the work — the application of the knowledge in daily practice. SAUNDERS' BOOKS ON GET A • THE NEW THE BEST t\ 111 6 n C Ci 11 STANDARD Illustrated Dictionary New 8th Edition— 1500 New Words The American Illustrated .Hedical Dictionarj' By W. A. New- man Borland, M. D.. Editor of " The American Pocket Medical Dic- tionan-." Large octavo of 1 1 37 pages, bound in full flexible leather. Price, ^50 net ; witli thumb index, $$.00 net. PaWshed August, ipis KEY TO CAPITALIZATION AND PRONUNCIATION— ALL THE NEW WORDS Hovrard A. Ytie^iliy,\A.S}.,Prcfezsor of Gynecologic Surgery , Johns Hopkins University. " Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient size. No errors hare been fonnd in kit use of it." Thornton's Dose^Book. Fourth Edition Dose-Book asd Mastaiof PREscajpnoN-WRinNG. By E. Q. Thornton, M.D., Assistant Professor of Materia Medica, Jefferson Medical College, Philadelphia. Post- ocmTO, 410 pages, illustrated. Flexible leather, $2.00 net. Published September, 1909 " I -win be able 10 make considerable use of that part of its contents relating to the correct terminology as used in prescription-'vrriting, and it will afford me much pleasure to recom- mend the book to my classes, ■who often fail to find this information in their other text- books." — C. H. Miller, '^l. T)., Professor of Pharmacology, Northivestem University Medi- zrJ School. Lusk on Nutrition Wei^r (3d) Edition Elements or tttf. Science or NrrEinoN. By Gbah.am LrsK, Ph. D., Professor of Ph^-siology in Cornell Tniversitx- Medical School. Octavo of 641 pages. Cloth, $4.50 net. Published July, 1917 " I shall recommend it highly. It is a comfort to hare ssch a discussion of the subject," — LrTrTELLYS F. Bailkee., M. Ti., Johns Hopkins University'. Camac's "Epoch-ma.king Contributions" Z?:cH-i»?AKiNG CoNTRiBraoNS IN MEDICINE AND SuRGERY. Collected and srri.—^'zi ry C. N. B. Camac, M. D., of New York City. Octavo of 450 pages, illus- trated. Artistically bonnd, ^00 net Published January, 1909 " Dr. Camac has provided us with a most interesting aggregation of classical essays^ We hope that members of the profession will show their appreciation of his endeavors."— lBERA,PEUTic Gazette. PRACTICE, MATERIA MEDICA, E^. The American Pocket Medical Dictionary New 9tfi Edmcn The AiiEsi'jAN P'jcket MeX'IO»_l DicnoiN'AaT. E.iited by W. A. 'STxyu^^ L'oa lA>rD, AL D., JiaiiDr •' Araerlcan in usiiared Medical Dicucnarv.'' 6ct pages. Flex; hie leatKer, with gold edges, St.25 net j wiifa. dnimh index, $1.50 neu '' ' AartL 1915 Strouse d Perry's Food Manual for Doctor and Patient A FCiOD i'LA^TTAL FOR DCCTOR AST) Pattest. Bv sorojiG^T SrsouHE, A. B., M- D^ Professor or Medicine. Post-Graduate Medical SdiooL Chicago: and M-aude ^ Persy, B. 5., Dietitian ilicliael Reese Hospital, rzmo of 27c pages. Clotli- $1.50 net. Po&ii^ed Arr gpint-j 1917 Here the science of rartritron is detailed for the layman, and. the physcLsn frnrf s his abstract theories translated into the terminology of the kitchsL Diets are givtai for diabetes {starvation treatmenfi . gout, nephritis. Hgrfi blood-pressure, kidney stone, diseases of the stomach, rntestrnes. liver. galL-stones. tabenroloss. fevos. -l-rrt nfec- tions, obesity, ant^mfa.. etc. There are in att 232 diets and memsj aTrd 124 fecial redpes. Cohen and Eshner's Diagnosis. Second ReviMd c^fitun. laaa EsszvTTALS OF Dr.iG>X'Sis. By 5. .-^OLrs-CoHZ^r. M. Z., Senicr A^sisajt Prufiaaur in Clinical Medicine. Jeirerson Medical College, PMLi- : and. A. A. EsencS,. M. D.,, Professor of Qinical Medicine. Philadelpoia Polyclinic. Past-actavo. ^^ pa^es 7 ?? illustradons. Qodi, 51.25 nee Zn Sarundir^ Qu£sdan-CjmiTiim.i Serids:. Morris' Materia Medica and Therapeutics- Se»«ntfe JL&Ssm. EiiENTiALi ;? MArEs.i.A Me2ICa. ~^^-^ A--T— ■— - A5D FRES^RrPTTC^'■-"W"s^rT^'"(T. By Hently Morris, M. D., late T'emonsxrarcr of Tienipeuiics. Jefescn Meiicn College. Phila. Revised by W. A. Basteto, M. D.. Instractor in ilaterra 3fedrca.aiid Pharmacologv at Coltnnbia Unive."5iEy= I2nio. jOfj^ages. Clctii, 51.J5 neu jji Sajuide^' Qtusiijn-Cam^ditd Series. Pabiished yoven&ar. 1905 Kelly's Cyclopedia of American Medical Bioigraphy Cyclopedia of AitERicAy MsDCCAi Biv^aRAPSY. Zy Hottarj:' A. Kejilt. iL D.. Johns Hopkins University. Two octavos of 5.15 pages each, with poiTrait5. Per ser Cloth. 1 10.00 net ; Half Morocco. 5x3.00 net. PoMi^ed Aani. rai2 Oertel on Bright's Disease ffluatrated The A>'AToinc Histoloc-icai. Processes of Brighx's Disease. Ey HoRsr Oertei., \r. D, Director of the RusseE Sage InstiTate of FathcLcay. XeTsrYork. Ccnt-a of 227 pages, with 44 text-cuts and 6 colored plates. Cloth. $5.00 net Deconber. I9ia Arnold's Medical Diet Charts METtCAL Diet Charts. Prepared by H. D. AR:fOLD. M. D.. Dran of Hanriad Graduate Medical School. Boston. Single charts. 5 cents : 5a chans, 5^.oo net ; 5Q0 charts, $rS.ao net : looc ciiarts, $_;o.Qo net. Eggleston's Prescription Writing ESSENTIALS OF Frescreftion- Wrtti^-G. By C\B.Y EgglestoN". M. D., Jnstrnctor in Pharmacolosv. Cornell Uniyeratv MedicaL SchaoL romo cf 125 pages. L.oth 5x.aa j^gj^ "" PnWirfrea Septenifrsr. iai3 1 6 SAUNDERS' BOOKS OA^ PRACTICE, Etc. Slade's Physical Examination and Diagnostic Anatomy Physical Examination and Diagnostic Anatomy. By Charles B. Slade, M. D., formerly of University and Bellevue Medical School. i2mo of 150 pages' illustrated. Second Edition— published September, 1916. Cloth $1.2- net' Abbott's Medical Electricity Medical Electricity. By George Knapp Abbott, M. D., Dean and Pro- fessor of Physiologic Therapy and Practice, College of Medical Evangelists, Loma Linda, California. 1 2mo of 132 pages, illustrated. Cloth, ^1.25 net. April, 1915 Stevens' Practice of Medicine New (loth) Edition A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., Professor of Pathology, Woman's Medical College, Phila. Specially intended fot students preparing for graduation and hospital examinations. Post-octavo, 629 pages, illustrated. Cloth, $2.50 net. Published July, 1915 Saunders* Pocket Formulary New (9th) Editioe Saunders' Pocket Medical Formulary. By William M. Powell, M. D. Containing 1831 formulas from the best-known authorities. With an Appendix con- taining Posologic Table, Formulas and Doses for Hypodermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Fetal Head, Obstetrical Table, Diet-list, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, etc., etc. In flexible leather, with side index, wallet, and flap, ^1.75 net. January, 1909 Deaderick on Malaria Practical Study of Malaria. By William H. Deaderick, M. D., Member American Society of Tropical Medicine ; Fellow London Society of Tropical Medicine and Hygiene. Octavo of 402 pages, illustrated. Cloth, ^^4.50 net; Half Morocco,, $6.00 net. Published Novembes, 1909 NileS on Pellag(ra second Edition— January, 1916 Pellagra. By George M. Niles, M. D., Gastro-enterologist to the Georgia Baptist Hospital, Atlanta. Octavo of 225 pages, illustrated. Cloth, $3.00 net. Hinsdale's Hydrotherapy Hydrotherapy. By Guy Hinsdale, M. D., Fellow Royal Society of Medicine of Great Britain. Octavo of 466 pages, illustrated. Cloth, $3.50 net. August, 1910 Todd*s Clinical Diagnosis Third Edition-October. 1914 Clinical Diagnosis : A Manual of Laboratory Methods. By James Camp- bell Todd, M. D., Professor of Pathology, University of California. i2mo of 5S5 pages, illustrated. Cloth, $2.50 net. This book gives you the exact tecknic, the precise procedure to fellow down to the smallest detail. An extremely important section is that on the use of the microscope, giving you the various parts, how to prepare the material, make slides, and interpret the findings. The third edition has been brought right down to the minute. The contents include 70 pages on the therapeutic use of vaccines and sero- diagnosis, taking up the preparation of autogenous vaccines, Abderhalden's serum test for ectopic preg- nancy, the urease methods for urea, the Rimini-Burnam test for formaldehyd, Huntoon's method for spores, Bonder's stain for diphtheria bacilli, and the luetin reaction. "A distinct improvement on many of its predecessors of similar scope. It deals with all the examina- tions which the clinician may have to undertake in the course of his work. "—British Medical Journal. COLUMBIA UNIVERSITY This bQok is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE •^r Z4 'se SFp ? m ^ r - -"■ '"'" " ' i C2B(63a)M60 ^^~^