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ROENTGEN INTERPRETATIOX 
 
 A MANUAL 
 
 FOR STUDENTS AND PRACTITIONERS 
 
 BY 
 
 GEORGE W. HOLMES, M.D. 
 
 nOENTGEXOLOGIST TO THE MASSACHUSETTS GENERAL HOSPITAL AND INSTRUCTOR 
 IN ROENTGENOLOGY, HARVARD MEDICAL SCHOOL 
 
 HOWARD E. RUGGLES, M.D. 
 
 ROENTGENOLOGIST TO THE UNIVERSITY OF CALIFORNLA. HOSPITAL AND CLINICAL 
 PROFESSOR OF ROENTGENOLOGY, UNIVERSITY OF CALIFORNIA MEDICAL SCHOOL 
 
 ILLUSTRATED WITH 181 ENGRAVINGS 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AND NEW YORK 
 
Copyright 
 
 LEA & FEBIGER 
 
 1919 
 
 W ^ - 
 
DEDICATED TO 
 
 WALTER J. DODD, M.D. 
 
 PIONEER IN EOENTGENOLOGY 
 
 AND 
 
 MARTYR TO HUMANITY 
 
PEEFACE. 
 
 It is hoped that this book will prove of practical aid to those 
 in search of a working knowledge of roentgen interpretation. The 
 intention has been to present the essentials in a comp^ehensi^'e 
 form. More detailed information may be secured through the 
 references to the recent literature, which will be found at the end 
 of the chapters. 
 
 The illustrations have been chosen as types of lesions, or as 
 momentary phases of constantly changing and extremely variable 
 processes. The beginner should not attempt to make diagnoses 
 from them by comparison with his own plates. 
 
 The necessity of a medical training as a prerequisite in this field 
 is, of course, recognized, but the particular importance of thorough 
 grounding in pathology is not always sufficiently plain. In attempt- 
 ing to study gross changes by means of shadows, a knowledge of 
 pathology is as essential to the roentgenologist as anatomy to the 
 surgeon. G. W. H. 
 
 H. E. R. 
 
 Boston, 1919. 
 
CONTEXTS. 
 
 Introduction -. , . . 17 
 
 CHAPTER I. 
 CoxFrsrs'G Shadow's an"d Aetefacts 19 
 
 CHAPTER n. 
 
 AnATOMIC.U. V.IEIATIOXS AND DE^"ELOPilEXT 26 
 
 CHAPTER in. 
 Feactitres an'd Dislocations 33 
 
 CH.\PTER IV. 
 BoxE Pathology 50 
 
 CHAPTER y. 
 Skull 83 
 
 CHAPTER VI. 
 
 JOES'TP, TeXDOXS -IND BuHS-E 97 
 
 CHAPTER VII. 
 The Chest Ill 
 
 CHAPTER VIII. 
 Ga-steo-lntestixal Teact 151 
 
 CHAPTER IX. 
 Gexito-ueix.\et Teact 191 
 
EOENTGEN INTERPRETATION. 
 
 INTRODUCTION. 
 
 It cannot be too strongly emphasized in the begmning that 
 roentgen images are shadowgraphs; that they are the record of the 
 varying opacities through which a bundle of rays has passed; 
 and that they are subject to the possibilit}' of erroneous deductions 
 consequent upon the fact that they are shadows. Objects are visible 
 when they differ in density from their surroundings. The outline 
 of the heart is distinct against the air-filled lung about it while the 
 uterus of similar density is lost in the shadow of the pelvis. 
 
 Furthermore, the roentgenogram is a projection on a flat surface 
 of everything in every plane between the plate and the tube's target. 
 It must not be forgotten that in addition to the patient this includes 
 opaque objects upon the filters, the clothing of the patient and the 
 envelope of the plate. The shadow of a rounded bone with ridges 
 on opposite sides will appear on the plate as a flat image with the 
 ridges lying side by side. It is therefore essential for the roentgen- 
 ologist to have a thorough knowledge of the projected appearance of 
 anatomical structures, so that he may be able to visualize from a 
 flat plate the relative depth of objects seen upon it. The study of 
 stereoscopic plates is of great value in this connection. 
 
 Another source of possible error lies in the fact that we commonly 
 employ divergent rays. Parallel rays are seldom made use of in 
 roentgenology except in determinations of the size of the heart. 
 Ordinarily plates are produced by a tube which is relatively close 
 to the plate; therefore we are using divergent rsiys, and the images 
 of objects in their path will be distorted according to their position 
 with reference to the plate. Objects in contact with the plate give 
 an image of actual size and are sharply outlined. As they recede 
 from it their outline becomes more hazy and their size increases. 
 When a wide field of illumination is employed the central rays are 
 practically parallel, but at the margins of the field they strike 
 2 . 
 
18 INTRODUCTION 
 
 obliquely, giving a markedly distorted image. It is customary, 
 therefore, to limit the rays as much as possible to the central bundle 
 by the use of diaphragms and to place the area under observation 
 as closely as possible to the plate. There is an additional advantage 
 to be gained in the employment of small diaphragms because the 
 plates are brighter. Anything in the path of the rays gives off 
 secondary radiation and scatters the primary beam just as light is 
 scattered by fog. This secondary and scattered radiation tends to 
 obscure the image cast by the primary rays, therefore the area of 
 tissue exposed to the rays should be as limited as possible. 
 
 One view is an isolated observation and is perhaps less to be 
 relied upon than a single observation in any field of medicine. As 
 far as possible, plates should always be secured in planes at right 
 angles to each other, and often additional plates at various angles 
 will establish a diagnosis which would otherwise be impossible. 
 This is particularly important in studies of the skull, spine and 
 the neighborhood of joints. 
 
 In conclusion, there are several axioms which form the basis for 
 successful roentgen interpretation: 
 
 1. Do not attempt to include e^'ery thing on one plate; several 
 small ones are always preferable. 
 
 2. Do not make a diagnosis before everything possible has been 
 done; thoroughness is essential. 
 
 3. Be familiar with the projected appearance of normal structures. 
 
 4. Use routine positions for all examinations as far as possible. 
 
 5. Do not give opinions on poor plates. 
 
 In order to avoid confusion in the use of the terms "increased" and 
 "diminished" density, it should be understood that when they occur 
 in this text they apply to the tissues of the patient. These expres- 
 sions may be employed to designate the thickness of the silver 
 deposit on the roentgenogram — the actual density in the image of 
 the emulsion — which necessaril}' is reciprocal to the density of the 
 patient. So, in this book, "increased density" means the loss of trans- 
 parency to the rays and light areas on the roentgenogram. Dimin- 
 ished density means increased radiability and darkening of the 
 plate. Most of the illustrations are positives of the original roentgen 
 negatives and therefore their values are the opposites of those in 
 the plates. 
 
CHAPTER I. 
 CONFUSING SHADOWS AND ARTEFACTS. 
 
 There are many shadows in normal plates which ma}' cause 
 errors in interpretation. Their significance is obvious when they 
 have once been recognized, but the beginner is prone to attach 
 undue importance to them, particularly when they occur in regions 
 to which his attention has been directed by the clinical picture. 
 In case of doubt it is always wise to take plates of the corresponding 
 parts or to compare them with other plates of the same region in 
 other individuals. 
 
 Lines Mistaken for Fractures.^ — The most common error here occurs 
 with the epiphyseal lines, which appear as a definite break in the 
 continuity of the bones. It is therefore essential for the roentgen- 
 ologist to have a complete knowledge of the time of appearance of 
 the, various centers of ossification, the location of epiphyseal lines 
 and the approximate age at which they disappear. 
 
 When one bone overlaps another or the edge of a muscle bundle 
 crosses a bone there may be a thin, sharply drawn black line which 
 at times resembles a fracture. This appearance is often noticed in 
 the trans^'erse process of the lumbar ^-ertebrse where the inner 
 margin of the psoas muscle crosses them. 
 
 A third possibility of error is furnished by the markings due to 
 bloodvessels which are particularly evident in the skull where the 
 course of the middle meningeal artery appears as a tortuous groove 
 behind the coronal suture and is more or less sharply outlined. 
 The venous channels in the diploe of the skull provide another s;et 
 of dark lines, irregular in their course and indefinite in outline.^ 
 In the long bones there is ordinarily a definite groove where the 
 nutrient artery enters the shaft, which may be mistaken for a 
 fracture when seen in profile, as, for example, in the phalanges of 
 the hands and feet. It is well, therefore, to be familiar with the 
 anatomy of these vessels. 
 
 An accurate knowledge of the location and appearance of the 
 sutures of the skull will prevent their misinterpretation, a common 
 
20 CONFUSING SHADOWS AND ARTEFACTS 
 
 error particularly with the parietomastoid, which is often called a 
 fracture of the base. 
 
 The characteristics of a fracture line which are usually sufficient 
 to identify it are that it is a dense black with sharply cut margins; 
 its course is usually irregular and, particularly in the skull, at vari- 
 ance with that of the bloodvessel markings. 
 
 Roughening of the Margins of Bones Mistaken for Periostitis. — 
 Frequently there is a thin plate of boiie extenduig out on the inter- 
 muscular septum, as, for example, between the tibia and fibula, 
 or radius and ulna, which seen in profile is quite suggestive of peri- 
 osteal proliferation, and one must be careful to differentiate this 
 condition from a true periostitis. 
 
 A similar process is liable to occur at the attachment of tendons, 
 such as the tendo Achillis, the triceps, along the margin of the iliac 
 crests, along the linea aspera of the femur and about the external 
 occipital protuberances of the skull. There is very commonly a 
 roughening and slight proliferation along the margins of the pha- 
 langes of the hands, which is without significance. The flange behind 
 the intercostal groove on the inferior margin of the ribs posteriorly 
 is often exaggerated and suggests a periostitis. The tibial tubercle 
 may be somewhat widened and its lateral margin projected outside 
 the outer border of the tibia a short distance below the head; it 
 is frequently mistaken for a localized proliferation of periosteum. 
 There is normally a variable amount of roughening on the inferior 
 margin of the pubes and ischial tuberosities. 
 
 A true periostitis consists of more or less extensive deposit of new 
 bone upon a normal appearing cortex. This deposit may be laid 
 down in multiple thin lamellae, giving it a delicately stratified struc- 
 ture, which is a form frequently seen in lues; or it may be a low 
 irregular fringe, as seen in some forms of osteomyelitis. 
 
 Calcifications. — Calcium salts cast a dense shadow wherever they 
 occur. They have an extensive distribution in the body outside of 
 the bony structures. Cartilage is perhaps the tissue in which cal- 
 cium salts are most prone to be deposited. This is seen in the costal 
 cartilages, where the deposit usually occurs upon the surface of the 
 cartilage in the form of irregular plaques appearing in the chest, 
 spine, gall-bladder and kidney plates. These shadows are without 
 significance and their nature is, as a rule, easily determined. 
 
 Calcification also occurs in the same manner in the cartilages of 
 the larynx and is easily recognizable in lateral views of the neck. 
 In anteroposterior views of this region, however, they are projected 
 
CALCIFICATIONS 21 
 
 in the region of the lateral masses of the cervical vertebrse and have 
 been mistaken for hypertrophic changes in the spine or calcified 
 vertebral arteries. 
 
 Another common seat of calcification is old tuberculous foci, 
 examples of which are the irregular masses in bronchial glands, the 
 characteristic agglomerations of small masses which produce the 
 irregular mulberry-like shadows typical of tuberculous glands, which 
 
 Fig 1 . — Calcified retroperitoneal gland suggesting gall-stones. 
 
 are frequently found in the neck and throughout the mesentery in 
 the abdomen. They are usually multiple. Small, rounded, dense 
 masses sometimes occur scattered throughout the spleen and may 
 occur anywhere beneath the peritoneum as the end-result of localized 
 tuberculous processes. An extensive calcification is sometimes 
 encountered in tuberculous kidneys. Extensive sheets of calcifica- 
 tion are sometimes seen in the pleura and very rarely in the peri- 
 cardium following tuberculous infection. 
 
22 CONFUSING SHADOWS AND ARTEFACTS 
 
 The calcification which occurs in arterial walls as a result of 
 arteriosclerosis is a familiar picture. It may be found in the course 
 of any of the arteries, and is sometimes extensive and striking. 
 The age of the patient must always be taken into consideration 
 in estimating its proper significance. When it occurs in a young 
 patient it is most commonly the result of lues. These changes in 
 the internal iliac arteries may be mistaken for stone in the ureter. 
 
 Calcification appears in veins most frequently in the form of 
 small, rounded, dense masses, so-called phleboliths, seen in the 
 pelvis and in the region of the ischial spines; they represent small 
 calcified thrombi on the distal side of the valves, and must not be 
 mistaken for ureteral stones. Rarely, calcification similar to that 
 seen in arteriosclerosis may be evident in old varicose veins. 
 
 Extensive calcification may occur in hematomata; this is most 
 commonly seen about the elbow and in the quadriceps extensor. 
 It may develop rather suddenly several weeks after an injury and 
 present an appearance on the plate which resembles periosteal sarcoma. 
 
 Definite irregular deposits of calcium salts may be found about 
 foreign bodies, such as silk sutures, and the cysts of parasites. 
 Coming under this head may be mentioned calcified pineal glands 
 which are fairly common and the rare cases of calcification within 
 a dead fetus. 
 
 Calcification is fairly common in tumor masses whose blood supply 
 has been obliterated, of which an ordinary example is that seen in 
 uterine fibroids. It is encountered also in other slow-growing and 
 benign tumors of the connective-tissue group, such as fibromata 
 and lipomata. It occurs in certain slowly growing scirrhous carci- 
 nomata and has been noted in some tumors in the pancreas and 
 gall-bladder as well as in glandular metastases. Angiomata may 
 contain round cyst-like masses of varying size, representing calci- 
 fied thrombi, and endotheliomata frequently contain irregular dense 
 areas, as, for example, in psammomata in the skull. 
 
 Ovaries are sometimes the site of calcification, in which case they 
 appear as flat oval masses resembling glands in the lateral portions 
 of the pelvis. 
 
 Mention must also be made of the fact that infarcts of any of the 
 viscera may subsequently calcify. Another rare condition is the 
 so-called calcareous metastasis in which in extreme resorption of 
 bone from extensive caries, malignant disease, etc., a widespread 
 deposit of calcium salts may occur in the cartilages, mucous mem- 
 branes of the mouth, stomach and arteries. 
 
AREAS OF INCREASED DENSITY IN SPONGY BONE 23 
 
 Areas of Increased Density in Spongy Bone. — Small round areas 
 of condensation are sometimes seen in cancellous bone. There is 
 no disturbance in the normal structure of the bone about them, 
 and their significance has been a matter of considerable speculation. 
 They may represent old healed areas of infection or some localized 
 
 Fig. 
 
 -Foreign body in soft tissues. (Metallic injection.) 
 
 disturbance in the growth of the bone. At any rate, they have no 
 pathological importance. They may occur near the ends of long 
 bones in the carpus, tarsus or within any of the flat bones. The 
 transverse dense lines, often multiple, which occur along the medullary 
 canal toward the end of the long bones, are the result of disturbances 
 of growth which occurred at the time when the epiphyseal line was 
 
24 CONFUSING SHADOWS AND ARTEFACTS 
 
 at that point; they may be hkened to the growth of rings In the 
 trunk of a tree. 
 
 Warts and Fibromata on the Skin. — Any area of skin which presses 
 heavily on the plate will be recorded as a spot of increased density, 
 common examples of which are outlines of the buttocks of a thin 
 individual in a plate of the entire pelvis, the breasts of women in 
 anteroposterior plates of the chest or the ears in lateral skull plates. 
 
 Fig. 3. — Gas gangrene. 
 
 In the same way warts and fibromata appear as rounded areas of 
 increased density, which when they occur in the kidney and gall- 
 bladder regions may strongly suggest calculi. A characteristic 
 which may help to identify them is that they ha^'e extremely sharp 
 margins because of the fact that they are in contact with the plate. 
 The presence of fibromata should always be noted in the patient's 
 record. 
 
DEFECTIVE PLATES 25 
 
 Metallic Salts. — Dense shadows of the metalHc salts may be seen 
 where there are bismuth or barium residues in the sinus which has 
 been injected or in portions of the gastro-intestinal tract; where 
 zinc or mercurial ointments are present on the skin, or iodin which 
 in any form casts a shadow of particular density. The presence 
 of iodin upon the skin or within the soft tissues as a result of intra- 
 muscular injection is quite striking (Fig. 3). Air or gas in the soft 
 tissues also gives a characteristic picture. 
 
 Gas in the Intestinal Tract. — Accumulations of gas, particularly 
 in the colon where it overlies the spine, the wings of the ilia or 
 sacrum, arc; sometimes mistaken for areas of rarefaction in the bone. 
 Careful inspection will reveal the presence of normal bone structure 
 in the doubtful area or the patient may be reexamined. 
 
 Defective Plates. — Plates may show irregular light or dark areas 
 as a result of defects of manufacture, or fogging by light or a;-rays. 
 One particularly troublesome defect is the occurrence of localized 
 thin spots in the emulsion which give shadows light in color resem- 
 bling those of stones. Irregular patterns of increased or diminished 
 density occasionally result from uneA'en immersion of the plate in 
 the developer; these are very sharply marked and have long curved 
 outlines. Finger marks appear on plates as light or dark spots, 
 depending upon the substance present on the finger at the time of 
 impression; their presence is always an indication of faulty dark- 
 room technic. 
 
 BIBLIOGRAPHY. 
 
 Wells, H. Gideon: Metastatic calcification, Arch. Int. Med., 1915, xv, p. 574. 
 
 Hetherington, .1. P.: Causes of apparent and real mistakes in ar-ray diagnosis. 
 Railway Surg. Jour., 1915-16, xxii, p. 223. 
 
 Pirie, A. H.: Interpretation of a;-ray negatives, British Med. .Jour., 1910, part 2, 
 p. 584. 
 
 Jones, R., and Morgan, D.: On osseous foi-mations in muscles due to injury, Arch. 
 Roent. Ray, 1904-5, ix, p. 245, and 190.5-6, x, pp. 10, 46, 72, 100, 199, 249, 275, .304. 
 
 Outerbridge, G. W.: Non-teratomatous bone formation in the human ovary. 
 Am. .Jour. Med. Sc, 1916, cli, 868. 
 
 Klotz, Oskar: Obsolete miliary tubercles of the spleen. Am. Jour. Med. Sc, 1917, 
 clxxx, p. 786. 
 
CHAPTER II. 
 ANATOMICAL VARIATIONS AND DEVELOPMENT. 
 
 Anatomical variations in bone structure may occur anywhere 
 in the skeleton and are of considerable importance aside from their 
 interest as curiosities, for they are commonly points of lowered 
 resistance. A strain or injury which would be without effect on a 
 normally constructed individual may give rise to severe and stub- 
 born symptoms when such anomalies are present. This is particu- 
 larly true of variations in the spine. 
 
 Skull. — The skull may show partial absence of bones or variation 
 in the width of sutures, of which extreme examples are acephalic 
 monsters. Thin areas appearing as holes are occasionally seen in 
 the frontal and parietal regions and along the sagittal suture. 
 The sinuses and mastoids are subject to wide variation, from com- 
 plete absence to enormous size. Cases have been observed in which 
 the mastoids communicated with the sphenoid sinus anteriorly and 
 with each other posteriorly. 
 
 Vertebrae. — A most common anomaly in the spinal column is the 
 presence of extra bodies, e. g., six lumbar or thirteen thoracic seg- 
 ments, or of extra portions of bodies which take the form of a 
 triangular wedge which may bear an extra rib when it occurs in 
 the thoracic region. 
 
 Another frequent finding is the failure of union of the posterior 
 ring. All degrees of this condition are seen from bifid spinous 
 processes to complete spina bifida. 
 
 There may be increase of length or size of the transverse processes, 
 particularly in the last cervical and last lumbar vertebrae. There 
 are all gradations found up to partial or complete fusion of the pro- 
 cess with the sacrum, or so-called sacralization. These enlarged 
 processes give rise to symptoms whenever, on account of size or 
 position, they cause pressure on nerve trunks or impinge on neigh- 
 boring bones. On the other hand, the processes of the first lumbar 
 are often short and have accessory ribs attached; these may be 
 mistaken for fractures. 
 
VERTEBR.^ 
 
 27 
 
 Fig. 4. — Congenital abnormality. Wedge-shaped vertebra. 
 
 P;q_ 5_ — Enlarged sacralized transverse process on fifth lumbar vertebra. 
 
28 ANATOMICAL VARIATIONS AND DEVELOPMENT 
 
 While spinous processes are ordinarily arranged in a straight 
 Hne, slight lateral deviations of individual processes may occur 
 without pathological significance. Unusually long or thick spinous 
 processes may impinge on one another, especially in the lumbar 
 spine in cases of exaggerated lumbar curve. 
 
 There is a considerable variation in the plane of the articular 
 facets at the lumbosacral junction. Normally these articular sur- 
 faces are approximately transverse, but one or both may be rotated 
 so that the plane of the articulation between them is anteroposterior. 
 These are a potential source of symptoms in the lower back because 
 they permit of various degrees of forward dislocation of the fifth 
 lumbar vertebra upon the sacrum. 
 
 Fig. 6. — Double cervical ribs. 
 
 Ribs. — One anomaly has already been mentioned; that is, the 
 occurrence of extra ribs which may appear in the lower cervical or 
 upper lumbar regions or attached to extra bodies. These cervical 
 ribs may be of sufficient length to articulate with the sternum or 
 be attached to the first rib. They are usually longer than they 
 appear on the plate, due to foreshortening of their shadow. On the 
 
VARIATIONS OF THE TARSUS 29 
 
 other hand, one or more ribs may be absent, or partially so, or 
 adjacent ribs may be fused. A mild form of this latter condition 
 is frequently seen near the sternal end, where a rib may flare con- 
 siderably before its attachment to the costal cartilage, and this 
 enlargement may or may not be perforated. 
 
 Scapulae. — These bones vary considerably in thickness and holes 
 may occur in the thin regions, especially in old people; in the same 
 way unusually prominent grooves may simulate fractures. There is 
 a condition known as congenital elevation of the scapula (Sprengel's 
 deformity) , in which a partially developed scapula is found high up 
 toward the neck. In cases of obstetrical paralysis there may be an 
 imperfect development of the lower half of the scapula. 
 
 Fig. 7. — Congenital abnormality of the scapulge. 
 
 Variations of the Carpus. — Perhaps the most important anomaly 
 here is the divided scaphoid, which is to be differentiated from a 
 fracture of the scaphoid. The margins of the halves are more 
 rounded and smooth and the space separating them is not quite so 
 black as in the case of fracture. The semilunar and the radial 
 sesamoid of the thumb may be similarly divided. Small extra 
 bones may be found, of which the most common is the styloid; this 
 develops from an extra center of ossification lying between the 
 trapezoid, the magnum and the third metacarpal. 
 
 Variations of the Tarsus. — The astragalus bears a backward pro- 
 longation of variable length which often exists as a separate bone, 
 the trigonum; when present it must be differentiated from a frac- 
 ture of a long process. The next in order of importance is the tibiale 
 externum, a small detached bone which sometimes occurs at the 
 
30 ANATOMICAL YARIATIOXS AND DEVELOPMENT 
 
 posterior end of the scaphoid on the inner side of the foot. The 
 peroneum in the tendon of the peroneiis longus overlying the 
 cuboid may be subdivided. 
 
 The small separate center of ossification on the outer side of the 
 posterior end of the fifth metatarsal may persist into adult life as a 
 small bone called the vesalianum. 
 
 Divided sesamoids in the tendons of the flexor hallucis brevis 
 beneath the head of the first metatarsal are fairly common. They 
 must be carefully dift'erentiated from fracture of single sesamoids, 
 which are extremely rare. 
 
 The subject of variations in the hands and feet is exhaustively 
 treated by Dwight. 
 
 Other Bony Variations. — In e\'ery roentgenological practice one 
 may encounter cases of partial or complete absence of long bones, 
 particularly the fibula, radius and phalanges. On the other hand, 
 supernumerary bones, usually extra fingers or toes, may also be 
 seen. Fusion of bones may be looked for occasionally; this is most 
 frequently found between the radius and the ulna. Adjacent carpal 
 and tarsal bones may be united, and there is an hereditary anomaly 
 in which the first and second phalanges of one or more digits may 
 coalesce with obliteration of the interphalangeal joint. Atavistic 
 variations may occur, as, for example, the hooked supracondylar 
 process occasionally found on the inner margin of the humerus above 
 the elbow. 
 
 Ossification. — Variability is also evident in the time of appearance 
 of centers of ossification. The following table taken from Rotch 
 and Morris's Anatomy gives figures which can be relied upon as 
 a working average. 
 
 Age of Age of 
 
 appearance. fusion. 
 
 Ribs: Epiphyses for head and tubercle 15 2-3 
 
 Clavicle: Small epiphysis of the sternal end 18 25 
 
 Humerus: Head 8 mos. 20 
 
 Greater tuberosity 3 20 
 
 I^esser tuberositj' 4 20 
 
 (All fuse at six years and join the shaft at twenty years). 
 
 Capitellum 1 17 
 
 Internal epicondyle 5 18 
 
 Trochlea 10 17 
 
 External epicondyle 12 17 
 
 (The capitellum, ti'oclilea and external epicondyle join 
 as a mass at seventeen and the internal epicondyle at 
 eighteen j'ears.) 
 
 Radms: Head 5 17 
 
 Lower epiphysis 2 20 
 
 Ulna: Olecranon 10 17 
 
 Lower epiphysis 4 18 
 
OSSIFICATION 31 
 
 Age of Age of 
 
 ,^ ,~v^ appearance, fusion. 
 
 Carpus: (IrTthe order of appearance.) 
 
 Magnum 1 
 
 Uneiform . ■-\'^""V^ 1 to 1| 
 
 Cuneiform . .."^y $-■- . 2 to 3 
 
 Semilunar . ■. ' \ '; . 4 to 5 
 
 Trapezium 5 
 
 Scaphoid . .' 5 to 6 
 
 Trapezoid . .' • 6 to 8 
 
 Pisiform . . . .' 12 
 
 Metacarpals: Epiphyses 3 20 
 
 Phalanges: Epiphyses 3 18 
 
 Peh-is: (Pubis and ischium unite at eight years; the acetabulum 
 closes at sixteen years.) 
 
 Epiphyses for 
 
 Crest of ilium, "I 
 
 Ischial tuberosity, I 15 20 
 
 Anterior inferior iliac spine, f 
 
 Tubercle of pubes, J 
 
 Femur: Head 1 19 
 
 Greater trochanter 4 18 
 
 Lesser trochanter 13 17 
 
 Lower epiphysis 8 mos. 20 
 
 Patella: . . . ' 3 24 
 
 Fibula: Upper epiphysis -. . . . 4 24 
 
 Lower epiphysis 2 20 
 
 Tibia: Upper epiphysis 9 mos. 22 
 
 Lower epiphysis 2 18 
 
 Tarsus: (In order of appearance.) ,. ,_^^ 
 
 Calcis . 5^=^"V^f '^' .^ 6 mos. 
 
 Epiphysis of calcis . ^ 10 
 
 Astragalus . . f—^'*'^ 7 mos. 
 
 Cuboid 9 mos. 
 
 External cuneiform 1 
 
 Internal cuneiform 3 
 
 Middle cuneiform 3 
 
 Scaphoid 4 
 
 Metatarsals: Epiphyses 3 to 8 20 
 
 Phalanges: Epiphyses 4 to 7 18 
 
 Sesamoids of flexor hallucis brevis: 5 
 
 Vertebrae: Ossification is from three primary centers, one for the body and one for 
 each lateral mass. The nucleus for the Ijody is often bilobed, A\'ith a par- 
 tial plane of cleavage in the vertical or horizontal diameter. The 
 laminse unite during the first year. Five secondary centers described 
 in the anatomies — namely, thin plates on the upper and lower surfaces 
 of the body and the tips of the mammillary tubercle, transverse and 
 spinous processes — appear at the age of fifteen to twenty years and 
 unite at twenty-five. The fifth lumbar vertebra is an exception in that 
 it ossifies from five centers, one for the body, one on each side from 
 which is developed the superior articular process, pedicle and trans- 
 verse process, and one on each .side which subsequently form the 
 inferior articular process, lamina and spinous process. 
 
 It is well to bear in mind that epiphyses which appear last are 
 the first to unite and that the nutrient foramen is directed toward 
 them; that ossification begins earliest in the epiphyses bearing the 
 largest relative proportion to the shaft (except the fibula); that 
 when an epiphysis ossifies from several centers, they fuse together 
 before uniting with the shaft. 
 
32 ANATOMICAL VARIATIONS AND DEVELOPMENT 
 
 Thomas Morgan Rotch has called attention to the fact that the 
 time of appearance of the carpal centers is the best index we have 
 of the actual development of an individual. 
 
 Delayed Union or Failure of Union. — Variations in the normal 
 process of the union of epiphyses are of great importance as a factor 
 in the production of deformities. For example, failure of develop- 
 ment of a center in the lateral masses of the fifth lumbar may result 
 in scoliosis. Abnormal fusing of the lower epiphysis of the radius 
 produces the malformation known as Madelung's deformity, in 
 which the plane of the radiocarpal articulation is rotated inward 
 and backward. 
 
 Delayed union may be an evidence of retarded mental or physical 
 development, of which a common example is cretinism; of infections, 
 prominent among which is lues; or of injury. 
 
 BIBLIOGRAPHy. 
 
 Milne, James A.: Congenital absence of the radii, British Med. Jour., 1915, ii, p. 
 821. 
 
 Piersol, George A.: Congenital perforations of the parietal bones, Univ. Peinia. 
 Med. Bull., 1902, xv, p. 203. 
 
 Skillei'n, P. G.: Congenital perforations of the parietal bones, Ann. Surg., 1914, 
 ix, p. 807. 
 
 Adams: Relation of anomalies of lumbar and sacral spine to lordosis. Am. Jour. 
 Orthop. Surg., 1915, xii, p. 45. 
 
 Hodgson, F. G. : Congenital deformities of the vertebrae and I'ibs, Am. Jour. Orthop. 
 Surg., 1916, xiv, p. 34. 
 
 Case, J. T. : Anacephaly successfully diagnosed before birth, Surg., Gynec. and Obst., 
 1917, xxiv, p. 312. 
 
 Boorstein, S. W. : Symmetrical congenital malformation of extremities, Ann. Surg., 
 1916, Ixiii, p. 192. 
 
 Rugh: Sprengel's deformity, Tr. Philadelphia Acad. Surg., 1915, xvii, p. 62. 
 
 Albers-Schonberg : A skeletal anomaly, the supracondylar process. Am. Jour. Roent., 
 1916, iii, p. 182. 
 
 Geist, E. S.: Supernumerary bones of the foot, Am. Jour. Orthop. Surg., 1914-15, 
 xii, p. 403. 
 
 Ruh, H. O.: Acrocephalosyndactylism, Am. Jour. Dis. Children, 1916, xi, p. 281. 
 
 Schueller, A.: Peculiar cranial defects in young individuals. Am. Jour. Roent., 1916, 
 iii, p. 497. 
 
 Ashhurst, A. P. C: Congenital absence of the fibula, Ann. Surg., 1916. 
 
 Peckham, F. E.: Congenital elevation of the scapula, British Med. Surg. Jour., 
 1916, clxxiv, p. 315. 
 
 Dwight, T. : Closure of cranial sutures as a sign of age, British Med. Surg. Jour., 
 1890, cxxii, p. 389. 
 
 Hartung, A.: Congenital anomalies and variations of the bony skeleton, Am. 
 Jour. Roent., 1916, iii, p. 430. 
 
 Dunlop: Adolescent tibial tubercle, Am. Jour. Orthop. Surg., 1912-13, ix, p. 313. 
 
 Goldwaite,'J., and Painter, C. F. : Congenital elevation of shoulder, Tr. Am. Orthop. 
 Assn., xix, p. 302. 
 
 Barnes, N. P.: The sesamoids of the flexor brevis hallucis. New Yoi'k Med. Jour., 
 1915, cu, p. 940. Tr. Am. Therap. Soc, 1915, p. 59. 
 
 Clark, D. A.: Sacralization of lumbar vertebra, Canadian Med. Assn., Jour. 1916, 
 vi, p. 914. 
 
 Pryor, J. W. : Ossifications of the bones of the hand, Bull. Univ. Kentucky, viii, No. 
 11, November, 1916. Reviewed in Am. Jour. Roent., 1916, iii, p. 416. 
 
 Sever, J. W.: Obstetrical paralysis, Am. Jour. Orthop. Surg., 1916, xvi, p. 456. 
 
CHAPTER III. 
 FRACTURES AND DISLOCATIONS. 
 
 FRACTURES. 
 
 It is most important for a roentgenologist to have a thorough 
 knowledge of roentgen anatomy and of the surgical pathology of 
 wound and fracture repair. Gross fractures are, of course^ obvious, 
 but in a doubtful case the diagnosis may depend entirely upon the 
 breadth of his anatomical and surgical experience. He should at 
 least know that the more accurately a fracture is reduced the 
 sooner will function be restored and the smaller the callus which 
 results ; that calcification begins in callus in from two to four weeks 
 and is usually complete in six; that at first callus may show very 
 little evidence of lime deposit when there is no displacement of 
 fragments; and that an extensive comminution or a malposition 
 of fragments should be accompanied by a large, thoroughly calcified 
 callus. 
 
 The prognosis of fractures involving joints should always be 
 guarded because of the fact that there is no means of estimating 
 from the roentgen examination how much damage has occurred to 
 the soft tissues or what eiTect their repair will have on function. 
 The possibility of organization and calcification in extensive hema- 
 tomata which may follow injuries to the supporting structures 
 should always be remembered. 
 
 The question of union is often a difficult matter to decide from 
 roentgen evidence alone. One cannot determine from a plate show- 
 ing a fracture without evidence of bony imion whether there are 
 soft tissues between the fragments which will interfere with repair, 
 whether an uncalcified callus is present or whether or not there is 
 firm fibrous union. It must not be forgotten that non-union is 
 prone to occur when the site of fracture involves a nutrient artery 
 or when the patient is syphilitic or asthenic. 
 
 In the reduction of fractures normal weight-bearing lines should 
 be restored as far as possible and every attempt should be made to 
 replace articular surfaces in their normal planes with reference to 
 3 
 
34 
 
 FRACTURES AND DISLOCATIONS 
 
 the shaft. In doubtful cases comparison plates of a symmetrical 
 part may help to decide whether a reduction is satisfactory. 
 
 Fracture lines will usually become obliterated in from three to 
 six months, and if reposition of the fragments has been accurate all 
 evidence of the injury may have disappeared in that time. The 
 shadow of linear fractures in the skull, however, may persist for a 
 longer period, but ordinarily are not visible beyond one year after 
 
 Fig. 8. — Fracture of the skull in a child. Compare the fracture line with the suture 
 
 line seen above it. 
 
 the injury. In any fracture, when reduction has been poor or the 
 callus formation extensive, evidence of the deformity may persist 
 for life. 
 
 The roentgenogram will often furnish evidence of value to the 
 surgeon aside from the position of the fragments, such as indica- 
 tions of a pathological process in the bone or of the presence 
 of foreign bodies within the wound, and occasionally the early 
 appearance of gas in the soft tissues as a result of infection with 
 Welch's bacillus. 
 
FRACTURES 
 
 35 
 
 Skull. — From its structure the skull is subject to linear fractures 
 which appear on the plate as thin black lines with sharp ragged 
 edges. They may run in any direction. They are to be differen- 
 tiated from suture lines, diploic vessels and arterial grooves, all of 
 which have fairly definite courses, smooth margins and are lighter in 
 color. Fracture lines may open up sutures or follow bloodvessel 
 markings, but they can usually be traced beyond the course of these 
 normal lines. 
 
 Fig. 9. — Fracture of the base of the skull. The line of fracture is seen in the petrous 
 portion of the temporal bone. 
 
 Comminuted and stellate fractures are usually obvious. A 
 depressed fracture often appears as a white line because of overlap- 
 ping of the margins of the break; whenever possible profile views 
 of them should be obtained. 
 
 Fractures of either the inner or the outer table appear as areas 
 of slight irregularity in the density and structure of the bone. 
 Fractures limited to the base are frequently overlooked; a vertical 
 projection of the base in addition to an anteroposterior, postero- 
 
36 
 
 FRACTURES AND DISLOCATIONS 
 
 anterior and both lateral views should be a routine in searching for 
 skull fractures. 
 
 Cranial aerocele may develop following fracture through the 
 sinuses, especially the frontal sinus. They are produced by the 
 increased air pressure within the nasal cavity when the patient 
 sneezes or blows the nose. At this time air and bacteria may be 
 forced through the _ fracture into the cranial cavity. The pocket 
 containing the air will appear on the plate as an area of markedly 
 diminished density, usually in the frontal region. Plates should be 
 taken from both sides, as it may be absent in one. 
 
 Fig. 10. — Fracture of the spine (lateral view). 
 
 Vertebrae. — Fracture lines are rarely seen in the bodies of verte- 
 brae. "What is seen is abnormality in outline or in relations to 
 neighborina; vertebra?. Crushing fractures of the bodies occur most 
 
FRACTURES 
 
 37 
 
 commonly in the thoracic and lumbar regions as the result of severe 
 injury. They may be overlooked in an anteroposterior view, and a 
 lateral view should always be obtained as a check. These fractures 
 run a long clinical course and give no evidence of callus formation 
 even after months or years. Localized hypertrophic spurs or 
 bridges to adjoining bodies often develop after these injuries. 
 
 Fig. 11. 
 
 -Fracture along the transverse process of the fifth lumbar and of the fourth 
 lumbar on the right. 
 
 Fractures of the body of the fifth lumbar may occur but it is not 
 common. This vertebra, owing to its tilted position, is so distorted 
 in the average picture that its outlines are recognized with difRculty. 
 A diagnosis of fracture of this body should not be made without a 
 good stereoscopic inspection of its direct anteroposterior diameter 
 in addition to a lateral view if possible. 
 
 Transverse processes may be fractured by severe lumbar injuries, 
 usually several vertebrte being affected. There may or may not 
 be considerable separation of the fragments. 
 
 Fracture of the posterior ring and transverse processes is seldom 
 
38 
 
 FRACTURES AND DISLOCATIONS 
 
 directly shown. They may be diagnosed by the change in the rela- 
 tions of the vertebrEe at the site of the lesion, usually a slight rota- 
 tion or angulation so that the spinous processes of the vertebree 
 above the lesion are out of line with those of the one below. This 
 condition is to be differentiated from the slight lateral deviations 
 which frequently occur in individual spinous processes without 
 significance. 
 
 Fig. 12. — Tj-pical Colles's fracture. The lateral view shows the amount of deformity. 
 
 Fractures of spinous processes may be suspected from deformities 
 of their outlines in anteroposterior views. A lateral view, however, 
 will usually confirm the diagnosis. 
 
 Pelvis. — Pelvic fractures are usually due to violent injuries such 
 as falls and crushes and the resulting deformity is easily recognized. 
 The regions about the sacro-iliac and the symphysis are most fre- 
 quently involved. A typical injury consists of fracture of the pubis 
 
FRACTURES 39 
 
 with more or less wide separation of the sacro-ihac, or fracture 
 through the sacrum or iUum close to the synchondrosis. The femoral 
 head may be driven into the pelvis, carrying the inner wall of the 
 acetabulum^before it. 
 
 Ribs. — Fractures of the ribs are usually obvious but may be over- 
 looked in the overlapping axillary shadows. Slight rotation of the 
 patient will bring the suspected area into clear view. Fracture of 
 the costal cartilage may occur which, of course, is not evident on the 
 roentgenogram unless the cartilage is extensively calcified. 
 
 Fig. 1.3. — Colles's fracture. The lateral "s-iew does not show well the amount of 
 deformity because the shadow of the ulna overlaps that of the radius. 
 
 Carpus. — T^he bones involved in the order of frequency are the 
 scaphoid, cuneiform and magnum. These fractures are often asso- 
 ciated with those of the radius and ulna and should not be over- 
 looked by exclusive attention to the latter. In case of doubt it is 
 advisable to secure plates of both wrists in symmetrical position 
 for comparison. 
 
 Colles's Fracture. — ^This is probably the most common of all frac- 
 tures. The usual deformity is a compression of the posterior margin 
 of the radius which results in a backward tilting of the articular 
 
40 
 
 FRACTURES AND DISLOCATIONS 
 
 Fig. 14. — Shell wound. Shot fired from German submarine off Cape Cod, July 21, 
 1918. The first person to be injured on American territory. 
 
 Fig. 15. — Fracture of the anatomical neck of the humerus along the epiphyseal line. 
 The amount of deformity is not well shown in the anteroposterior ^new. 
 
FRACTURES 41 
 
 surface as seen in the lateral position. After reduction, the former 
 relation of the styloid processes of radius and ulna should be restored 
 and the plane of the articular surface should be tilted toward the 
 palmar surface forming a normal angle with the axis of the shaft. A 
 special type of this injury results from backfiring of automobiles and 
 consists of an oblique fracture through the styloid of the radius. 
 
 Fig. 16. — Subperiosteal fracture of the tibiae. The line of fracture is not visible, Init 
 there is a definite break in outline. 
 
 Elbow. — Fractures here in the order of frequency are supra- 
 condylar fractures of the humerus, fractures of olecranon, head of 
 radius and coronoid process. The two latter injuries may occur 
 without a great deal of displacement and may be overlooked unless 
 they are carefully searched for. 
 
 Shoulder. — Fractures of the anatomical and surgical neck are 
 usually the result of falls and they may or may not be impacted. 
 Stereoscopic observation of this region or a lateral view is always 
 recommended for the recognition of the true relation of the frag- 
 ments. 
 
42 
 
 FRACTURES AND DISLOCATIONS 
 
 Fractures of the scapula are often overlooked on flat plates. 
 Stereoscopic examination will minimize this error. 
 
 Tarsus. — ^Fractures of the os calcis are the most frequent. They 
 produce more or less disturbance in the normal structure consequent 
 upon crushing of the spongy bone and deformity of outline. The 
 
 Fig. 17. — Fracture into the knee-joint. Also fracture of the patellae. The fracture 
 is not visible in the lateral view. 
 
 line of fracture is seldom seen. The resulting disability is usually 
 severe. More rarely fractures of the astragalus and cuboid may 
 occur. 
 
 Pott's Fracture. — In any fracture of the tibia it is essential that 
 the fibula be explored throughout its extent in order to avoid missing 
 breaks which occur at a different level from that of the tibial injury. 
 The essentials in reduction of a Pott's fracture are that the weight- 
 
Fig. 18. — Old fracture of the femur, with extensive callus and deformity. 
 
 Fig. 19. — Pathological fracture of the upper end of the tibia in a case of Paget's 
 
 disease. 
 
Fig. 20.^-Greeii-stick fracture of the tibisB, with considerable callous formation 
 suggesting periosteal changes. 
 
 Fig. 21. — Fracture of the neck of the femur, with marked absorption of the neck. 
 
DISLOCATIONS 45 
 
 bearing line be restored accurately and that the foot be slightly 
 inverted. 
 
 Knee. — Fractures of the condyles of femur and tibia have the 
 characteristics of fracture involving an}' joint. The spine of the 
 tibia may be evulsed; the patella may sustain a transverse break 
 with wide separation of the fragments or it may suffer a stellate 
 fracture or shelving fractures of the upper or lower margins as a 
 result of division of the attachment of the patellar tendon. 
 
 Hip.- — These fractures occur anywhere in the neck of the femur 
 between the head and intertrochanteric line. ^^ hen there is any dis- 
 placement of the fragments, there will be a disturbance of Shenton's 
 line, which is a smooth, regular curve formed by the upper margin 
 of the obturator foramen, the inferior border of the neck of the 
 femur and the inner margin of the shaft. 
 
 In the prognosis of hip fractures the possibility of failure of union 
 and of absorption of the head of the femur must always be kept in 
 mind. 
 
 Fig. 22. — Double congenital dislocation of the hip. 
 
 DISLOCATIONS. 
 
 Dislocations of the spine are usually accompanied by fracture. 
 They are most common in the cervical region. The first cervical 
 vertebra may be displaced backward on the second with fracture 
 of the odontoid or, more rarely, rotated upon the second without 
 fracture of the odontoid. The most frequent injury is a forward 
 displacement of the upper cervical vertebrae upon the ones below 
 in the region of the third to the seventh. 
 
46 
 
 FRACTURES AND DISLOCATIONS 
 
 \u,. --■;.- ni.«location of the shoulder. 
 
 Fig. 24. — Displacement of the epiphysis of the humerus- 
 
DISLOCATIONS 47 
 
 The sacro-iliac joint may be disarticulated as a result of severe 
 trauma. The so-called sacro-iliac slip is not demonstrated on plates. 
 
 Subeoracoid dislocations of the shoulder usually have an asso- 
 ciated fracture of the greater tuberosity, which is reduced when the 
 head of the humerus is replaced. 
 
 Fig. 25. — Dislocation of the sixth on the seventh cervical vertebrse. 
 
 In the carpus the semilunar is occasionally dislocated forward 
 and may be overlooked in an anteroposterior view although it is 
 obvious in a lateral one. 
 
 Epiphyseal separations usually involve a fragment of the adjom- 
 ing shaft. When unaccompanied by a fracture of the shaft they 
 can only be diagnosed by the abnormal relations of the epiphyses, 
 
46 
 
 FRACTURES AND DISLOCATIONS 
 
 Fig. 23. — Dislocation of the shoulder. 
 
 Fig. 24. — Displacement of the epiphysis of the humerus. 
 
DISLOCATIONS 47 
 
 The sacro-iliac joint may be disarticulated, as a result of severe 
 trauma. The so-called sacro-iliac slip is not demonstrated on plates. 
 
 Subcoracoid dislocations of the shoulder usually have an asso- 
 ciated fracture of the greater tuberosity, which is reduced when the 
 head of the humerus is replaced. 
 
 Fig. 25. — Dislocation of the sixth on the seventh cer\-ical vertebrse. 
 
 In the carpus the semilunar is occasionally dislocated forward 
 and may be overlooked in an anteroposterior ^'iew although it is 
 obvious in a lateral one. 
 
 Epiphyseal separations usually involve a fragment of the adjoin- 
 ing shaft. AVhen unaccompanied b}' a fracture of the shaft they 
 can only be diagnosed by the abnormal relations of the epiph}'ses, 
 
48 
 
 FRACTURES AND DISLOCATIONS 
 
 which do not often occur. Plates of symmetrical parts should always 
 be taken to check up these findings. ^Yhen these separations are 
 promptly and accurately replaced there is rarely any interference 
 with the growth of the bone. 
 
 Fig. 26. — Fracture of the fifth cervical vertebree. 
 
 Delayed union of the ossification center of the tibial tubercle is 
 fairly common, particularly in the presence of a chronic infection 
 such as lues. Separation of the tibial tubercle (Osgood-Schlatter 
 disease) occurs usually as a result of indirect violence. The tubercle 
 is elevated from the diaphysis and the margins of the epiphyseal 
 line beneath it are thickened and ragged. A similar injury may 
 occur to the epiphysis of the os calcis. 
 
 Congenital dislocations of the hip may be single or double. They 
 are characterized by displacement of the head of the femur upward 
 on the ilium, flattening and deformity of the head, and shallowness 
 of the acetabulum. 
 
BIBLIOGRAPHY 49 
 
 Dislocations may occur at any joint. They are usually obvious 
 and require no particular description. In any dislocation careful 
 search should be made after reduction, as well as before, for fractures 
 which may have been overlooked. 
 
 BIBLIOGRAPHY. 
 
 Cotton, F. J.: Fractures of the transverse processes of the vertebrae, Interstate 
 Med. Jour., Supplement on Roentgenology, October, 1916, p. 1.38. 
 
 Sever, J. W. : Fracture of a lumbar vertebra, Surg., Gynec. and Obst., 1916, 
 xxii, p. 338. 
 
 Young, J. K. : Ununited fractures of lumbar vertebrae, Ann. Surg., 1916, Ixiii, 
 p. 374. 
 
 Boardman, W. W.: Pseudofracture of the sesamoid bones of the big toe, Surg., 
 Gj'nec. and Obst., 1915, xxi, p. 394. 
 
 Crook, J. L. : Fractures of the astragalus. Rail. Surg. Jour., 1916, p. 17. 
 
 Cotton, F. J.: Os calcis fracture, Ann. Surg., Ixiv, p. 480. 
 
 Codman, E. A., and Chase, H. M.: Fracture of the carpal scaphoid and disloca- 
 tion of the semilunar bone, Ann. Surg., May, 1905. 
 
 Solomon, E. P.: Unusual surgical conditions following trauma, luternat. Jour. 
 Surg., 1916, xxix, p. 248. 
 
 Skillern, P. G. : Fractures of sesamoid bones of the thumb, Ann. Surg., 1915, Ixii, 
 p. 297. 
 
 Scudder, C. L. : Treatment of fractures, with notes upon a few common disloca- 
 tions, Ed. 8, rev. Philadelphia, 1915. 
 
 Pancoast, Henry K. : Roentgen examination of the spine; surgery of the spine 
 and spinal cord, Franzier-Appleton, New York. 
 
CHAPTER IV. 
 BONE PATHOLOGY. 
 
 Normal bones are smooth and regular in outline, the cortex is 
 homogeneous and the cancellous tissue of imiform consistency. The 
 thickness of the cortex and the texture of the spongy bone vary 
 considerably with the individual. The cortex is thickest along the 
 center of the shaft of the long bone, diminishing toward the ends 
 to a thin line which continues beneath the articular cartilage. The 
 student should have a general idea of the normal thickness of the 
 cortex of each individual bone. 
 
 Bone disease is manifested by changes in size, in outlme and in 
 density. Various forms and combinations of these changes result 
 from the action of pathological agents, so that it is often difficult 
 from the roentgen findings alone to identify positively the causati^■e 
 factor. For this reason the clinical history should always be com- 
 bined with the roentgen findings in making a diagnosis. 
 
 Bones are increased in size in osteomyelitis, tumors, Paget's 
 disease, s^-philis and cystic disease. They are diminished in size 
 in paralysis, chronic disease of neighboring joints or in develop- 
 mental anomalies. Changes in outline result from periostitis, which 
 may be traumatic or infectious, from callus formation and from 
 tumors of the bone. 
 
 Changes in density may be either local or diffuse. Diminished 
 density (increased radiability) occurs as a result of disuse, infection 
 or of actual destruction from involvement by tumor, cyst or surgical 
 intervention. The form of rarefaction due to disuse is commonly 
 referred to as bone atrophy although this term is not strictly correct. 
 There are two t^'pes: spotted and diffuse. In the spotted form small 
 local areas of rarefaction appear scattered through the spongy bone 
 and may be noticed as early as one week after complete fixation 
 of the parts. This condition may be mistaken for metastatic malig- 
 nancy but the history will usually differentiate them. The diffuse 
 form occurs in more chronic processes as a result of prolonged fixa- 
 tion, chronic infections in neighboring joints or atrophy of the soft 
 parts, or as a result of senile changes. As the name implies, it is a 
 
OSTEOMYELITIS 
 
 51 
 
 more extensive process and consists in a uniform decrease in density 
 with thinning of the cortex and trabeculye. Increased density occurs 
 as a diffuse process in old osteomyehtis, in syphilis and in Paget's 
 disease. It is found locally about certain low-grade infections and 
 carcinomatous metastases of slow development. 
 
 In the presence of a pathological process in bone, the following 
 points should be determined: (1) Is there involvement of the med- 
 ulla; (2) is there evidence of involvement of the cortex; (3) is there 
 
 Fig. 27 
 
 -The bone atropliy of disuse. 
 
 any associated pathology in the soft parts; (4) is the lesion multiple; 
 (5) is it confined to the shaft or does it invade the epiphysis and 
 joint; ((3) are neighboring bones affected; (7) is it destructive or 
 proliferative or both? 
 
 Osteomyelitis. — The characteristics of this process are a ^'ariable 
 amount of destruction of medulla and cortex; extensive reaction 
 of the periosteum whenever involved; sequestration and irregular 
 sclerosis. It may attack any bone at any age and rarely extends 
 beyond the epiphyseal line. 
 
54 
 
 BONE PATHOLOGY 
 
 Fig. 30. — Necrosis of the skull. 
 
 Fig. 31. — Osteomyelitis of the ilium in a child. 
 
TUBERCULOSIS 
 
 55 
 
 atrophy may be severe so that the bones appear of the density of 
 soft parts with finely penciled outlines. Enlargement and squaring 
 of the epiphyses is the rule. As the process continues there is more 
 or less destruction of the joint surfaces eventually resulting in anky- 
 losis as the process heals. Periostitis may develop in the neighbor- 
 hood of tuberculous lesions, but only as a result of secondary 
 infection. 
 
 Fig. .32. — Tuberculous spine (anteroposterior view). 
 
 The rare cases of tuberculosis of the shaft appear as an irregular 
 destruction in the medulla resembling that seen in a syphilitic osteo- 
 myelitis but without involvement of cortex or periosteum. 
 
 In the spine tuberculosis usually begins in the neighborhood of 
 the intervertebral disks and destroys the adjacent body or bodies, 
 which collapse, producing a k^'phos. This portion of the spine is 
 
56 BONE PATHOLOGY 
 
 often suiToiinded by the fusiform shadow of a prevertebral abscess. 
 Calcification may occur later in such an abscess. 
 
 Caries sicca is a slow destructive process which is most common 
 in the shoulders. It causes irregular erosion of the joint surfaces and 
 
 Fig. 33. — Tiiherculous spine (lateral view 
 
 the epiphyseal end of the humerus. There is no bone atrophy; on 
 the contrary, there may be slight increase in density in the affected 
 area. 
 
 Dactylitis (spina ventosa) is characterized by considerable 
 increase in the diameter of the diseased phalanx, which shows 
 extensive areas of destruction in the medulla. The cortex may be 
 
SYPHILIS 57 
 
 somewhat thin or sHghtly mcreased in thickness. This condition 
 is differentiated from syphiHtic dactyUtis by the fact that the 
 enlargement in the latter is due to periosteal proliferation with the 
 formation of a collar of new bone outside of the old cortex; there is 
 \QT\ little involvement of the medulla and from giant-celled 
 sarcoma bv the absence of trabeculation. 
 
 Fig. 34. — C'rauial tub 
 
 Syphilis. — Syphilis is a destructive and proliferative process, 
 assuming ^•aried form.s which may simulate other conditions. It 
 attacks any bone at any age. Its commonest manifestations are 
 periostitis and irregular areas of destruction. 
 
 Periostitis is usually limited to the shaft, and the picture which 
 results from it varies according to the age and activity of the 
 process. ^Yhen acute the appearance is that of multiple distinct, 
 thin laminse laid do^^m upon the old cortex, and the outline of the 
 free margin is usually irregular. As the condition becomes more 
 chronic these laminae become thicker and more compact, so that 
 
58 BONE PATHOLOGY 
 
 ultimately the area involved becomes as dense as the normal cortex. 
 At the same time the surface loses its fringy character and becomes 
 smooth, although it may be more or less irregular. This increase in 
 thickness of the cortex will often give an appearance of bowing, as is 
 seen in the so-called sabered tibia, for example. It should be noted 
 that this thickening of the cortex usually occurs on the convex 
 side of the curve as compared with rickets, where it appears on the 
 
 Fig. 35. — Congenital syphilis (periosteal type). 
 
 concave side. There is often an accompanying endosteal prolifera- 
 tion with narrowing of the medullary canal. 
 
 Periostitis may also occur as small local elevations of the perios- 
 teum (bone blisters) at times near the ends of the long bones 
 and assumes the form of multiple confluent small blisters. There is 
 another type of lesion, a sort of lacework pattern, which consists of 
 strands of calcified material which run out at right angles to the 
 cortex and arch together at their terminations. Running through 
 
SYPHILIS 
 
 59 
 
 this pattern, parallel to the shaft and midway between the cortex 
 and the periphery, there is a definite thin sheet of calcification. 
 At the margins of the process where it blends into the normal bone 
 is the usual type of laminated periosteal thickening. In the con- 
 genital form in infants the periosteum may be floated away from the 
 shaft for a considerable distance, giving a clear space between it 
 and the cortex. 
 
 ii_i 
 
 Fig. 36. — Types of specific periostitis of the tibia;. 
 
 Irregular areas of destruction may occur in any bone, usually as 
 a result of gummatous changes. In the skull the picture is striking 
 and represents punched-out areas involving borh the outer and inner 
 table. In the long bones they are usually associated with periosteal 
 changes, although at times a bone may be riddled with these areas of 
 rarefaction and show only slight periosteal change. This is partic- 
 ularlv common in the more acute cases. In children a common picture 
 
60 
 
 BONE PATHOLOGY 
 
 is the so-called jiixta-epiphyseal lesion, which occurs in the diaphysis 
 near the epiphyseal line. They are characterized at first by an 
 irregular loss of substance close to the epiphyseal line and perhaps 
 a slight periostitis. The affected area later becomes sclerosed, lead- 
 
 FiG. 37. — Specific periostitis (congenital type). 
 
 ing to the formation of a white line, which resembles somewha.t 
 that seen in scorbutus. 
 
 Joint lesions may be unilateral or symmetrical. Ordinarily little 
 is seen beyond an increase in density in the soft parts, due to 
 
TYPHOID 
 
 61 
 
 effusion and synovial thickening. Later on, low rounded hyper- 
 trophic growths may appear about the margins of these joints. 
 Extensive destructi\e processes may sometimes occur in the epiphy- 
 seal ends of bones, causing considerable deformit}'. Localized areas 
 of destruction suggesting tuberculosis may sometimes be found in 
 the epiphyses of children. 
 
 Fig. 38. — Specific dactilitis. 
 
 In the spine, lues causes the destruction of one or more bodies, 
 usually preserving the intervertebral disks. The affected area is 
 often surrounded by calcified masses of detritus. Extensive hyper- 
 trophic changes are seen on the neighboring vertebrae. 
 
 Typhoid. — Typhoid in the bone is a localized destructive and pro- 
 liferative process of long duration, usually occurring in early adult 
 life. It is characterized by circumscribed areas of destruction in the 
 ribs, the margins of vertebral bodies and occasionally the cortex and 
 long bones. It may cause a local periostitis and at times extensive 
 irregular periostitis indistinguishable from that of syphilis. In the 
 spine the first roentgen evidence usually appears at an interval of 
 weeks or months after the onset of symptoms, when a small area of 
 destruction may appear in the corner of a vertebra close to the disk. 
 
62 BOXE PATHOLOGY 
 
 Subsequently coarse hypertrophic bridges may appear about this 
 area or the intervertebral disk ma}' be destroyed with a resulting 
 fusion with the adjacent vertebrae. 
 
 Actinomycosis. — Actinomycosis causes a chronic osteomyelitis. 
 It usually occurs in the jaw, and is characterized by its slow course 
 and by the pronounced proliferation of bone vrith the resulting 
 general increase in density. 
 
 Oidiomycosis. — Oidiomycosis may attack the bone in severe cases. 
 The roentgenogram will show extreme bone atrophy in in^'olved 
 areas, with more or less irregular destruction which suggests tuber- 
 culosis when it occurs in the region of a joint. Local areas of destruc- 
 tion may occur in the cortex with loose fuzzy strands of proliferating 
 periosteum overlying them. 
 
 Leprosy. — Leprosy is characterized in its early stages by bone 
 atrophy of the terminal phalanges and a variable amount of peri- 
 ostitis. As the disease progresses these phalanges disappear and 
 there is progressiA'e involvement of the other phalanges. 
 
 Phosphorous Poisoning. — Phosphorous poisoning causes a chronic 
 osteomyelitis of the jaw, indistinguishable roentgenologically from 
 the ordinar}' pyogenic form. 
 
 BONE TUMORS. 
 
 Li the study of hone neoplasms it is particularly important to 
 determine whether or not they are chiefly medullary or cortical and 
 as far as possible whether or not there is involvement of the soft 
 tissues. The most important question which one is called upon to 
 decide is whether the lesion is benign or malignant. This may be 
 a matter of considerable difficulty. 
 
 Benign Lesions. — Osteomata. — Osteomata are merely irregular 
 extensions of normal bone into the surrounding tissues. They are 
 characterized by their very slow development, by the fact that their 
 structure is that of normal bone and that they blend into the bone 
 at their site of origin. They are most commonly found near the ends 
 of the long bones in adults. They may consist of hook-shaped pro- 
 cesses called exostoses or broad, romided masses — true osteomata. 
 
 Enchondromata. — Enchondromata cause irregular eccentric enlarge- 
 ments of the bones. They are usually multiple and are most common 
 in the hands, feet and long bones. There is considerable distortion 
 in the outline as a result of tumor growth with or without thinning 
 of the cortex, and the trabeculse of the medulla may be replaced by 
 
BONE TUMORS 
 
 63 
 
 a homogeneous, putty-like shadow or by multiple small rounded 
 areas of rarefaction. In extensive tumors the thinning of the cortex 
 may be so extreme that it is reduced to small, thin flakes of bone on 
 the periphery of the growth, which in the flat plate are projected 
 upon the tumor and must be differentiated from calcification within 
 the growth. 
 
 Fig. 39. — Osteomata of the femur. 
 
 Multiple Cartilaginous Exostoses. — Multiple cartilaginous exostoses 
 are an hereditary anomaly of development, in which large cartilagi- 
 nous outgrowths of diminished density and irregular outline appear 
 in the region of the epiphyseal lines. These growths are multiple, 
 usually involving most of the epiphysis, and cause considerable 
 deformity and interference with the normal development of the bone 
 involvement. 
 
64 
 
 BONE PATHOLOGY 
 
 Bone Cysts. — Bone cysts occur in the long bones and in the jaw. 
 They are characterized by sharply defined, rounded or oval areas 
 of rarefaction containing few or no trabeculse. The process is 
 entirely within the shaft, and spreads longitudinally in the medulla 
 without involving the cortex which, however, may be considerably 
 thinned from pressure. There is no deformity in outline unless a 
 
 Fig. 40. — Multiple cartilaginous exostosis. 
 
 fracture has occurred. Spontaneous fractures are often the first 
 indication of the presence of a lesion and they are usually followed 
 by extensive callous formation. 
 
 Osteitis Fibrosa. — Allied to cystic disease is a rare condition which 
 may involve one or all of the bones. It consists in the replacement 
 of the normal structure by irregular strands of trabeculse enclosing 
 
BONE TUMORS 
 
 65 
 
 multiple cysts which vary in size and shape. There is considerable 
 expansion in the bone, and spontaneous fractures are common as 
 a result of the thinning of the cortex. There is no periosteal pro- 
 liferation. When cysts occur in the neighborhood of epiphyseal 
 lines there may be interference with growth. 
 
 Fig. 41. — Bone cyst in upper end of humerus. Fig. 42. — Bone cyst and fracture. 
 
 Osteitis Deformans (Paget's Disease). — Osteitis deformans is a 
 slowly progressive process which usually involves most of the 
 bones, but in rare forms may be limited to one, particularly 
 one end of the tibia. It shows extensive thickening of the cortex 
 on both sides, with enlargement and bowing of the bone and re- 
 arrangement of the trabeculse into strands or bundles running lon- 
 gitudinally. The medulla shows mottled areas of rarefaction which 
 usually extend into the epiphysis. This involvement of the epiphysis 
 is important in the differentiation from lues, which very rarely 
 affects the epiphysis in the same manner. In the skull this condition 
 causes an increase in the size of the head as a result of expansion 
 of the cranial bones, which show great thickening of both tables 
 and coarse mottling throughout the diploe. 
 5 
 
66 
 
 BONE PATHOLOGY 
 
 Malignant Lesions. — Sarcoma. — Giant-celled sarcoma is probably 
 not a true malignancy and should be classed with the benign lesions, 
 although one case in our experience became malignant following 
 
 Fig. 43. — Paget's disease. 
 
 intensive roentgenization. This tumor, which is of slow growth, 
 occurs as an isolated lesion, usually near the end of a long bone or 
 in the jaw. The growth is eccentric, that is, it causes asymmetrical 
 enlargement of the bone and tends to balloon out the cortex rather 
 
BONE TUMORS 
 
 67 
 
 than to spread along the medullary canal. Ordinarily it does not 
 break through the cortex. The mass of the tumor consists of 
 irregular areas of rarefaction containing coarse trabeculae, sometimes 
 suggesting a mass of soap-bubbles, 
 
 Osteosarcomata are slowly growing masses which usually originate 
 in the medulla of long bones or in the flat bones. Their charac- 
 teristic is an early, extensi^'e, irregular deposition of lime salts 
 throughout the growth. They are not particularly malignant. 
 They may be mistaken for an old osteomyelitis but the history will 
 usually differentiate them. 
 
 Fig. 44. — Giant-cell sarcoma of the finger. 
 
 Bound or S'pindle-celled (niedvllary) sanomaia are of very rapid 
 development and metastasize early. They involve the shaft, often 
 the greater part of it. Their appearance is that of extensive rare- 
 faction with destruction of trabeculse, early invasion of the overly- 
 ing cortex and extension into the soft parts. Often there is a com- 
 plete loss of bone substance in the area occupied by the tumor, the 
 outline of which can be traced into the soft tissue. At times the 
 
68 BONE PATHOLOGY 
 
 picture resembles that of a virulent osteomyelitis which should be 
 differentiated by the history and clinical course. 
 
 Periosteal sarcomata are rapidly growing tumors which are 
 extremely malignant and which originate from the periosteum, 
 most commonly along the shaft of the long bones. In the earliest 
 stages they may appear as a slight erosion of the cortex or a blister 
 
 Fig. 45. — Medullary sarcoma of the lower end of the fibxila. 
 
 beneath the periosteum which is elevated by the growth. As the 
 growth increases, the shadow of its outline in the soft tissues becomes 
 evident, A most characteristic finding is the presence of fine strands 
 of calcified material radiating into the substance of the tumor and 
 terminating freely. There may be slight erosion of the cortex which 
 ends abruptly at the limits of the growth. In the early stages careful 
 
BONE TUMORS 
 
 69 
 
 examination of the entire periphery of the bone may be necessary 
 to demonstrate the lesion. 
 
 Carcinoma. — Carcinoma is practically always metastatic and may 
 involve any one or all of the bones. It may be identified by a 
 moth-eaten appearance due to the irregular destruction of bone 
 
 Fig. 46. — Periosteal sarcoma of the femur in a child. 
 
 substance and its replacement by tumor mass. The cortex may be 
 involved, but ordinarily only in the later stages. There is no perios- 
 teal reaction and no change in outline unless spontaneous fracture 
 occurs. In the skull it appears as irregular areas of bone destruction 
 which typically are limited to the diploe and do not involve either 
 table. When the spine is involved there is more or less extensive 
 
70 BONE PATHOLOGY 
 
 destruction of several bodies but ordinarily the>' do not collapse 
 owing to the fact that the dense tumor tissue affords considerable 
 support. This is of importance in the differentiation from tubercu- 
 losis and lues, in which collapse of the affected bodies is the rule. 
 
 There is a second form of metastatic carcinoma usually secondary 
 to a tumor of the prostate or breast, which is of extremely slow 
 development— cases having been seen ten years after the recognition 
 
 Fig. 47. — Metastatic carcinoma of the femur. 
 
 of the primary disease. It is characterized by the extensive produc- 
 tion of new bone in the vicinity of the growths. Its usual site is in 
 the spine and pelvic bones, which become greatly increased in density 
 and coarsely mottled from the intermingled areas of rarefaction and 
 condensation. The bones are sometimes enlarged and may be 
 mistaken for osteitis deformans. The long history may also be 
 suggestive of this condition. More careful inspection will show 
 
BONE TUMORS 
 
 71 
 
 that the picture is produced by adjacent areas of bone destruction 
 and proliferation, with the latter predominating, and that there is 
 no evidence of the rearrangement of trabeculae into bundles, which 
 is typical of Paget's disease. Furthermore, the distribution of the 
 lesions is quite dissimilar. Osteitis deformans more commonly 
 attacks the long bones and skull and rarely involves the spine, while 
 this form of carcinoma shows a preference for spongy bone. The 
 demonstration of a primary growth particularly in the prostate 
 should be conclusive. 
 
 Fig. 48. — Metastatic sarcoma of the skull in a child. 
 
 Rarer Bone Tumors. — Any type of tumor may be encountered 
 in the bones and the roentgen appearance of different pathological 
 entities is naturally very similar, as they are manifested only by 
 irregular areas of bone destruction which are not characteristic of 
 any particular neoplasm. They are commonly diagnosed as carci- 
 noma roentgenologically. Under this heading come h}T)ernephroma, 
 myeloma, m;yTioma, fibroma, etc. The age of the patient and 
 the distribution of lesions may help. 
 
72 
 
 BQNE^ PATHOLOGY 
 
 Hypernephroma. — Hypernephroma occurs as multiple small areas 
 of rarefaction with loss of trabecule and no attempt at new bone 
 formation. It may be distributed throughout the skeleton and is 
 particularly common throughout the skull, sternum, ribs and bodies 
 of vertebrae. 
 
 Fig. 49. — Multiple medullary- 
 mj'eloma. 
 
 Fig. 50. — Pulmonary osteoarthropathy. 
 
 Myeloma.— Myeloma is a low-grade malignancy of slow evolu- 
 tion which typically causes small multiple areas of rarefaction, 
 
BONE TUMORS 
 
 73 
 
 usually limited to the flat bones, although extensive single lesions 
 have been obseived in long bones. Owing to its slow growth, defor- 
 mities in outline occur as a result of thinning and expansion of the 
 cortex overlying the growth. For the same reason spontaneous 
 fracture is fairly common. Its appearance often resembles that of 
 carcinoma, although the areas are usually smaller, more rounded 
 and more sharply defined. It is accompanied by the presence of 
 Bence-Jones bodies in the urine. Some cases have responded well 
 to roentgen therapy. 
 
 Fig. 51. — Acromegalia. 
 
 Myxoma. — M^'xoma is a slowly growing tumor which usually 
 involves a single long bone. It causes irregular enlargement of the 
 whole shaft, irregular rarefaction of the medulla and thinning of 
 the cortex. It may also invade the soft tissues and show small 
 spicules of periosteal bone in the soft tissue mass, suggesting sar- 
 coma. Pathological examination may be necessary in a dift'erential 
 diagnosis. 
 
74 
 
 BONE PATHOLOGY 
 
 DISEASES OF NUTRITION. 
 
 Pulmonary Osteoarthropathy.— The first stage in this process is 
 enlargement of the soft tissues of the ends of the fingers, so-called 
 
 Fig. 52. — Bowing of the tibia in the adult, due to racliitis. 
 
 club fingers. Later proliferation of the periostemn, which is difficult 
 to distinguish from that of lues, appears along the metacarpals and 
 phalanges and frequently about all the long bones. As a result, 
 
DISEASES OF NUTRITION 
 
 75 
 
 these bones have a thickened cortex and in the later stages are 
 increased in width. 
 
 Acromegaly. — Acromegaly, in addition to the characteristic changes 
 in the skull, gives rise to a general enlargement of the skeleton. 
 A typical finding is the change which occurs in the cancellous bone, 
 the texture of which becomes very coarse and heavy. There is also 
 clubbing of terminal phalanges. 
 
 Active rachitis. 
 
 Rickets. — This is a disease usually occurrmg during the first 
 dentition. It shows in the roentgenogram a flaring and widening 
 of the diaphysis above the epiphyseal line ; the bone between shaft 
 and epiphysis is increased in thickness, with ragged, fringy margins. 
 The shaft side of the epiphyseal line may appear as a broad white 
 
76 
 
 BONE PATHOLOGY 
 
 line, as a result of the deposit of lime salt. The shaft may be bowed 
 and the cortex considerably thickened on the concave side of the 
 curve. Mild periosteal proliferation sometimes occurs. There may 
 be areas of decreased density in the cranial bones along with promi- 
 nence of the frontal and parietal bosses. In the form which comes 
 on later during adolescence there is irregular rarefaction and enlarge- 
 ment of the long bones, resulting in disturbance of the weight-bearing 
 lines, as, for example, coxa vara and genu varum. 
 
 Fig. 54. 
 
 -Scurvy, well advanced. Case showing separation of the periosteum and 
 displacement of the epiphysis due to hemorrhage. 
 
 Scorbutus. — This condition is commonly seen during the first 
 years of life and may or may not have an associated rickets. The 
 earliest evidence of its presence is a wiiite line in the shaft margin 
 of the epiphyseal zone. This line is thinner, more dense and more 
 sharply defined than the one seen in rickets. Later in the clinical 
 course subperiosteal hemorrhages appear as more or less extensive 
 irregular elevations of the periosteum over the entire length of the 
 
DISEASES OF NUTRITION 
 
 77 
 
 shafts of the long bones. In severe cases the hemorrhage may be 
 sufficient to produce separation of the epiphysis. The final process 
 consists of organization of the clot which produces a shadow of 
 considerable density about the shaft. 
 
 Fig. 55. — Osteogenesis imperfecta. 
 
 Differential diagnosis is from lues and osteomyelitis. Lues is 
 more apt to be a generalized process, the periosteum is less elevated 
 and epiphyseal dislocation does not appear. In osteomyelitis there 
 is destruction of the shaft which is unaffected in scorbutus, and the 
 clinical picture is, of course, quite characteristic. 
 
78 
 
 BOXE PATHOLOGY 
 
 Achondroplasia (Chondrodystrophy Fetalis) .—The bones in this 
 condition are shortened, compact and at times bowed. The epiphy- 
 seal Hne is very thin and sharply defined and closes considerably 
 earlier than the normal. This results in an adult whose long bones 
 are very much shortened, with corresponding loss of weight. This 
 process is said to involve only those bones in which ossification has 
 begun before the sixth month. 
 
 Fig. 56. — Osteomalacia in a child. 
 
 Osteogenesis Imperfecta (Fragilitas Ossium, Periosteal Dysplasia 
 or Osteopsathyrosis). — In the infantile form of this disease the bones 
 show great diminution in lime salts and thinning of the cortex 
 without changes in size. This results in a weakening of the structure 
 of the bones and multiple spontaneous fractures occur, usually 
 followed bv a fair amount of callous formation. 
 
DISEASES OF NUTRITION 
 
 79 
 
 In the adult form the bones are nearly normal in size and calcium 
 content but usually present considerable deformity as a result of 
 the multiple spontaneous fractures which the patient has suffered. 
 
 Fig. 57. — Osteomalacia, with pathological fracture in adult female. 
 
 Osteomalacia. — This is a condition of extreme and irregular 
 diminution in the density of all the bones. There is usualh' consider- 
 able deformity due to bending and spontaneous fractures with poor 
 -callous formation. This condition may result from any one of several 
 causes and is therefore not properly to be regarded as an entity. 
 
80 
 
 BONE PATHOLOGY 
 
 A TABULATION OF THE FINDINGS IN THE MORE COMMON BONE 
 LESIONS FOR USE IN DIFFERENTIAL DIAGNOSIS. 
 
 Osteomyelitis. 
 
 1. Usually a single lesion. 
 
 2. Both destructive and proliferative. 
 
 3. A disease of the shaft, involving the 
 
 epiphysis — rarely the joint. 
 
 4. Produces bone atrophy. 
 
 Usually starts in the medullary por- 
 tion and involves the cortex, peri- 
 osteum, and soft tissue. 
 
 Occurs at any age. 
 
 Enlargement and deformity of the 
 bone. 
 
 Syphilis. 
 
 1. Usually a multiple process. 
 
 2. Usually proliferative. The gumma- 
 
 tous form, which is rare, is both 
 proliferative and destructive. 
 
 3. Usually a disease of the shaft, but 
 
 rarely it involves the joint and 
 epiphysis. 
 
 4. Usually confined to the periosteum, 
 
 but may involve the cortex. Does 
 not caupe bone atrophy. 
 
 5. May appear at any age. 
 
 6. There maj' be enlargement and con- 
 siderable deformity of the bones. 
 
 Periosteal Sarcoma. 
 
 1. Always single. 
 
 2. Proliferative. 
 
 3. Involves the shaft only, as a rule — 
 
 rarely invades the epiphysis. Never 
 enters a joint. 
 
 4. Invades the soft tissues in the im- 
 
 mediate neighborhood, presenting 
 characteristic ray-like formation. 
 Bone atrophy is absent. 
 
 5. Common in young adults. 
 
 Cakcinom.\. 
 
 1. Multiple lesion. 
 
 2. Usually purely destructive; rarely 
 
 there is bone proliferation about 
 the invaded area. 
 
 3. Attacks the medulla and cortex of the 
 
 long and flat bones. The perios- 
 teum and joints are not involved. 
 
 4. A disease of adults. 
 
 5. In the proliferative type, the bones 
 
 may be enlarged and deformed. 
 
 Tuberculosis. 
 
 1. Usually a single lesion. 
 
 2. A destructive process. 
 
 3. A disease of the joints and epiphyses. 
 
 4. Rarely invades the shaft and soft 
 
 tissues ; the neighboring bones show 
 marked atrophy. The periosteum 
 is not involved. 
 
 5. More common in children. 
 
 Paget's Disease. 
 
 1. A multiple lesion. 
 
 2. Proliferative. 
 
 3. Involves the shaft and epiphysis- 
 
 the joints are not affected. 
 
 4. Late adult life. 
 
 5 . Overgrowth of the bony structures 
 and abnormal trabeculation. The 
 soft tissues are not invaded. 
 
 Giant-cell Sarcoma. 
 
 1. Single lesion. 
 
 2. Destructive type. 
 
 3. Involves the medullary portion of the 
 
 shaft; the cortex may be thin but 
 is not invaded. The joints and soft 
 tissues are unaffected. 
 
 4. Childhood and young adults. 
 
 5. The bone is not deformed. 
 
 Bone Cyst. 
 
 1. Single lesion. 
 
 2. Purely destructive. 
 
 3. Located in the medullary portion of 
 
 shaft. Does not invade the cortex, 
 joint, or soft tissue. 
 
 4. Children and young adults. 
 
 5. The bone is not deformed. 
 
BIBLIOGRAPHY 81 
 
 Medullary Sarcoma. Osteoma 
 
 1. Siagle lesion. 1. Usually a single lesion. 
 
 2. Purely destructive in the bone. 2. Purely proliferative. 
 
 3. Involves the shaft , rarely the epiphy- 3. Arises from the cortex. Never invades 
 
 sis; never the joint. the bone. 
 
 4. The cortex of the bone is destroyed 4. Common in children and young 
 
 and the soft tissues invaded. adults. 
 
 .5. Usually in young adults. 5. There may be some deformity of 
 
 bone from pressure. Structure of 
 the growth resembles normal bone. 
 
 BIBLIOGRAPHY. 
 
 Kuth, J. R. : Early congenital bone lues, Arch. Ped., 1915, xxxii, p. 244. 
 
 Risley, E. H.: Skeletal cancer, British Med. Surg. Jour., 1915, clxxii, p. 584. 
 
 Boorstein, S. W. : Syphilis of bones and joints, Surg., Gynec. and Obst., 1914, 
 xviii, p. 46. 
 
 Fitz Simmons, H. .1.: Multiple bone tuberculosis, British Med. Surg. Jour., 1914, 
 clxx, p. 547. 
 
 Locke, E. A.: Secondary hypertrophic osteoarthropathy, Arch. Int. Med., 1915, 
 XV, p. 659. 
 
 Kessel, L.: Relation of hypertrophic osteoarthropathy to pulmonary tuberculosis, 
 Ai-ch. Int. Med., 1917, xix, p. 239. 
 
 Cotton and McCleary: Myxoma of femur, Am. Jour. Roent., 1918, v, p. 95. 
 
 Fassett, F. J.: Kohler's disease, Jour. Am. Med. Assn., 1914, Ixii, p. 1155. 
 
 Hetzel: Kohler's disease, Am. Joar. Orthop. Surg., 1917, xv, p. 214. 
 
 Lock, N. F.: Note on tunnels and large cavities in bone, British Jour. Surg., July, 
 1916, p. 145. 
 
 Murphy, J. B.: Bone and joint diseases in relation to typhoid fever, Surg., Gynec. 
 and Obst., 1916, -xxiii, p. 119. 
 
 Wile, Udo. J., and Senear, F. E.: A study of the involvement of the bones and 
 joints in early syphilis, Am. Jour. Med. Sc, 1916, clii, p. 689. 
 
 Wilde: Acute bone atrophy after an accident, Am. Jour. Roent., 1916, cxi, p. 54. 
 
 Perussia, F. : Phosphorus necrosis of the maxillge, Am. Jou". Roent., 1916, cxi, p. 
 177. 
 
 Gouldesbrough, C: Pulmonary osteoarthropathy, Arch. Roent. Ray, 1913, xviii, 
 p. 208. 
 
 Ehrenfried, Albert: Multiple cartilaginous exostoses, Jour. Am. Med. Assn., 1915, 
 Ixiv, p. 1642. 
 
 Murphy, John B.: Typhoid spine, Surg., Gynec. and Obst., 1916, xxiii, p. 119. 
 
 Gaenslen, F. J.: Osteitis deformans, Am. Jour. Orthop. Surg., 1915, xiii, p. 96. 
 
 Bythell, W. S. J.: Bone tumors: in proceedings of Roj^al Society of Medicine, 
 Electrotherapeutical Section, March 20, 1914, Arch. Roent. Ray, 1914, xix, p. 185. 
 
 Royce, C. E.: Sarcoma of the scapula, Surg., Gynec. and Obst., 1916, xxiii, p. 74. 
 
 Weber: Multiple cartilaginous exostoses, Am. Jour. Roent., 1916. 
 
 Hirsch: Bone tumors, Am. Jour. Electro, and Radiol., January, 1917. 
 
 Boggs, R. H.: X-ray in bone disease, New York Med. Jour., 1917, cv, p. 112. 
 
 Symmers, D., and Vance, M.: Hemangio-endothelioma, Am. Jour. Med. Sc, 
 1916, clxxix, p. 28. 
 
 ConneU; Giant-celled tumor of bone, Surg., Gynec. and Obst., 1915, xxii, p. 427. 
 
 Barrie, G.: Cancelloiis bone lesions, Ann. Surg., 1915, Ixi, p. 129. 
 
 Coon, C. A.: Bone and joint .syphilis, Am. Jour. Surg., 1915, xxix, p. 211. 
 
 Mclntyre, Milne: Diffuse myxochondroma of a long bone. Lancet, December, 
 1916, p. 1013. 
 
 Cotton, F. J.: Diagnosis of periosteal sarcoma with the x-ray, British Med. Surg. 
 Jour., 1916, p. 946. 
 
 Rugh, J. T.: Typhoid spine, with autopsy findings, Am. Jour. Orthop. Surg., 1915, 
 xiii, p. 289. 
 
 Henderson, M. S.: Osteochondromatosis, Am. Jour. Orthop. Surg., 1917, xv, p. 351. 
 6 
 
82 BONE PATHOLOGY 
 
 Kohler, A.: Kohler's disease, Aliinchen. med. Wchnschr., 1908, Iv, p. 1923. 
 
 PfaUer: Kohler's disease, Surg., Gynec. and Obst., 1913, xvii, p. 625. 
 
 Neve, A.: A case of leprosy diagnosed by x-rays, British Med. Jour., December 4, 
 1915, p. 814. 
 
 Connell, F. G.: Giant-celled tumor of bone, Tr. Western Surg. Assn., 1915, xxiv, 
 p. 221. 
 
 Denit, G. B.: Giant-celled sarcoma of pehis, Ann. Surg., 1915, Ixii, p. 636. 
 
 Landon, L. H.: Ostitis fibrosa cystica, Tr. Philadelphia Acad. Surg., 1915, xvii, 
 p. 90. 
 
 Van Zwaluwenburg: Ostitis fibrosa. Jour. Michigan Med. Soc, 1915, xiv, p. 46. 
 
 For complete bibliography of ostitis fibrosa cystica and of bone cysts, see Blood- 
 good: Ann. Surg., Iri, Nr). 2, p. 145. Muller: Univ. Pennsylvania Med. Btill., Septem- 
 ber, 1906, p. 173. Stiiunpf: Deutsch. Ztschr. f. Chir., 1912, pp. 114, 417. Silver: 
 Am. Jour. Orthop. Surg., 1911-12, ix, 563. 
 
 Vance: Multiple mj^eloma, Am. Jour. Med. Sc, November, 1916, p. 691. 
 
 HaussHng, F. R., and Martland, H. S.: Bone tumors, Ann. Surg., 1916, Ixiii, p. 454. 
 
 McCrae, T.: Tjiphoid and paratj-phoid spondylitis, with bony changes in the 
 vertebra?, Am. Jour. Med. Sc, 1906, clix, p. 878. 
 
 Lord, F. T.: Analysis of twenty-six cases of typhoid spine, Boston Med. Surg. 
 .Jour., 1902, cxl^d, p. 689. 
 
 Koch, J. C.: Laws of bone architecture. Am. Jour. Anat., 1917, xxi, p. 177. 
 
 Walker, C. A., and Cummins, W. T.: Echinococcic bone disease. Jour. Am. Med. 
 Assn., 1917, Ix^dii, p. 839. 
 
 Fisher, A. L.: Sj^philitic bone and joint lesions sim\ilating tuberculosis. Jour. 
 Am. Med. Assn., 1917, Ixviii, p. 366. 
 
 Grey and Carr: Bone atrophy, Johns Hopkins Med. Bull., 1915, xxvi, p. 381. 
 
 Elaine, E.: Idiopathic infantile osteopsathj-rosis. Am. Jour. Roent., 1916, iii, 
 p. 438. 
 
 Hiu-ndtz, S. H.: Monoosteitic form of Paget's disease. Am. Jour. Roent., 1915, 
 ii, p. 755. 
 
 Langnecker, Hany L. : Lesions of the lumbosacroiliac region. Jour. Am. Med. Assn., 
 1915, Ixv, p. 1866. 
 
 Jacobsohn: The causes of rickets. New York Med. Jour., 1916, ciii, p. 68. 
 
 Hirsch, 1. S.: Bone tumors. Am. Jour. Electro, and Radiol., 1917, xxxv, pp. 1, 72, 
 113, 116. 
 
 Bythell and Scott: Bone tumors, Proc. Roy. Soc. Med., London, 1913-14, Electro- 
 therapeutic Section, pp. 63-78. 
 
 Lovett: Rickets, Jour. Am. Med. Assn., 1915, Ixv, p. 2062. 
 
 Crawford, H. de L. : Congenital syphilis of hands and feet, Tr. Roy. Acad. Med., 
 Ireland, 1915, xxxiii, p. 224. 
 
 Berard and Alamartine: Bone disease simulating bone tumors. Rev. de Chir., 
 1914-15, p. 137. 
 
 Cameron, H. C: Osteogenesis imperfecta, Proc. Roy. Soc. Med., 1915-16, Section 
 on Diseases of Children, ix, part 1, p. 43. 
 
 Hess, J. H.: Osteogenesis imperfecta. Arch. Int. Med., 1917, xix, p. 163. 
 
 Ehrenfried, A.: Hereditary deforming chondroplasia, "multiple exostoses," British 
 Med. Surg. Jour., 1916, clxxiv, p. 327. 
 
 Montgomery: Congenital exostoses, Internat. Chn., 1916, xxvi. 111, p. 140. 
 
 Carman, R. D., and Fisher, A. C. : Multiple congenital csteochondromata, Ann. 
 Surg., 1915, Ixi, p. 142. 
 
 MacCoUum, W. G.: Chondrodystrophia fetalis, Johns Hopkins Hosp. Bull., 
 1915, xxvi, p. 182. 
 
 Young, J. K. : Chondrodystrophia fetalis. Arch. Ped., 1914, xxxi, p. 371. 
 
 Honeij, James A.: Bone changes in leprosy. Am. Jour. Roent., New York, October, 
 1917. 
 
CHAPTER V. 
 
 SKULL. 
 
 RoENTGEXOLOGY of the skull, its contents, sinuses, mastoids and 
 teeth has become a field of its own. There is naturally a close asso- 
 ciation between the teeth and sinuses, and the two should always be 
 studied together. The bones of the skull are subject to fractures 
 and diseases affecting the skeleton generally, which ha^"e already 
 been considered. 
 
 Fig. 
 
 -Oxjcephalus 
 
 The suture line and the grooves of the vessels are 
 obliterated. 
 
 Hydrocephalus. — Hydrocephalus is perhaps the commonest brain 
 condition with which the roentgenologist has to deal in children. 
 The picture is one of chronic intracranial pressure — enlargement and 
 great thinning of the vault of the skull, with exaggeration of the 
 convolutional depressions and often separation of the sutures. 
 
84 
 
 SKULL 
 
 Oxycephalus. — A condition in which there is early union of the 
 cranial sutures followed by increased intercranial pressure. On the 
 Roentgen plate the skull appears small and thin with absence of 
 the suture line. Areas of diminished densit}' due to pressure of the 
 convolution are unusually prominent. 
 
 Fig. 59. — Tumor of the brain located in the frontal lobe. The plate shows localized 
 
 pressure atrophy. 
 
 Brain Tumor. — Brain tumor rareh' gi^'es direct e-\'idence of its 
 presence. Localized erosion of the cah^arium o^'er the lesion or 
 increased density due to new bone formation by the dura overh'ing 
 it or, very rarely, calcification in the mass itself ma^' help to localize 
 the process. In 90 per cent, of the cases all that appears on the plate 
 is the evidence of intracranial pressure and the common findings 
 are compression or destruction of the posterior clinoid processes, 
 enlargement of the bloodvessel channels distributed to the affected 
 
SELLA 85 
 
 area and, at times, increased impressions of the cerebral convolu- 
 tions. In severe cases separation of one or more suture lines may 
 be present. 
 
 Subdural Hemorrhages. — Subdural hemorrhages cannot be diag- 
 nosed on the roentgenogram. Thin areas in the temporal region or 
 areas of increased density in the parietals are often erroneously 
 pointed out as hemorrhages. 
 
 Fig. 60. — Pituitary tumor. The sella is enlarged and its floor destroyed. 
 
 Sella. — True lateral views, preferably stereoscopic, are essential 
 for the proper observation of Uie sella. It is subject to considerable 
 variation both in size and shape, of which the latter is the more 
 important. As already noted, deformity of the posterior clinoids 
 may occur as a result of tumor in any portion of the brain. Hypo- 
 physeal tumors cause a ballooning of the sella with thinning of the 
 floor and usually of both anterior and posterior clinoid processes. 
 Associated with these changes may be seen more or less enlargement 
 of the sinuses, elongation of the mandible and general enlargement 
 
86 SKULL 
 
 of the bones, particularly those of the hands and feet. The clinoids 
 occasionally meet, bridging in the roof of the sella. Attention has 
 been called to the fact that this is a common occurrence in epilepsy 
 and sterility. (Faulty technic in securing views of the sella which 
 are not true laterals may cause an appearance of roofing which a 
 true lateral will correct.) 
 
 Fig. 61. — Very large sinuses. Anatomical variations. 
 
 Calcified Pineal Glands. — Calcified pineal glands are frequently 
 seen in individuals over thirty. They appear as dense white spots 
 a millimeter or two in diameter located in the mesial plane several 
 centimeters above the mastoids. They are without significance. 
 
 Sinuses. — For a proper study of the sinuses anteroposterior, 
 lateral, and vertical projections are necessary. The anteroposterior 
 plate, in addition to the outline of the sinuses themselves, affords 
 
SINUSES 
 
 87 
 
 some evidence of the shape of the septum, size of the turbinates and 
 relative depth of the floor of the nose and the floor of the antra. 
 The lateral plate is particularly useful in checking up the antero- 
 posterior of the frontals to determine their depth and the thickness of 
 their walls. Teeth or foreign bodies in the antra may be well 
 projected in this view which often gives a clue to the condition of 
 the sphenoidal sinus, but is of little value in the study of the ethmoids. 
 The vertical projection outlines the sphenoidal sinus very well. 
 The normal sinus, because of its air content and thin walls, 
 appears as a more or less darkened area with sharply defined edges. 
 
 Fig. 62. — Sinusitis. All of the sinuses on the left side are dull. 
 
 Any change in the amount of air contained within it or in the thick- 
 ness of its walls will be recorded as a change in density on the plate, 
 and both these factors must be considered in making a diagnosis. 
 This is particularly true in the case of the frontals, where a degree of 
 density which is normal for one individual may be quite pathological 
 in the case of another whose air space is larger and walls thinner 
 and whose sinuses should therefore appear darker. For the recog- 
 nition of pathology, it is essential to compare the two sides and to 
 have a fairly definite mental picture of the appearance of the normal 
 sinus. In the study of the frontals both anteroposterior and lateral 
 views must be combined. 
 
88 SKULL 
 
 A general haziness with a sHght increase in density in one or more 
 sinuses usually means thickening of the lining membrane. This may 
 be corroborated in the case of the frontals by the additional evidence 
 of thickening of the septal markings which become hazy and are 
 surrounded by an indefinite zone of slightly increased density, as 
 contrasted with the sharply outlined normal septa. This general 
 thickening may involve only one sinus, all of the sinuses on one side, 
 
 Fig. 63. — Osteoma of the frontal sinus. 
 
 or those of both sides. In the last condition, some difficulty may arise 
 from the fact that comparison of opposite sides is impossible and the 
 roentgenologist must fall back upon his empirical knowledge of 
 what the normal should be. 
 
 Granulations, pus or tumors produce a shadow of greater density, 
 which usually obliterates the sinus completely. Their shadows are 
 identical in every respect, so that it is usually impossible to tell 
 
POLYPI 89 
 
 ^Yhich one we are dealing with from the roentgen plate alone. When 
 there is a fluid exudate in a sinus it is often possible to make out a 
 fluid level in the suspected cavity upon a plate taken with the patient 
 upright. However, the absence of a fluid level does not rule out pus. 
 Tumors of the sinuses will ordinarily give some evidence of their 
 nature by erosion or invasion of the walls or adjacent bones, ^'ery 
 rarely a sinus or portion of the orbit will be occupied by a dense 
 osteoma. Absence of frontal sinuses is fairly common and must be 
 differentiated from thickening which has obscu'-ed the margins and 
 obliterated the outline of a well-developed sinus. A lateral view 
 will show no evidence of a sinus and no room for it at the base of 
 the frontal. Careful inspection of the anteroposterior view should 
 show the presence of bone structure in the suspected area. 
 
 Fig. 64. — Sclerosed and normal ma.stoid. 
 
 It must not be forgotten that a sinus may be found filled with 
 mucoid material at operation and yet cast no abnormal shadow on 
 the plate. In fact, mucoceles by erosion of the bone overlying them 
 often appear as areas of diminished density. 
 
 Polypi. — Polypi can sometimes be visualized in the frontals and 
 antra as romided areas of slightly increased density. The entire 
 sinus will usually appear somewhat hazy as a result of the thickened 
 membrane. 
 
 Burnham has called attention to the occurrence of a dense 
 fusiform shadow OA'erlapping the septum in a case of gumma of 
 the septum. 
 
90 
 
 SKULL 
 
 The patency and course of nasal ducts may be determined from 
 roentgenograms made with opaque probes in situ. 
 
 Mastoids. — Plates of both sides should always be taken as a 
 routine for purposes of comparison. Normally the cells are bright 
 and clear with sharply outlined walls. The broad grooves of the 
 lateral sinus can usually be traced down across the mastoid as a 
 streak of diminished density. In an acute mastoiditis there is 
 general haziness of the affected cells and blurring of their margins, 
 followed later by destruction of the cells and loss of their outlines, 
 which are replaced by an indefinite area of increased density. In 
 chronic cases there is more or less absence of cells and a variable 
 degree of sclerosis. 
 
 Teeth. — The roentgenologist should have a general knowledge of 
 the development, anatomy and pathology of the teeth, for he will 
 surely be called upon to do a certain amount of dental roentgenology. 
 An understanding of the course of dentition is helpful not only in 
 the interpretation of dental conditions in children and adults but 
 also in the determination of the ages of children. The following 
 table from Thoma can be relied upon as a working basis. : 
 
 Tooth, 
 temporary. 
 
 Central incisor . 
 Lateral incisor. 
 
 Cuspid 
 
 First molar. . . . 
 Second molar. . 
 Central incisor. 
 Lateral incisor. 
 
 Cuspid 3 years 
 
 First bicuspid. ... 4 " 
 Second bicuspid. . 5 " 
 
 First molar Before birth 
 
 Second molar .... 5 years 
 Third molar 9 " 
 
 Calcification 
 begins. 
 
 1 year 
 1 " 
 
 Calcification 
 complete. 
 
 1 5 years 
 
 2 " 
 20 months 
 20 
 
 10 years 
 10 
 12 
 12 
 12 
 9 to 16 
 
 17 to 18 
 
 18 to 20 
 
 Eruption. 
 
 6 to 8 months 
 1 to 9 
 
 17 to 18 
 14 to 15 
 
 18 to 24 
 
 7 to 8 years 
 7 to 8 " 
 
 12 
 10 
 11 
 6 
 13 
 18 
 
 Shed. 
 7 vears 
 
 s" " 
 
 12 " 
 
 10 " 
 
 11 " 
 
 The importance of good technic in dental roentgenology must be 
 insisted upon. This includes adequate exposures with the least 
 possible amount of distortion, preferably from several angles and 
 the use of both plates and films. 
 
 Anomalies of development, irregularity of eruption, misplaced 
 and unerupted teeth are perhaps the most frequent examples and 
 the diagnosis is obvious. Impaction, which is particularly common 
 in the molars, is a common finding. The presence of retained 
 temporary teeth is readily recognized. 
 
 In adult teeth the roentgen examination is often of value in demon- 
 
Alveolar abscess 
 
 91 
 
 strating fracture of the teeth below the gum le^'el, the extent of 
 carious processes, and in determining the extent and position of 
 root canal fillings and the results of operative procedures. Pulp 
 stones are often revealed in the pulp cavities. They are small, 
 round, dense masses frequently multiple, which form in the pulp 
 chamber of one or more teeth. They have been accused of being 
 the cause of severe neuralgias. Inasmuch as they are frequently 
 seen without s;y'TQptoms, their significance is questionable. 
 
 The most important pathological conditions with which the 
 roentgenologist has to deal are, of course, pyorrhea and alveolar 
 abscess. 
 
 Fig. 65. — Multiple pus pockets involving the roots of the molars and bicuspids. 
 
 Pyorrhea. — Pyorrhea in its early stages gives little roentgen 
 evidence aside from a slight increase in the width of the dark line 
 about the tooth, which represents the peridental membrane. As the 
 infection continues and the alveolar process becomes involved, the 
 bone retracts from the neck and finally the roots of the teeth, which 
 are then kept in place only by the fibrous tissue of the gums. As 
 a general rule, when the retraction of the alveolar process involves 
 over half of the root the tooth is doomed. 
 
 Alveolar Abscess. — Alveolar abscess in the acute stage, like osteo- 
 myelitis, gives no roentgen evidence of its presence. Very shortly, 
 however, rarefaction appears about the root involved and at first 
 
92 
 
 SKULL 
 
 
 4 ^^H 
 
 Fig. 66. — i, pyorrhea pocket about the mesiobuccal root of the left upper first 
 molar; S, advanced Rigg's disease, with absorption and recession of the alveolus, 
 but without definite pyorrhea pockets; 3, chronic abscesses at apices of palatal and 
 mesiobuccal roots of the left upper first molar; 4. osteomyelitis arising from the roots 
 of the left lower first molar; 5, proliferative inflammatory granuloma, with central 
 softening at the apex of the right upper second bicuspid; 6, devitalized left lower 
 molar showing caries, root canal fillings and small apical granuloma; 7, impacted right 
 lower third molar, with pus pocket; 8, small pyorrhea pockets about both upper 
 central incisors; transverse fracture of the left upper incisor. 
 
CYSTS 
 
 93 
 
 the resulting dark area merges into the structure of the surrounding 
 cancellous bone. As the process becomes more chronic, a limiting 
 wall appears about it and the picture then becomes one of a definite 
 dark sac attached usually about the apex of the root. This is the 
 familiar form of alveolar abscess. Pathologically most of them are 
 found to be a mass of granulation tissue containing a certain number 
 of bacteria, less frequently a definite abscess cavity with a lining 
 membrane. Erosion of the tip of the root extending into this cavity 
 is often seen and in long-standing cases deposits of new bone laid 
 down about the apex of the root produce bulbous enlargements and 
 may wholly or in part fill the old abscess cavity. The treatment 
 of such an abscess is one to be decided by all the other evidence, 
 medical and dental, which can be acquired. Not every tooth which 
 shows an alveolar abscess should be extracted. Each case should be 
 
 Fig. 67. — Impacted upper canine tooth. 
 
 treated upon its indi^•idual merits. Abscesses must not be confused 
 with extensions of the antra downward or pockets in the antra in 
 the region of the upper bicuspids and molars nor with the sub- 
 mental foramen which frequently overlies the apex of a lower 
 bicuspid. Films of the upper incisors occasionally show the shadow 
 of the nostril overlying a root which simulates an abscess. 
 
 Cysts. — Cysts are fairly common in the jaw. There are two forms: 
 root cyst and dentigerous cyst. The former arises perhaps most 
 frequently from an old alveolar abscess. It appears as a large 
 rounded area of rarefaction in the jaw, usually attached to or 
 partially enclosing one or more tooth roots and showing little or no 
 evidence of trabeculation. They may be multiple. Dentigerous 
 cysts have a similar appearance except that they develop from a 
 buried tooth bud and generally contain teeth or portions of them. 
 The bony structure of the jaws may be subject to any of the diseases 
 
94 
 
 SKULL 
 
 which affect the rest of the skeleton. Osteomyelitis is fairly common 
 and shows the same irregular destruction and proliferation seen 
 
 Fig. 6S. — Simple cyst of the jaw 
 
 Fig. 69. — Dentigerous cyst. 
 
CYSTS 
 
 95 
 
 elsewhere. A particular sort of osteomyelitis occurs with phos- 
 phorous poisoning; the bone becomes increased in density and 
 thickness as a result of new bone production which is followed later 
 by suppuration and necrosis represented by irregular rarefaction. 
 Syphilis occurs occasionally in the form of an irregular mottling 
 of the bone due to extensive spotted rarefaction. 
 
 Tumors of all sorts may be encountered — giant-cell sarcoma and the 
 more malignant forms of sarcoma, carcinoma and hypernephroma, 
 for example. Their appearance is identical with that of similar 
 growths in other flat bones. In addition, the jaw is the seat of a 
 
 Fig. 70. — Cystoma of the jaw. 
 
 tumor peculiar to it, the odontoma, which is a dense mass made up of 
 various tooth tissues and may be attached to a tooth or be composed 
 of several teeth fused together. Sometimes they take the form of 
 undefined masses of considerable density, which continue to grow 
 and develop into large deforming tmnors. Salivary calculi must be 
 mentioned in any consideration of the teeth. They cast dense round 
 or oval shadows seen in the position of the salivary glands or ducts. 
 When projected upon the mandible in oblique views they must 
 not be mistaken for areas of density in the bone. The shadows of 
 calcified glands often appear in tooth plates. They are spotted 
 
96 SKULL 
 
 mulberry-like shadows, characteristic of calcified glands anywhere. 
 The tip of an nnnsually long styloid process may be projected upon 
 the upper molar region and be mistaken for an extra tooth root or 
 supernumerary tooth. 
 
 BIBLIOGEAPHY. 
 
 Heuer, G. J., and Dandy, ^Y. E.: Roentgenography in the locahzation of brain 
 tumors, Johns Hopkins Hosp. Bull., 1916, xxvii, p. 311. 
 
 Veasey, C. A.: Osteorfia of sinuses, Ann. Ophth., 1916, xxv, p. 699. 
 
 Probert, C. C: Osteoma of sinuses, Jour. Michigan Med. Soc, 1916, xv, p. 304. 
 
 Boas, E. P., and Scholz: Calcification of the pineal gland. Arch. Int. Med., 1918, 
 xxi, p. 66. 
 
 Stewart, W. H., and Luckett, W. H.: Roentgen diagnosis of fracture of the skull, 
 Arch. Radiol., 1915-16, xx, p. 1.50. 
 
 Gould and Le Wald: Chloroma, Med. Rec, 1916, p. 7.57. 
 
 Sharpe, W.: Oxycephaly, Am. Jour. Med. Sc, 1916, cli, p. 840. 
 
 Osgood: Lesions of tibial tubercle, British Med. Surg. Jour., January 29, 1903. 
 
 Mauclaire, P.: Absence d'ossification du cartUage de conjugaison des deux tuber- 
 osities tibiales anterieures chez un adulte, Bull, et Mem. Soc. de chir. de Paris, 1915, 
 xli, p. 2457. 
 
 Gushing, Harvey P.: Pituitary body and its disorders, Philadelphia, 1912. 
 
 Thoma, K\irt. H. : Oral abscesses, Boston, 1916. 
 
CHAPTER VI. 
 JOINTS, TENDONS AND BURS.E. 
 
 There is as yet no really satisfactory classification of the 
 joint diseases because of the lack of accurate pathological knowl- 
 edge. Probably the best one so far proposed is that of Barker, 
 upon which the following outline is based. It must be insisted 
 that no hard-and-fast adherence to the general types described 
 below is possible. Atypical joints and those which fall under more 
 than one heading are often observed. In the study of a pathological 
 joint, the following features should be carefully noted: (1) Peri- 
 articular swelling in the soft parts, (2) effusion in the joint, (3) 
 erosion of cartilage as evidenced by diminution of the joint 
 space, (4) changes in density of the bone, (5) outgrowths of new bone 
 formation and (6) the joints in^'olved. Probably the commonest 
 form of arthritis is the hypertrophic, which occurs in individuals 
 over forty, more often men. Its characteristic feature is the pres- 
 ence of spurs or lipping on the margins of articular surfaces, which 
 include vertebral bodies. These outgrowths are dense with sharp 
 edges and in some cases cause fixation of a joint by interlocking 
 or fusion. There is no fluid in the joint unless it has been recently 
 injured. There is no loss of articular cartilage and no decalcification 
 of adjacent bone. It may attack any joint, usually the larger, and 
 is very common in the spine. These joints may exist for a consider- 
 able length of time without giving many symptoms but they are 
 apparently points of lowered resistance, for after injur}' they may 
 be the seat of acute painful reactions which are entirely out of pro- 
 portion to the injury and would not have occurred in a normal 
 joint. This condition is continually being encountered in industrial 
 accident work. 
 
 Gout. — Gout is less common but, like the first type, occurs after 
 forty, more frequently in men than in women. In a typical case it 
 presents peri-articular swelling and very characteristic punched-out 
 areas in the bones at the margins of the articular surfaces. These 
 holes are sharply cut and vary from one to several millimeters in 
 diameter, in severe cases causing complete destruction of an articular 
 7 
 
98 
 
 JOINTS, TENDONS AND BURSM 
 
 end of the bone. There is httle effusion in the joint, erosion of the 
 cartilages occurs only in the late severe cases and there is no decal- 
 cification. Usually some slight hypertrophic spurs are present. It 
 ordinarily occurs in the phalangeal joints of the hands and feet, 
 but may affect the carpus or tarsus and in rare cases a large joint, 
 such as the knee, simulating here an early Charcot joint from the 
 
 Fig. 71.— Gout. 
 
 amount of destruction and new bone formation which takes place. 
 In the early stages before the punched-out areas become evident 
 it may be mistaken for a hypertrophic arthritis. It is, of course, 
 accompanied by other clinical evidence of the disease. 
 
 Charcot Joints. — A striking picture which occurs in patients with 
 tabes or syringomyelia is seen usually in middle age. There is tre- 
 mendous swelling of the soft parts, destruction of articular surfaces. 
 
ATROPHIC ARTHRITIS 99 
 
 amounting to complete disorganization, and large irregular masses 
 of calcified material scattered throughout the joint. There is no 
 decalcification of bone. Its commonest sites are the knee, hip, 
 ankle and spine. Conditions which may be confused with it are 
 (1) gout, which is rare in large joints and always involves the smaller 
 ones in addition; (2) loose bodies in joints, in which case the cal- 
 cified masses are small, dense and few in number, and the joint 
 
 Fig. 72. — Charcot joint. 
 
 surfaces are not disturbed except that the point of origin of the 
 fragment may be evident in a chipped-off area on the inner condyle 
 of the femur; or (3) calcified hematomata, in which the calcification 
 is much more extensive. The joint surfaces are intact. 
 
 Atrophic Arthritis. — Atrophic arthritis is more common in women 
 and it is seen between the ages of twenty-five and forty-five. It 
 begins with periarticular swelling followed by gradual loss of 
 articular cartilage, sho\Mi by narrowing of the joint space and by 
 
100 JOINTS, TENDONS AND BURSM 
 
 severe atrophy of the soft parts, and decalcification of bone. There 
 is no tendency to new bone or spur formation. The process extends 
 over a period of years, ending typicality in complete ankylosis. 
 
 Infectious Arthritis.^ — Infectious arthritis attacks any joint at any 
 age. Its forms are extremely varied owing to the number of causa- 
 tive agents. The most common types are pyogenic, gonorrheal, 
 tuberculous and syphilitic. 
 
 Fig. 73. — Infectious arthritis of the knee-joint. An early case. 
 
 Pyogenic Arthritis. — Pyogenic arthritis is usually due to staphylo- 
 C3CCUS, streptococcus or pneumococcus. The acute forms attack one 
 or many joints which show soft tissue swelling and effusion in the 
 synovial cavity. The process may then subside with disappearance 
 of these signs. If it persists for several weeks, decalcification of the 
 articular ends of the bones will occur and there may be erosion of 
 cartilage with narrowing of the joint space. Later, as repair begins, 
 hypertrophic changes may make their appearance at the margins 
 
TUBERCULOSIS 
 
 101 
 
 of the articular surfaces or the cartilage may be entirely destroyed 
 and ankylosis result when healing is complete. 
 
 Gonorrheal Arthritis. — Gonorrheal arthritis is usually monarticular 
 but it may be indistinguishable roentgenologically from other 
 pyogenic joints. However, there are two findings in addition to 
 those of pyogenic infection which are very suggestive of Xeisserian 
 origin. One is a localized destruction of the cartilage on the under 
 surface of the patella which sinks in towards the condyles of the 
 femur. Subsequently hypertrophic changes appear on its margins 
 
 Fig. 74. — Hypertrophic arthritis of the knee-joint. 
 
 and on the adjacent areas of the femur. The "second is the occur- 
 rence of small localized areas of rarefaction in the bone at the junc- 
 tion of articular surfaces and cortex. Another result of this infec- 
 tion is the development of spurs upon the os calcis which tend to 
 grow out along the plantar fascia. These spurs may be the result 
 of the activity of streptococcus but the great majority are gonorrheal. 
 Tuberculosis. — Tuberculosis is more common in children. It 
 causes slight enlargement of the soft parts, efl'usion in the capsule, 
 and general haziness and muddiness of the entire joint area. There 
 is extreme decalcification so that the outlines of the bones mav be 
 
102 
 
 JOINTS, TENDONS AND BUBSM 
 
 Fig. 75. — -Tuberculosis of the knee-joint. 
 
 Fig. 7G. — Tuberculosis of the hip. An early case. 
 
TUBERCULOSIS 
 
 103 
 
 Fig. 77. — The same case as Fig. 76, two j'ears later. The process is now well 
 advanced and quite typical. 
 
 Fig. 78. — -The same case as Fig. 76, three years after the first oxainiiintion. The 
 disease is now arrested. 
 
104 
 
 JOINTS, TENDONS AND BURSM 
 
 reduced to a thin pencilled white line. Enlargement and squaring 
 of the epiphyses are seen and later more or less destruction of joint 
 surfaces, and interference with the growth of the bone. There is 
 no new bone formation. The occurrence of periosteal reaction and 
 bony ankylosis in these joints is the result of secondary infection. 
 During the process of repair there is increase in density due to 
 deposit of lime salts. Caries sicca is seen most commonly in the 
 shoulders in adults. It shows a chronic ragged erosion of the 
 articular surfaces, no soft tissue swelling, no effusion and no 
 decalcification. 
 
 Fig. 79. — Gumma ol \\w .-.piuc. 
 
 Syphilis. — Syphilis may be seen at any age and it is manifested 
 by increased density in the soft tissue and the occurrence of a 
 slight periostitis at the junction of the periosteum and synovial mem- 
 brane ; occasionally by destruction of articular surfaces, particularly 
 those of the small bones, such as carpus and tarsus, and by local 
 lesions in the epiphyses suggesting tuberculous foci. In some cases, 
 as the result of chronic low-grade inflammation in the synovial 
 membrane, low, rounded hypertrophic ridges will appear at the 
 margins of the articular surfaces. 
 
 Villous Arthritis. — Villous arthritis consists of a thickening in the 
 soft parts due to overgrowth of synovial fringes. It may be 
 
Fig. so. — Syphilis of the knee-joint. 
 
 Fig. 81. — Multiple calcified bodies in the knee-joint. 
 
106 
 
 JOINTS, TENDONS AND BURSM 
 
 seen in lateral views of the knee, where the posterior portion 
 of the capsule is occupied by a mass of slightly greater density than 
 normal, and where a stringy, fan-shaped shadow can be made out 
 radiating anteriorly between the condyles of the femur and tibia. 
 Hemophilia. — AVhen the joints are involved in this disease the 
 signs are those of chronic joint irritation suggesting tuberculosis. 
 There is bone atrophy amounting even to pencilling of the outlines, 
 effusion into the joint and moderate enlargement and squaring of the 
 epiphyses. At times erosion of the articular ends of the bones may 
 occur, or calcification of the blood-clot within the joint. 
 
 Fig. 82. — Hemophilia with organizing blood-clot in the capsule of the elbow-joint. 
 
 Osteochondritis Desiccans. — Osteochondritis desiccans is charac- 
 terized by the presence of a mass of cartilage loose in the joint 
 whose site of detachment may usually be made out upon the articu- 
 lar surface of the inner condyle of the femur. If these loose pieces 
 do not calcify they are invisible, but fortunately most of them 
 do in the course of time. 
 
 Osteochondritis Deformans (Perthe's disease). — Osteochondritis 
 deformans is revealed by a flattening and mushrooming of the head 
 of the femur, suggesting tuberculosis but without typical clinical 
 signs. The joint is not involved. There is little bone atrophy and 
 interference with growth is not marked. It is possibly due to 
 
OSTEOCHONDRITIS DEFORMANS 107 
 
 Fig. S3. — Osteochondritis desiccans. 
 
 Fig. 84. — Perthe's disease. An early case. Note the slight deformity of the 
 head of the femur. 
 
lOS 
 
 JOINTS, TENDONS AND BURSM 
 
 Fig. 85. 
 
 -Perthe's disease. The same case as Fig. 84, one year later, 
 is now well marked and quite typical. 
 
 The process 
 
 Fig. 86. — Perthe's disease. Same case as Fig. 84, three years after the first 
 examination. The head of the femur is more dense, showing that repair is taking 
 place. 
 
TENDONS AND BURSJE 
 
 109 
 
 interference with the blood supply of the epiphysis. The end result 
 of such a process as seen in adults is a flattening of the head, which 
 is sometimes displaced downward slightly on the neck. 
 
 TENDONS AND BURS-ffi. 
 
 Effusion or hemorrhage in or about these tissues is shown by an 
 area of slightly increased density with indefinite margins. S^Tlo- 
 vitis of the Achilles, quadriceps or extensor longus pollicis tendons 
 may occasionally be suspected from thickening of the shadow and 
 blurring of its ordinarily sharp outlines. Areas of increased density 
 seen in the region of the subdeltoid bursa maA' be true calcifications 
 
 Fig. 87. — Subdeltoid bursitis. 
 
 in the bursa, which are rare; accumulations of an opaque gelatinous 
 substance in the bursa; or, what is more common, calcification 
 about the tendon of the supraspinatus beneath it. Calcification 
 may occur in any bursa which has been the seat of tramna or 
 infection. 
 
110 JOINTS, TENDONS AND BURS.E 
 
 BIBLIOGRAPHY, 
 
 Gushing, H.: Hereditarj- ankylosis of the proximal phalangeal joints (sympha- 
 langism), Jour. Nerv. and Ment. Dis., 1916, xliii, p. 445. 
 
 Goldthwait, J. E.: Lumbosacral articulation, British Med. Surg. Jour., 1911, 
 clxiv, p. 365. 
 
 OgUvy: Subluxations of atlas upon the axis. Am. Jour. Orthop. Surg., 1914-15, 
 xii, p. 314. 
 
 O'Eeilly, A.: Joint sj-philis. Am. Jour. Orthop. Surg., 1913-14, xii, p. 431. 
 
 Brickner, W. M.: Subacromial bursitis, Am. Jour. Surg,. 1916, xxx, p. 108. 
 
 Dunlop: Deposit simulating subacromial bursitis. Am. Jour. Orthop. Surg., 1916, 
 xiv, p. 102. 
 
 Brickner, W. M.: Subacromial bursitis, Jour. Am. Med. Assn., 1916, Ix^d, p. 912. 
 
 Stein: Syphilitic arthritis, Med. Rec, 1915, p. 472. 
 
 Skillern: Joint lues, Internat. Clin., 1914, xxiv, p. 192. 
 
 Whitelocke: Loose joint bodies, British Jour. Surg., 1914, p. 650. 
 
 Legg, A. T.: An obscure affection of the hip-joint, British Med. Surg. Jour., 
 1910, clxii, p. 202. 
 
 Berrj-, John McW. : Roentgenological shadows associated -ndth subdeltoid bursitis. 
 Am. Jour. Orthop. Surg., 1916, xiv, p. 476. 
 
 Scott, S. G.: Myositis ossificans, Charcot's joint associated with. Arch. Radiol., 
 1917, xxi, p. 239. 
 
 Barker, L. F. : Differentiation of diseases included under chronic arthritis, Am. 
 Jour. Med. Sc, l(fl4, cxhdi, p. 1. 
 
 Legg, A. T. : Osteochondral trophopathj- of the hip-joint, Surg., Gynec. and Obst., 
 1916, xxii, p. 307. 
 
 Freiberg, A. H.: Hemophilia affecting the knee. Lancet, Chn., 1916, exv, p. 588. ■ 
 
 Brickner, W. M.: Cause of Roentgen shadow in eases of subacromial bursitis. 
 Am. Atlas Stereoroent., 1916, i, p. 34. 
 
 Henderson, M. S.: Loose bodies in the knee-joint, Am. Jour. Orthop. Surg., 1916, 
 xiv, p. 265. 
 
 Brickner: Prevalent fallacies concerning subacromial bursitis, Am. Jour. Med. So., 
 1915, p. 540. 
 
 Carnett, J. B.: Typhoid .spine, with a report of cases. Am. Surg., Philadelphia, 
 1915, Ixi, pp. 456-471. 
 
 Perthes, G. : L^eber osteochondritis deformans juvenalis, Arch. f. klin. Chir., 1913, 
 ci, p. 779. 
 
 Bracket, E. G., and Hall: Osteochondritis desiccans. Am. Jour. Orthop. Surg., 1917, 
 XV, p. 79. 
 
CHAPTER VII. 
 THE CHEST. 
 
 The shadow of the chest may be divided into (1) that of the 
 thoracic wall, (2) a central shadow consisting of supraposed ster- 
 num, heart, great vessels, mediastinum and spine, (3) the diaphragm 
 and (4) the lung fields. 
 
 Pathological processes in the thoracic wall may consist of injuries 
 to the ribs, of infections and of tumors. They are similar to the same 
 processes elsewhere. Occasionally there is an emphysema of the 
 soft tissues usually associated with fracture of the ribs or surgical 
 interference. The plate is very striking and shows the presence of 
 dark areas representing air scattered through the muscles and sub- 
 cutaneous tissue. 
 
 The central shadow is concerned with the outlines of the thymus 
 and thyroid, of mediastinal masses and with the shape, size and 
 position of the shadows of the great vessels and pericardium. Nor- 
 mally the thyroid and thymus are not visible in a chest plate. A 
 substernal thyroid or enlarged thymus appears as a dilatation of 
 the upper end of the central shadow with sharp margins which 
 extend upward beyond the clavicles. In children, an enlarged thymus 
 gives a particularly characteristic shadow. It is roughly quad- 
 rangular with rounded lower corners and sharp margins which extend 
 straight down from above the clavicles and overlap the shadow of 
 the heart and vessels. It is less dense than other tumors and is 
 easily overlooked. In our experience, lateral and oblique views are 
 of little value in its recognition. 
 
 Thyroid. — The thyroid, when intrathoracic, shows as a dense, 
 sharply defined shadow extending down and overlapping the great 
 vessels. It may be differentiated from thymus and other medias- 
 tinal tumors by the fact that it moves with deglutition. 
 
 Mediastinal masses may be due to enlargements of the medias- 
 tinal glands, growths, aneurysms, vertebral abscesses and dilatations 
 of the esophagus. 
 
 Enlargement of the glands is usually due to tuberculosis, 
 Hodgkin's disease or malignancy. Their outline is sharp and irregu- 
 lar or lobulated and the process is usually bilateral. They seldom 
 show pulsation although large masses may transmit the impulse 
 
112 
 
 THE CHEST 
 
 of heart or aorta. By careful fluoroscopic examination it is some- 
 times possible to separate their shadow from that of the aorta or 
 to demonstrate a normal aorta. 
 
 The most common tumors are lymphosarcoma, Hodgkin's disease, 
 and carcinoma, primary or metastatic. They produce dense 
 shadows with sharply defined borders and may displace or com- 
 press the surrounding organs, often showing transmitted pul- 
 sation. They may- be mistaken for aneurysm, but careful study 
 with the fluoroscope and plates at difl:'erent angles will usually 
 
 Fig. 88. — Malignant tumor of the mediastinum, resembling aneurysm. 
 
 dift'erentiate them . In lymphosarcoma and Hodgkin's disease, glands 
 elsewhere in the bod}' are usually involved and the masses tempo- 
 rarily disappear with great rapidity under roentgen radniatio.^ 
 Primary malignancy is rare. It usually occurs as a unilateral, 
 irregular enlargement of the hilus shadow which shows a tendency 
 to grow in the direction of the affected bronchi. Metastatic malig- 
 nancy, in addition to the enlargement of the hilus shadows, may 
 show the characteristic, annular, sharply defined patches through the 
 lung fields. Teratomata may invade the mediastinum in rare cases, 
 
THYROID 
 
 113 
 
 Fig. 89. — The same case as Fig. 88. After a series of treatments with .r-rays the 
 decrease in the size of the tumor rules out aneurysm. 
 
 Fig. 90. — The same case as Fig. 88, one year after the first examination. 
 
114 
 
 THE CHEST 
 
 causing an increase in the Avidth of the central shadow without 
 distinguishing characteristics. Dermoid cysts may occur and 
 should be recognized by their cystic wall and the fact that they 
 arise from the mediastinum. Lipomata may also develop in this 
 region. 
 
 THE HEART AND GREAT VESSELS. 
 
 In an examination of the heart we should obtain the following 
 data: Size, shape, its movements with respiration, pulsation of the 
 
 Fig. 91. — Teleradiogram of the normal heart and great vessels: 
 No. I on the right is the ascending aorta. 
 No. II on the right is the right auricle. 
 No. 1 on the left is the aortic arch. 
 No. 2 on the left is the pulmonarj- arteiy. 
 No. 3 on the left is the left auricle. 
 Xo. 4 on the left is the left ventricle. 
 
 various chambers, and any change of shape which may" occur with 
 change in position of the patient. "We should also note the size 
 
THE HEART AND GREAT VESSELS 
 
 115 
 
 Fig. 92. — Tracing showing the shape of the normal heart and great vessels and 
 the points from which measurements are taken. (From Groedel.) 
 
 Fig. 93. — A tracing showing the normal respiratory excursion of the heart and 
 diaphragm during quiet and forced breathing. Patient is standing. 
 
116 
 
 THE CHEST 
 
 and shape of the aorta in both its anteroposterior and lateral 
 diameters. 
 
 This data may be obtained by means of orthodiagraphy or by 
 combination of tele-roentgenology and fluoroscopic examination. 
 
 Fig. 94. — The drop heart of the ptotic. 
 
 The advantages of orthodiagraphy are its accuracy in the hands 
 of experts and ability to outline the apex. Its disadvantages are: 
 the time required to perfect a technic, and constant chance for error 
 due to the personal limitations of the operator. 
 
Fig. 95. — The enlargement of the left ventricle and aortic regurgitation. 
 
 Tig. 96. — The same case as Fig. 95, but taken at two instead of six feet. Note the 
 distortion of the enlarged left ventricle. 
 
lis 
 
 THE CHEST 
 
 Tele-roentgenology has the advantage of ehminating the personal 
 equation and of producing a permanent record. Its disadvantages 
 are: the shghtly higher cost and the difficulty of demonstrating 
 the apex and the junction of the left auricle with the left ventricle. 
 These points are of importance, as without them all the measure- 
 ments cannot be obtained. 
 
 7.6 
 
 ' :; 
 
 . 
 
 
 h/ 
 
 / 
 
 / 
 
 ^x^ 
 
 A 
 
 
 / 
 
 
 \A> 
 
 
 / 
 
 
 ^'^\ 
 
 
 / 
 
 
 4- \ 
 
 
 w 
 
 
 
 X*^ 
 
 7 
 
 
 
 X^cf 
 
 / 8.S 
 
 
 
 /2.6 \. 
 
 ' / 
 
 t 
 
 ^- 2i .1-^ \^^^ 
 
 Fig. 97.— The dilated heart. 
 
 By fluoroscopy it is possible to obtain a fairly accurate outline 
 of the shape and position of the heart shadow and of its movements 
 with respiration ; also of any change of shape which may occur with 
 change of position. By combining this data with the data obtained 
 from a plate taken at a seven-foot target film distance, all the 
 required findings are present. 
 
 This method of combined fluoroscopy and tele-roentgenography 
 has been in use at the Massachusetts General Hospital for the past 
 five years and has proved quite satisfactory. The fluoroscopic 
 observation is made first. The patient is placed in the upright posi- 
 
THE HEART AND GREAT VESSELS 
 
 119 
 
 tion behind a fixed screen. The focal spot of the tube is at a distance 
 of 24 inches from the screen. From 2 to 3 ma. at 60,000 volts gives 
 a good image. 
 
 A thin plate of glass in front of the fluoroscopic screen serves as 
 a receptacle for the tracing which is made of the outline of the heart 
 and gi'eat vessels during normal breathing, forced inspiration and 
 forced expiration. 
 
 s.s 
 
 
 7.2/ ^ 
 
 / 
 
 
 \ 
 
 Fig. 98. — Mitral disease. 
 
 The patient is then rotated to the left so that his right chest is 
 in contact with the screen, and the posterior mediastinal space with 
 the arch of the aorta are studied. By changing the position of the 
 patient slightly, the size of the shadow of the aorta will be seen to 
 grow larger or smaller. The smallest possible shadow which can be 
 obtained represents the true diameter of the aorta plus the amount 
 of magnification due to its distance from the screen. 
 
 A tracing is made of the aorta in this position for comparison 
 
120 
 
 THE CHEST 
 
 with the tracing made in the anteroposterior view. From the two 
 tracings an estimate can be made of the amount of overlapping of 
 the ascending and descending aorta. The glass with its tracing is 
 removed and the pulsation of the various chambers of the heart 
 is studied and compared. If there is anything in the findings 
 which suggests a pericardial effusion, the patient is examined in the 
 prone position. 
 
 Fig. 99. — The water-bottle shape of the heart shadow seen in pericardial 
 effusion with the patient upright. 
 
 After the fluoroscopic observations are completed, a mark is placed 
 on the patient's chest opposite the center of the heart shadow to 
 serve as a point upon which to focus the tube for the plate which is 
 taken with the patient standing. The focal spot of the tube should 
 be at a distance of at least six feet from the plate. 
 
 Special care must be taken so to place the patient that the central 
 rays from the tube pass through the chest at right angles to its 
 
THE HEART AND GREAT VESSELS 121 
 
 transverse diameter. At this distance a small amount of displace- 
 ment of the tube to the right or the left from the median line does 
 not appreciably distort the heart shadow, but a slight rotation of 
 the patient does produce definite distortion. 
 
 In stout patients it is better to have the plate in contact with the 
 chest wall and the patient standing erect. If the plate is placed at 
 
 Fig. 100. — The same ca.se as Fig. 99, but taken with the patient prone. Note 
 the change in the shape of the heart shadow, due to the .shifting of the fluid within 
 the pericardium. 
 
 right angles to the central ray from the tube, its upper portion 
 may be some distance from the chest wall; and as we are not 
 dealing with absolutely parallel rays, a slight amount of magnifica- 
 tion of the aorta will result. 
 
 On the other hand, if the patient is allowed to lean forward to 
 bring the chest entirely in contact with the plate, there will be a 
 certain amount of apparent sagging of the contents of the chest. 
 
 The time of exposure should be sufficiently long to cover one full 
 
122 
 
 THE CHEST 
 
 heart cycle, so that the shadow obtained will be the shadow of the 
 heart in diastole. Where very rapid exposures are made the result- 
 ing picture may represent the heart either in systole or diastole or 
 at some phase between. The period of diastole is the one from which 
 estimates of the heart size are made. 
 
 
 V 
 
 '■V 
 6 
 
 ■y 
 
 S 6 
 
 
 
 • 
 
 '5.5 //T^x ^ 
 
 Fig. 101. — The triangular shape and indefinite outline of the heart seen in adhesive 
 
 pericarditis. 
 
 Therefore, it is evident that a relatively long exposure is desirable. 
 The patient should be instructed to keep still, but it is not desirable 
 for him to take a deep breath nor is it necessary to hold the breath. 
 The amount; of movement of the heart shadow in normal respiration 
 is very slight. ^Yith deep inspiration there is a definite change both 
 in the shape and size. The amount of current passed through the 
 tube may vary according to the type of apparatus available. About 
 the same degree of penetration should be used as in frontal sinus 
 work. Intensifying screens are desirable. 
 
 After the plates are developed and dried the measurements are 
 
THE HEART AXD GREAT VESSELS 123 
 
 made from them according to the plan adopted by Groedel. This 
 plan includes six points from which measurements are taken: three 
 on the right and three on the left side of the heart shadow. The 
 upper point on the right is at the junction of the heart shadow with 
 that of the great vessels. The second point on the right is at the 
 furthest point of the heart shadow to the right, and the lowest point 
 is at the junction of the heart shadow with the diaphragm. On the 
 left, the highest point is at the junction of the left auricle with the 
 left ventricle. The second point is at the greatest distance to the 
 left, and the third point is at the heart apex. A line is then drawn 
 along the center of the spinal column. This may be used as the 
 midline. 
 
 The greatest distance to the right and the greatest distance to 
 the left from this line are easily obtained. Their sum represents the 
 greatest transverse diameter of the heart shadow. A line drawn 
 from the highest point on the right to the heart apex represents the 
 total length of the heart; and lines drawn at right angles to it, 
 one to the highest point on the left and one to the lowest point on 
 the right, give us the diameter of the base. 
 
 By comparing these figures and the shape of the heart and aorta 
 with the respiratory movements and pulsations as recorded on the 
 tracing, the conclusions are made. 
 
 To interpret the findings one must have a thorough knowledge 
 of the anatomy of the heart and great vessels, and of the normal 
 radiographic shadow. 
 
 'Normally, the central shadow approximates the outline in Fig. 91. 
 At the top, on the left side, the edge of the arch of the aorta appears 
 with the descending aorta extending downward from it; below it 
 the slight prominence of the pulmonary artery and the small left 
 auricular appendage in the angle between it and the ventricle. The 
 rounded mass of the ventricle makes up the largest part of the 
 shadow and disappears below the diaphragm line. The location of 
 the apex is a matter of considerable uncertainty, as it A'aries with 
 the size, shape and position of the heart and of the patient, and the 
 position and shape of the diaphragm. 
 
 The right border begins at the top with the poorly defined shadow 
 of the superior vena cava above and overlapping the ascending 
 aorta, which is sometimes indented by the right bronchus in its 
 lower portion. The line then curves outward over the right auricle 
 to join the right diaphragm at an acute angle at the apex of which 
 the inferior vena cava is sometimes apparent. 
 
124 THE CHEST 
 
 Diseases of the Heart Valves. — Diseases of the heart valves are 
 accompanied by an enlargement of the corresponding chamber or 
 chambers. For instance, in mitral regurgitation, the enlargement of 
 the shadow is to the right and across the base because of the changes 
 in the left auricle and the right ventricle (see Fig. 98) . 
 
 Aortic Disease. — The enlargement is almost entirely to the left. 
 A knowledge of the physiology and pathology of the heart will 
 enable one to accurately interpret these lesions from the changes 
 in the shape of the heart shadow. 
 
 Auricular Fibrillation. — Auricular fibrillation may be demonstrated 
 by the tremendous enlargement of the shadow of the auricles and 
 absence of visible pulsation in them. In certain of these cases the 
 heart shadow seems to rock. 
 
 Heart Block. — In this condition, if the pulsation is not too rapid, 
 it is possible to compare the beats of the auricle with those of the 
 ventricle and determine their respective rates. 
 
 Dilatation. — Dilatation is seen as a general enlargement of the 
 heart shadow with weak pulsation and an absence of the rounding 
 of the apex seen in hypertrophy. 
 
 Congenital Abnormalities. — Congenital abnormalities give rise to 
 changes in shape and abnormal areas of pulsation. Here again the 
 knowledge of the anatomical and pathological variations of the heart 
 and great vessels will enable one to arrive at a diagnosis from their 
 appearance on the plate or screen. 
 
 Pericardial Effusion. — With fluid in the pericardium the heart 
 shadow tends to become more triangular in shape. When the 
 patient is prone there is an increase in the width at the apex of the 
 triangle, and when upright an increase at the base, or it may assume 
 a water-bottle shape. The cardio-hepatic angle is seldom obliterated, 
 although it may be so to percussion. Pulsation is considerably 
 diminished. In obtaining the shape of the heart in different posi- 
 tions for comparison, it is not wise to depend on screen observa- 
 tions alone. Either a careful tracing or plates taken at a distance 
 of seven feet should be made and the outlines thus obtained 
 superimposed. 
 
 Adhesive Pericardium. ^It has been noted in a small group of 
 cases that the respiratory excursion of the heart is limited. There 
 is also apt to be some haziness in outline of the heart shadow and 
 apparent obliteration of the angle between it and the diaphragm. 
 
 Dilatation of the Arch, — The dilatation of the aorta as seen radio- 
 graphically occurs most frequently as the result of specific disease. 
 
THE HEART AND GREAT VESSELS 125 
 
 There may be a slight amount of dilatation present in arterio- 
 sclerosis and cases with high blood-pressm-e. 
 
 Very large hearts seem to have a relative enlargement of the 
 aortic shadow. With a high position of the diaphragm the aortic 
 shadow is slightly wider than in cases with a low diaphragm. 
 Probably part of these variations are due to the difference in the 
 shape of the aortic arch. In a wide arch there is less overlapping 
 of the ascending and descending aorta and consequently an increased 
 diameter of the shadow. 
 
 Specific aortitis tends to appear first just abo^"e the aortic valves 
 and as the wall of the aorta becomes weakened, a bulging of this 
 area takes place. On the plate or fluoroscopic screen the position 
 of this bulge is seen just above the shadow of the right auricle. 
 
 A marked prominence of the aortic shadow to the right is almost 
 always due to specific aortitis. In arteriosclerosis the calcified 
 plaques in the aorta are not visible unless extensive. The tortuous 
 aorta, however, does give a definite, fairly characteristic change in 
 the appearance of the aortic shadow. There is a distinct, sharp 
 increase in the upper part of the shadow to the left. 
 
 Diffuse dilatation of the aorta also occurs and is seen as a general 
 enlargement of its shadow. There is much more difficulty in inter- 
 preting this type from roentgen evidence, as the findings may be 
 the result of the changes in the aortic curve already mentioned. 
 
 Aneurysm. — The size, position and location of aneurysms of the 
 aorta are seen on the plate or fluoroscopic screen in sharp contrast 
 to the surrounding lung structure. Should the lesion occur in the 
 subclavian or vessels of the neck, which are not in contact with the 
 lung structure, the aneurysm is invisible. 
 
 Aneurysms of the ascending aorta are seen to the right, while 
 aneurysms of the arch usually show to the left of the spine high up. 
 Aneurysms of the descending aorta are seen in the lower portion of 
 the aortic shadow to the left and they may be partially hidden by 
 the shadow of the heart. Large diffuse aneurysms may appear as 
 a general increase in the shadow of the great vessels. 
 
 The pulsations of aneurysms are not always seen on the fluoroscopic 
 screen. It is extremely difficult to differentiate between expansile 
 and transmitted pulsations, so that the presence or absence of pul- 
 sation, as observed fluoroscopically, is not of conclusive value in 
 the diagnosis. The position of the sac is of more importance. Its 
 outline should be sharply defined and the shadow of the normal 
 aorta should not be seen through it. Mediastinal tumors other than 
 
126 
 
 THE CHEST 
 
 aneurysms are usually less sharply defined. They may be nearer 
 the front or back of the chest than the position of the great vessels, 
 or they may occupy a position higher or lower than is usually occu- 
 pied by aneurysms; and occasionally the shadow of a normal aorta 
 may be seen through them. They are more likely to displace the 
 heart and aorta than are aneurysms. 
 
 The following table worked out by Claytor and Merrill^ gives a 
 fairly good guide as- to the measurements of the normal heart. 
 
 Males (37 cases). 
 
 Weight, pounds. 
 
 Cases. 
 
 Mr. 
 
 Ml. 
 
 T. D. 
 
 L. D. 
 
 
 
 
 3 
 
 7.0 
 
 10.7 
 
 11.8 
 
 Minimum 
 
 120-129 
 
 3 
 
 3.7 
 
 7.2 
 
 10.9 
 
 12.6 
 
 Average 
 
 
 
 4.3 
 
 7.5 
 
 11.3 
 
 13.5 
 
 Maximum 
 
 
 
 3.5 
 
 7.5 
 
 Tl.O 
 
 12.0 
 
 Minimum 
 
 130-139 
 
 5 
 
 3.8 
 
 8.0 
 
 11.8 
 
 13.2 
 
 Average 
 
 
 
 4.2 
 
 8.5 
 
 12,5 
 
 14.0 
 
 Maximum 
 
 
 
 3.4 
 
 7.0 
 
 11.0 
 
 12.0 
 
 Minimum 
 
 140-149 
 
 9 
 
 4.0 
 
 7.7 
 
 11.9 
 
 13.4 
 
 Average 
 
 
 
 4.6 
 
 8.4 
 
 13.1 
 
 14.5 
 
 Maximum 
 
 
 
 3.2 
 
 7.8 
 
 11.5 
 
 12.5 
 
 Minimum 
 
 150-159 
 
 8 
 
 3.9 
 
 8.4 
 
 12.3 
 
 13.5 
 
 Average 
 
 
 
 4.5 
 
 9.0 
 
 13.0 
 
 15.0 
 
 Maximum 
 
 
 
 3.7 
 
 8.0 
 
 12.0 
 
 14.0 
 
 Minimum 
 
 160-179 
 
 6 
 
 4.0 
 
 8.2 
 
 12.4 
 
 14.6 
 
 Average 
 
 
 
 4.8 
 
 9.0 
 
 13.8 
 
 15.8 
 
 Maximum 
 
 180-200 
 
 6 
 
 3.8 
 
 7.0 
 
 11.0 
 
 14.0 
 
 Minimum 
 
 
 
 4.2 
 
 8.7 
 
 12.9 
 
 14.7 
 
 Average 
 
 
 
 4.5 
 
 9.7 
 
 13.4 
 
 15.3 
 
 Maximum 
 
 Females (51 cases). 
 
 Weight, pounds. Cases. 
 
 100- 
 
 -109 
 
 110- 
 
 -119 
 
 120- 
 
 -129 
 
 130- 
 
 -139 
 
 140- 
 
 -149 
 
 150- 
 
 -159 
 
 160- 
 
 -175 
 
 14 
 
 19 
 
 Mr. 
 
 Ml. 
 
 T. D. 
 
 L. D. 
 
 
 3.2 
 
 6.7 
 
 9.9 
 
 12.0 
 
 Minimum 
 
 3.3 
 
 6.8 
 
 10.2 
 
 12.1 
 
 Average 
 
 3.5 
 
 7.0 
 
 10.5 
 
 12.3 
 
 Maximum 
 
 3.0 
 
 7.0 
 
 10.0 
 
 11.5 
 
 Minimum 
 
 3.1 
 
 7.6 
 
 10.7 
 
 11.9 
 
 Average 
 
 3.2 
 
 8.0 
 
 11.1 
 
 12.4 
 
 Maximum 
 
 2.3 
 
 6.4 
 
 10.2 
 
 10.5 
 
 Minimum 
 
 3.5 
 
 7.5 
 
 11.0 
 
 12.2 
 
 Average 
 
 4.2 
 
 8.6 
 
 12.2 
 
 13.8 
 
 Maximum 
 
 3.0 
 
 6.4 
 
 9.6 
 
 11.2 
 
 Minimum 
 
 3.4 
 
 7.8 
 
 11.2 
 
 12.4 
 
 Average 
 
 4.0 
 
 8.8 
 
 12.6 
 
 13.3 
 
 Maximimi 
 
 2.6 
 
 7.0 
 
 10.0 
 
 12.2 
 
 Minimum 
 
 3.5 
 
 7.6 
 
 11.1 
 
 12.7 
 
 Average 
 
 4.1 
 
 8.3 
 
 11.8 
 
 13.2 
 
 Maximum 
 
 3.1 
 
 7.6 
 
 10.9 
 
 12.3 
 
 Minimum 
 
 3.6 
 
 8.0 
 
 11.6 
 
 12.9 
 
 Average 
 
 4.8 
 
 9.3 
 
 12.8 
 
 14.2 
 
 Maximum 
 
 3.5 
 
 6.5 
 
 10.6 
 
 11.8 
 
 Minimum 
 
 3.8 
 
 7.9 
 
 11:7 
 
 12.6 
 
 Average 
 
 3.8 
 
 8.5 
 
 12.3 
 
 13.0 
 
 Mean 
 
 4.1 
 
 9.0 
 
 12.8 
 
 13.2 
 
 Maximum 
 
 J Claytor and Merrjll: Am. Jour. Med. Sc, 1909, New Series, cxxxviii, p. 554. 
 
THE HEART AND GREAT VESSELS 
 
 127 
 
 Fig. 102. — A tracing showing the limited respiratory movements of the heart in 
 
 adhesive pericarditis. 
 
 Q.l 
 
 Fig. 10-3. — Dilatation of the ascending aorta, due to specific aortitis. The aorta is 
 partially hidden by the shadow of the right auricle. 
 
128 
 
 THE CHEST 
 
 Perivertebral or Mediastinal Abscess. — Perivertebral abscess will 
 usually give a more or less fusiform shadow appearing on both 
 sides of the central shadow unless it occurs behind the heart. It 
 must not be confused with the shadow of the aorta. Inasmuch as 
 they practically always result from a lesion in the spine, the recog- 
 nition of a destructive process in the vertebrtne is of considerable 
 aid in the dias'nosis. 
 
 Fig. 104. — Dilatation of the ascending aorta, due to syphilitic aortitis. A 
 well-marked case. 
 
 Esophagus. — In an occasional case of cardiospasm the esophagus 
 may be dilated to such an extent as to appear as a long, smooth 
 shadow c.iu"ving outward into the right lung fields. It may be 
 recognized by the fact that it continues upward above the clavicles 
 and by the use of a bariimi meal. It must not be forgotten that 
 diverticulum of the esophagus may simulate mediastinal tumor, 
 capsulated empyema and aneurysm. 
 
THE HEART AND GREAT VESSELS 
 
 129 
 
 Diaphragm. — Xormally the diaphragm curves smoothly from the 
 pericardmm downward to form a sharp angle with the plem-a. 
 The right side is higher than the left (one or more centimeters), and 
 in some cases shows several small curves near the dome due to 
 inequalities in the liver which have no significance. Fluoroscopically, 
 it should move freely and equally on the two sides both on quiet 
 and deep respiration. 
 
 
 1 
 67 
 
 8,5 
 
 10.3 
 
 ^5 
 
 
 ^^ U : 
 
 Fig. 105. — Aneur^-sm of the ascending aorta. 
 
 Changes in Outline. — ^Marked irregularities on the surface of the 
 liver ma}' be transmitted through it. Bands of adhesions to the 
 pleura or the chest wall may elevate small stringy or triangular 
 areas. 
 
 Changes in Mobility. — Slight limitation of motion may be observed 
 when the patient is breathing quietly, which disappears completely 
 with deep respiration. Bilateral limitation of motion may be due 
 9 
 
130 
 
 THE CHEST 
 
 to emphysema, ptosis, ascites, peritonitis, pleuritis at the base of 
 both lungs, or fibrosis from an old inflammatory process. When 
 unilateral, we must look above the diaphragm for tuberculosis or 
 disease of the pleura on that side or below it for an inflaimiiatory 
 process such as a diseased appendix or gall-bladder, subdiaphrag- 
 matic or liver abscess. Paradoxical excursion of the diaphragm is 
 seen in paralysis of the phrenic nerve and diaphragmatic hernia. 
 The afi'ected side ris'es during inspiration and falls during expiration. 
 
 Fig. 106. — An abscess of the liver which contained gas as well as pus. 
 was taken with the patient in the upright position-. 
 
 The plate 
 
 Changes in Position. — It is low in ptosis and emph^^sema. It is 
 high in adiposity, ascites and subphrenic abscess, eventration and 
 hernia of the diaphragm. Eventration and hernia are both more 
 common on the left side. In eventration, although considerably 
 elevated, its contour is preserved and movement is normal in direc- 
 tion though limited. In hernia its outline is obscured and its move- 
 ment paradoxical. In both cases the barium meal will demonstrate 
 the position of the abdominal viscera. 
 
 Pleural Effusions. — Pleural effusions obliterate the costodiaphrag- 
 matic angle if small or the entire diaphragmatic shadow if they are 
 
LUNG FIELDS 131 
 
 extensive. It is worth noting that in rare cases fluid may be 
 obtained from a chest that is roentgenologically negative. 
 
 Subdiaphragmatic Abscess. — Subdiaphragmatic abscess causes 
 marked upward displacement of the shadow of the diaphragm. 
 The top is usually considerably flattened and excursion is abolished. 
 Encapsulated fluid above the diaphragm may strongly resemble 
 subdiaphragmatic eftusion. 
 
 Fig. 107. — Encapsulated empyema. The process is between the lower and 
 
 middle lobes. 
 
 LUNG FIELDS. 
 
 Technic. — Lung examination should include both fluoroscopy and 
 plates, preferably in the erect position. AVhen the patients can 
 hold their breath, stereoscopic plates have great value but they are 
 not necessities. In certain conditions examination in the prone, 
 oblique and lateral positions should be made. It is usually advis- 
 able to take both anteroposterior and postero-anterior plates. The 
 
132 THE CHEST 
 
 number and position of the plates to be taken may be determined 
 at the fluoroscopic examination. 
 
 Normal Lung. — The normal lung markings consist of small areas 
 of density at the hilus which often show calcified spots, and strands 
 of density corresponding to the bronchial tree spreading out through 
 the lung fields for a considerable distance but never quite reaching 
 the plem'a. The descending bronchi on both sides are usually more 
 dense than those above. The fields are of equal density on the two 
 sides. They are slightly obscm-ed by the pectoral muscles and in 
 the breasts in postero-anterior views and there is usually some slight 
 haziness in the left base in the region of the apex of the heart. 
 
 Pathological Changes. — Diffuse increase in density on one or both 
 sides is found in thickened pleura, fluid, consolidation or bronchial 
 stenosis. A general increase in radiability is due to emphysema. 
 Local areas of increased radiability may be due to pneumothorax 
 or cavity formation. Localized areas of increased density are most 
 likely to be abscess, localized pneumonia about a foreign body or 
 malignancy. 
 
 Licrease in size of the root shadows may be due to infection or 
 tumor. 
 
 Increased thickening of the bronchial markings means infection 
 or fibrosis. Fine mottling along the bronchi is usually due to the 
 early manifestations of tuberculosis. Fine mottling in the lung 
 tissue usually means tuberculosis, fibrosis or malignancy. Coarse 
 mottling in the lung tissue is due to bronchiectasis, tuberculosis 
 or metastatic malignancy. Displacement of mediastinal contents 
 occurs with eftusion, adhesions, fibrosis and tumors. Li the case 
 of tumors, displacement is often toward the side affected by the 
 growth. 
 
 Pleura. — I'hickening occm's as a result of inflammation and may 
 obscm-e all of one or both chests or may be limited to the base or 
 apex. The shadow is fairly dense although the ribs can usually be 
 seen through it. A thin, ciuved, white line, convex upward, extend- 
 ing across the chest is occasionally seen as the end-result of an 
 interlobar pleurisy. Adhesions appear as strands of increased 
 density. At the apex theii" appearance may suggest cavities. 
 
 Pleural Exudate. — An effusion or empyema usually gives a shadow 
 of extreme density located at the base, obscuring the ribs and 
 diaphragm with a superior margin which curves upward toward 
 the chest wall in the axilla, unless pneumothorax is present, when it 
 will^show a fluid le\'el which changes as the patient's position is 
 
LUNG FIELDS 
 
 133 
 
 shifted. In the prone position the shadow is uniform throughout 
 the chest and often resembles that of thickened pleura. If an effu- 
 sion is extensive, there is usually displacement of the heart and great 
 vessels. The apex is usually clear. In young children fluid may 
 appear as a dense area along the periphery of the lung field. 
 
 Encapsulated fluid gives a dense, sharply defined shadow in con- 
 tact with the pleura. It is most common at the base, along the 
 axillary border or between lobes. When the collection is between 
 lung and diaphragm it may simulate subdiaphragmatic abscess. 
 
 Fig. 108. — Pneumothorax, with complete collapse of the left lung. 
 
 Pneumothorax. — Pneumothorax is characterized by the presence 
 in the periphery of the lung field of an area of greatly increased 
 radiability from which the lung markings are absent. Its borders 
 are sharph' defined and consist of the walls of the chest cavity and 
 the margins of the compressed lung. When the pneumothorax is 
 complete and there are no adhesions, the lung collapses to a lobu- 
 lated mass at the hilus in which can usually be seen the suggestion 
 
Fig. 
 
 109. — Hydropneumothorax. This plate was taken with the patient upright. 
 The fluid level is well shown at about the middle of the left chest. 
 
 Fig. 110. — Old empyema, with calcification in the right pleura. 
 
LUNG FIELDS 
 
 135 
 
 of lung marking. In the presence of pleural adhesions where the 
 collapse is incomplete, the shadow of the pnemnothorax may be 
 divided by bands which give it a sacculated appearance and pneumo- 
 thorax and lung tissue may overlap each other. A small localized 
 pneumothorax may be difficult to detect unless it is seen in profile; 
 otherwise it appears as an area of somewhat increased radiability 
 overlaid by normal lung markings. This should not be confused 
 with large cavities which occur in the substance of the lung and may 
 or may not have well-defined borders. 
 
 Calcifications frequently appear in the pleura in a form of ragged 
 plaques or lines which occur in any portion of it. 
 
 Fig. 111. — Peribronchial tuberculosis. Advanced tuberculosis two years later. 
 
 Tuberculosis. — ^The primary focus in tuberculosis is probably in 
 the periphery of the lung but it is not always evident. However, 
 w^e see an increase in the root shadows as a result of glandular 
 involvement which, particularly in children, is often marked. In 
 the acute stage their outlines are blurred and indistinct. If healing 
 occurs the shadows gradually diminish in size, increase in density 
 and sharpness of outline, and subsequently show areas of calcification.,, 
 As the infection progresses, the next change is general thickening 
 
136 
 
 THE CHEST 
 
 of the bronchial markings along the track of the disease, usually 
 toward one or both tops. When this has occurred the patient will 
 usually show dullness at the affected area clinically. Because of 
 the normal thickening toward both bases the stage is difficult to 
 recognize when the extension is downward but it is much less com- 
 mon in this situation. Plates of most adult lungs show a certain 
 amount of thickening of the bronchial markings as a result of pre- 
 vious infections and have no particular significance. When due to 
 
 Fig. 112. — Tuberculosis at both apices. 
 
 tuberculosis, the changes are permanent. The demarcation between 
 the normal and the pathological is not sharp and it takes consider- 
 able experience in the observation of plates, combined with all that 
 can be found by clinical methods, to establish a correct diagnosis. 
 If the process continues, small bead-like masses appear along 
 the course of the thickened bronchial shadows and fan-shaped areas 
 of filmy density may be seen w4th their bases on the pleura and 
 apices, extending inward toward the thickened markings. These 
 fan-shaped areas are probably the earliest evidence of definite 
 
LUNG FIELDS 
 
 137 
 
 involvement of the lung parenchjTaa, but unfortunately they are 
 not commonly seen and they may occur m other infections. 
 
 The next stage is the appearance through the diseased area of 
 finely stippled grayish spots, apparently independent of the bronchial 
 markings now extended to the periphery of the lung. These spots 
 mean definite involvement of lung tissue and at this time rales are 
 
 Fig. 113. — Miliary tuberculosis of the lungs. The changes are most marked 
 in the upper lobes. 
 
 beginning to be evident upon clinical examination. This charac- 
 teristic fine mottling is the only sure basis for a roentgen diagnosis 
 of active tuberculosis. It is seen in its most typical form in the 
 cases of miliary tuberculosis. 
 
 With the further progress of the disease there occurs an enlarge- 
 ment and effusion of these spots and their extension to new areas, 
 resulting in coarse mottling and finally evidence of cavity formation. 
 
138 
 
 THE CHEST 
 
 Areas of healing may occur at any stage, or progress and healing 
 may be simultaneous so that it may be impossible to decide from 
 roentgen evidence alone whether a case is active or quiescent. In 
 general, active lesions are dim, gray and blurred; healed ones are 
 more dense and sharply outlined. 
 
 The only condition which must be differentiated from extensive 
 tuberculosis is that seen in pneumonoconiosis, where the fibrous 
 changes and symmetrical portions of both lungs cast a cotton-like 
 
 Fig. 114. — Lobar pneumonia. The process is in the lower part of the right upper lobe. 
 
 shadow very similar to that of fibroid tuberculosis. However, the 
 apices are usually not involved and the patient will give a history 
 of having worked underground or in a dusty occupation and his 
 physical signs are not those of a tuberculous process of similar extent. 
 Miliary tuherculosis presents a characteristic, fine, hazy mottling 
 scattered throughout the lung fields which must be differentiated 
 from metastatic malignancy and from pneumonoconiosis. Meta- 
 stases in rare cases appear as definite small discrete areas of increased 
 
LUNG FIELDS 
 
 139 
 
 density scattered throughout both hmgs, but the spots, while approx- 
 imating those of mihary tuberculosis in size, are more dense and 
 more sharply outlined. From pneumonoconiosis it may be differ- 
 entiated by the fact that it is a more diffuse process involving all 
 portions of the lung, whereas pneumonoconiosis typically in^'olves 
 symmetrical areas and spares the apices. The mottling in the latter 
 is much finer and the dense spots are smaller than those seen in 
 tuberculosis. 
 
 Fig. 115. 
 
 -Pleurisy, with effusion at the left base. Note the position of the .shadow in 
 the axillary border and the displacement of the heart to the left. 
 
 Lobar Pneumonia. — Lobar pneumonia is characterized by areas of 
 increased uniform density which are sharply defined and, when fully 
 developed, usually occupy the position of a lobe. In the early 
 stages the shadow, while uniform, is less dense and may be triangular 
 in shape with the base on the pleura and the apex toward the hilus. 
 The lung markings distributed to this area are thickened and the 
 
140 
 
 THE CHEST 
 
 hilus glands are enlarged. It has been observed in children that 
 dulhiess and changed breath and A'oice sounds are not ordinarily 
 perceptible until the shadow reaches the hilus. 
 
 The character of the shadow changes with the progress of the 
 disease and as resolution appears it becomes distinctly mottled. 
 After the shadow itself has disappeared, thickened bronchial mark- 
 ings or large glands may persist for a considerable time. It must be 
 differentiated from fluid where the shadow is more dense, does not 
 conform to lobar outlines, and displaces the heart and vessels. 
 
 Fig. 116. — Bronchopneumonia follo-^v-ing operation upon the nose. The patient died 
 two days after this plate was taken and the findings were confirmed at autopsy. 
 
 Bronchopneumonia. — Bronchopneumonia occurs more frequently 
 than is generally thought. Chving to the absence of physical signs, 
 the diagnosis may depend largely upon the roentgen examination and 
 the history. The appearance is that of single or multiple areas of 
 increased density with hazy outlines, usually situated near the course 
 of the larger bronchi. The differentiation from abscess, bronchiec- 
 tasis and malignancy depends largely upon the clinical history. 
 
LUNG FIELDS 
 
 141 
 
 Unresolved Pneumonia. — Unresolved pneumonia gives a shadow 
 resembling that of pneumonia. It must be distinguished from an 
 interlobar empyema, tuberculous pneumonia, or bronchial stenosis 
 largely by the clinical and laboratory findings. It has been noted 
 that unresolved pneumonias may disappear after mild roentgen 
 radiation. 
 
 Bronchitis. — Bronchitis, when acute, gives no characteristic pic- 
 ture. The chronic inflammations appear as an increase in the size 
 and density of bronchial m.arkings and glands. 
 
 Fig. 117. — Lung abscess. The cavity of the abscess can be seen as an area of 
 diminished density in the center of the dull area in the right chest. 
 
 Lung Abscess. — Lung abscess usually follows influenza or the 
 inspiration of infected material at operation or of foreign bodies. 
 Clinically it is a disease of symptoms rather than physical signs, so 
 that the roentgen examination is of the greatest help in indicating 
 the site and extent of the process from its early stages. The lesions 
 are usually single, although they may be multiple and may occur 
 in either lung field, showing, however, a decided preference for the 
 bases, particularly the right. They assume the form of irregular 
 areas of increased density which are most marked at the center, 
 
142 THE CHEST 
 
 fading out toward the periphery. Cavity formation is extremely 
 common in the areas of infiltration. When filled with fluid they are 
 indistinguishable from the general shadow about them but the 
 larger ones become very evident w^hen filled with air, particularly 
 if they certain sufficient fluid to cause a fluid level. They are seen 
 as round areas of greatly diminished density and, if a fluid level is 
 present, its surface shifts according to the position of the patient. 
 Small cavities may t>e entirely overlooked. The bronchial markings 
 distributed to the areas involved are enlarged and coarse and the 
 hilus shadows are increased in size. Abscesses may persist for a 
 long time as areas of thickening or heal spontaneously without leav- 
 ing a trace of their presence on the roentgenogram. Their localiza- 
 tion is often disappointing to the surgeon because of the zone of 
 pnemnonic infiltration about them which magnifies the area of 
 involvement. iVbscesses may be confused with tuberculosis, broncho- 
 pneumonia and bronchiectasis. The similarity to tuberculosis 
 lies in the occurrence of cavities. In tuberculosis there is other 
 roentgen evidence of the disease in the form of characteristic mot- 
 tling elsewhere in the lungs and especially at the apices. Abscess 
 is more common at the bases and the apices are clear. Broncho- 
 pneumonia may be differentiated by the fact that it gives a shadow 
 of more uniform density and there is no cavity formation. Bron- 
 chiectasis is usually a diffuse process and the bronchial changes are 
 more extensive. However, the two conditions blend into each 
 other at times. .-^ - 
 
 Bronchiectasis. — The characteristic picture in a well-advanced 
 case is an extensive thickening of the lung markings along the 
 course of the larger bronchi and enlargement of the hilus glands 
 with the presence of single or multiple areas of increased density 
 in the lung fields near the bronchi, which may show considerable 
 change in plates taken before and after evacuation. Cavities can 
 often be demonstrated. In the early stages the picture is much 
 less characteristic and depends upon the demonstration of small 
 ring-like shadows of dilated bronchi which, however, are usually 
 obscured by the infiltrated lung about them. 
 
 Foreign Bodies. — Foreign bodies most commonly lodge in the right 
 bronchus and may be recognized if of sufficient density to cast a 
 shadow. Their presence may be the cause of an area of increased 
 density due to a localized pneumonia about them, to abscess forma- 
 tion or to collapse of one or more lobes as a result of broncho- 
 stenosis. Examination for foreign bodies should include obserN'a- 
 
LUNG FIELDS 
 
 143 
 
 tion of the entire respiratory tract from different angles, a lateral 
 view of the chest is often very helpful, any inspection of the larynx 
 and the neck should be included. 
 
 Fig. 118.- 
 
 -Bronchiectasis. The process is fairly well localized in the right lower 
 chest. The dilated and sacculated bronchi are visible. 
 
 Bronchostenosis. — Bronchostenosis gives a uniform dense shadow 
 throughout the area supplied by the affected bronchus and the 
 movements of the diaphragm are limited on the affected side. It 
 occurs as a result of inspired foreign bodies, aneurysm, tumors or 
 lues. 
 
 Gangrene. — Gangrene casts an extensive shadow which may 
 occupy one entire lung field. Its characteristic features are the 
 
144 
 
 THE CHEST 
 
 presence of large irregular areas of diminished density and a general 
 coarse mottling of the lung. The heart and mediastinal contents 
 are not displaced. This appearance may be simulated by a lung 
 which has recently expanded after a prolonged pneumothorax. 
 
 Primary Malignancy. — Primary malignancy of the lung is rare. 
 It is practically always unilateral. The usual growth is a carcinoma 
 which occurs in two t\TDes, nodular and infiltrating. The former 
 
 Fig. 119. — Malignant disease of the lungs in a child. The entire left chest, including 
 the apex, is dull. The trachea, as well as the heart, is displaced to the right. 
 
 consists of dense, rounded masses, sharply marked off from the lung 
 tissue, occurring near the hilus. Ragged, irregular cavity formation 
 in the tumor mass sometimes occurs. In the infiltrating tj^pe, the 
 tumor arises from a bronchus and infiltrates the lung along the 
 bronchial ramifications. The edges of the growth are apt to be 
 smooth except along the advancing margin tow^ard the periphery 
 of the lung. These growths may also extend toward the root and 
 form large masses at the hilus. Collapse of the lung with displace- 
 
LUNG FIELDS 145 
 
 ment of the heart to the affected side may take place. Fluid in 
 the pleural space occurs early. 
 
 Metastatic Malignancy. — ^Metastatic malignancy appears in three 
 forms. In the first there is progressive enlargement of the hilus 
 shadows which is unrecognizable in the early stages and unmis- 
 takable in the later ones when large masses have developed at the 
 lung roots and usually an effusion at one or both bases. A second 
 
 Fig. 120. — Malignant metastasis in the lungs from carcinoma of the stomach. 
 
 and perhaps more common form is that in .which the growths take 
 the form of multiple, thin, rounded plaques of variable size, with 
 sharp margins which are scattered throughout the lung fields. 
 In the third type there is a fine mottling throughout the lung fields 
 which may suggest miliary tuberculosis, but the small areas of 
 increased density are a little larger, more dense, and more sharply 
 outlined than those of tuberculosis. Two or more of these forms 
 may occur together. 
 10 
 
Fig. 121. — Metastasis. Malignant disease of the lung and pleura. 
 
 Fig. 122. — Metastatic carcinoma involving the bones, lungs and pleura. 
 
LUNG FIELDS 
 
 147 
 
 Syphilis. — There is considerable discussion on the subject of lung 
 sj'philis but undoubted cases have been reported. It is evidenced 
 in three types. In the first, there is a general thickening of all of the 
 bronchial markings, particularly marked toward the hilus, giving 
 a fan-shaped shadow radiating out into the lung fields. In the 
 second, supposed to be gummata, there are one or more dense dis- 
 crete masses to be made out in the region of the hilus. The third 
 
 Fig. 123. — There is an extensive chronic inflammatory process involving both lungs, 
 the left much more than the right. Clinically it was thought to be syphilitic. 
 
 form occurs as a diffuse shadow obscuring one entire side of the 
 chest which may clear wholly or in part under appropriate treat- 
 ment. One characteristic feature of these patients is that the lesions 
 are much more extensive than their condition would lead one to 
 suspect, 
 
 Echinococcus. — Echinococcus occurs as dense, circular, sharply 
 defined areas of increased density within the lung field. They may 
 or may not have an evident cystic wall and ordinarily are not con- 
 
Fig. 124. — Echinococcus cyst at the base of the right lung 
 
 Fig. 125. — Actinomycosis of the hmgs. In this case the changes are most marked 
 around the right descending bronchus and resemble bronchiectasis. 
 
THE HEART AND GREAT VESSELS 
 
 149 
 
 nected with the mediastinum. If rupture of the cyst has occurred, 
 the picture will simulate that of lung abscess. 
 
 Actinomycosis. — ^Actinomycosis usually occurs in the form of a 
 lung abscess and diagnosis is made bacteriologically. 
 
 Pneumonoconiosis ( Anthracosis, Chalicosis) . — Pneumonoconiosis 
 may occur as a diffuse, fine mottling s^Tnmetrically distributed 
 throughout both lungs. The apices may be involved although such 
 is not usually the case. The picture is very suggestive of miliary 
 
 Fig. 126. — Potterj- workers' lungs. Pneumonoconiosis. 
 
 tuberculosis. However, there will usually be a long history of 
 occupational exposure to dust and there is little or no clinical evi- 
 dence of a process as extensive as the roentgenogram would indicate, 
 the mottling is more dense and the areas are smaller, more .sharply 
 defined, and more uniform in size than tho.se of tuberculosis. 
 
 Another form of this disease is seen frequently in gold mine and 
 pottery workers, and appears as a diffuse process involving bothjungs, 
 particularly the upper lobes, and from the plates alone cannot be 
 distinguished from fibroid phthisis. 
 
150 THE CHEST 
 
 BIBLIOGRAPHY. 
 
 Adler, Isaac: Primary malignant growths of the kings and bronlphi, Longmans, 
 1912. 
 
 Howell, W. W. : Studies in bronchial glands, Am. Jour. Dis. Children, 1915, x, p. 90. 
 
 Morse, J. L. : Case of congenital heart disease. Am. Jour. Dis. Children, 1915, x, 
 p. 27. 
 
 Jackson, H.: Multiple metastatic sarcomas of the lungs, Jour. Am. Med. Assn., 
 1916, Ixvi, p. 833. 
 
 Miller, C. L. : Use of the rc-ray in the diagnosis and study of pulmonary tubercu- 
 losis, Internat. Clin., 1916, Series 26, iii, p. 109. 
 
 Van Zwaluwenburg, J. 6.: The value of the orthodiagraph, Jour. Michigan Med. 
 Soc, 1910, ix, p. 211. 
 
 Pancoast, Henry K. : Roentgen diagnosis of pulmonary tuberculosis. Am. Jour. 
 Roent.,. September, 1917. 
 
 Moore, Alexander B.: Roentgen diagnosis of non-tuberculous disease of the lungs, 
 Journal-Lancet, July 1, 1917, xxxvii, p. 430. 
 
 Crane, A. W. : Roentgenocardiograms, Jour. Am. Med. Assn., October 14, 1916, 
 Ixvii, p. 1138. 
 
 Banjamin and Lang: Enlarged thymus in children, Am. Ped. or Arch. Ped., 1917. 
 
 Dunham, Kennon: Pulmonary tuberculosis, stereoroentgenography, Southworth 
 Company, Troy, N. Y., 1915. 
 
 Wessler, H.: The role of the roentgen ray in diagnosis of obscurer forms of heart 
 disease, Am. Jour. Roent., November, 1915, ii. 
 
 Brown, Percy: The recognition of pleural disorders by a--rays, with special refer- 
 ence to empyema, Boston Med. and Surg. Jour., 1915, clxxiii, p. 802. 
 
 Holt, Oliver P. : Multiple metastatic sarcomas of the lungs, with report of a case. 
 Jour. Am. Med. Assn., 1916, Ixvi, p. 171. 
 
 Watkins, W. W. : Roentgen diagnosis of lung syphilis. Am. Jour. Syph., 1917, i, 
 p. 760. 
 
 Keilty, Robert A.: Primary endothelioma of the pleura, Am. Jour. Med. Sc, 
 June, 1917, p. 180. 
 
 Boardsman: Pneumonoconiosis, Am. Jour. Roent., 1917, iv, p. 292. 
 
 Hertzler, A. E.: Dermoids of the mediastinum. Am. Jour. Med. Sc, 1916, clii, 
 p. 165. 
 
 Dunn, C. H.: Tuberculosis, Am. Jour. Dis. Children, 1916, ii, p. 85. 
 
 Mason, H. H.: Lobar pneumonia in children. Am. Jour. Dis. Children, 1916, ii, 
 p. 188. 
 
 Kanoky, J. P.: Thyroid tumors, Surg., Gynec. and Obst., 1916, xxii, p. 679. 
 
 Post, A.: Syphilis of the lungs, British Med. Surg. Jour., 1916, clxxiv, p. 876. 
 
 Baetjer, W. A.: Pulmonary tuberculosis, Internat. Clin., 1916, xxvi, iii, p. 124. 
 
 Wood, N. K.: Syphilis of the lungs, British Med. Surg. Jour., 1916, clxxv, p. 677. 
 
 Simon, C. E.: Yeast infection of the lungs. Am. Jour. Med. Sc, 1917, cliii, p. 231. 
 
 Scott, E., and Forman, J.: Primary carcinoma of the lungs, New York Med. 
 Rec, 1916, xc, p. 452. 
 
 Hulst, H.: Roentgenological diagnosis of tuberculosis of the lungs. Am. Jour. 
 Roent., 1916, iii, p. 465. 
 
 Dietlen: Munchen. med. Wchnschr., 1913, clx, p. 1763. 
 
 Vaquez and Bordet: Le Coeur et I'aorte: Etudes de Radiologic Clin. 
 
 Jaugeas: Precis de Radiolog. Tech. et Clin. 
 
 Bietlen, H.: Deutsch. Arch. f. klin. Med., 1906-1907, Ixxxviii, p. 55. 
 
 Holzknecht: Fortschritte a. d. Geb. d. Roentgenstr. Erganzungheft, 6, p. 117. 
 
 Guttman: Ztschr. klin. Med., 1906, Iviii, p. 353. 
 
 Groedel, F. M.: Die Roentgendiagnostic der Herz- und Gefasserkrankungen, 
 Berlin, 1912, pp. 14-16. 
 
 De la Camp: Verhand. f. d. Cong. f. miinchen. Med., 1904, xxi, p. 208. Con- 
 clusions of Resume. 
 
 A. Kohler: Teleroentgenography, Deutsch. med. Wchnschr., 1908, xxxiv, p. 186. 
 
 Dietlen: Orthodiagraphie und Teleroentgenographie als Methoden der Herz- 
 messung, Munchen. med. Wchnschr., 1913, Ix, 1763-1766. 
 
 Albers, Schonberg: Die Roentgen technik. 
 
CHAPTER VIII. 
 
 GASTRO-INTESTINAL TRACT. 
 
 Technic. — Both fluoroscopy and plates are necessary for adequate 
 examination of the gastro-intestinal tract. Fluoroscopy gives infor- 
 mation in regard to mobility and function which cannot be secured 
 from plates, and plates give details of structure which may be over- 
 looked on the screen so that the methods are complementary. The 
 value of fluoroscopy depends upon the experience of the man who 
 is doing it, and when fluoroscopy is referred to hereafter it is under- 
 stood to mean that of a thoroughly trained operator. With a good 
 screen examination, six or eight plates should be sufficient in 
 most cases. The secret of success in this work is thoroughness, 
 which is more essential here than in any field of roentgenology. 
 Examinations must be frequently repeated and the patient ade- 
 quately studied before an opinion is rendered. As far as possible, 
 a routine technic should be employed throughout. There should 
 be no preliminary catharsis. A standard meal of uniform amount 
 and composition should be administered to the patient at about 
 his customary meal time. The barium may be given in 8 ounces 
 of buttermilk or potato starch gruel and the original meal maj' be 
 followed along its course or the double meal may be employed. 
 In the latter method the patient should receive his barium in a 
 carbohydrate breakfast of at least 16 ounces, reporting for exami- 
 nation six hours later, when the position of the morning meal is 
 observed and a second standard meal administered. This latter 
 method is the one most in use in the larger clinics, perhaps because 
 of the saving in time it effects. It will be found thoroughly prac- 
 ticable in most cases. The patient should be examined in the stand- 
 ing, prone, supine and right lateral positions, A brief knowledge 
 of the clinical history is essential, and whether it be secured before 
 or after the roentgen examination is a matter of personal preference, 
 but the roentgen findings and the history must be correlated at some 
 time before a diagnosis is made. The accuracy of the method will 
 vary with the personality and training of the observer. The diag- 
 
152 
 
 GASTRO-INTESTINAL TRACT 
 
 noses of the a^'erage man will be about 75 per cent, correct. With 
 the best roentgenologists under the most favorable circumstances, 
 roentgen findings in this field should be 85 to 90 per cent, correct. 
 
 ESOPHAGUS. 
 
 The esophagus is grossly outlined with the ordinary barium meal. 
 For more prolonged observation, particularly in cases of suspected 
 new growth, a mixture of barium sulphate and mucilage of acacia or 
 gelatin is of great value. In the right oblique diameter the normal 
 
 Fig. 127. — Cardiospasm. 
 
 Note the esophagus to the right and the round, smooth 
 borders of the barium shadow. 
 
 esophagus is easily seen throughout its course. It presents a slight 
 indentation at the level of the arch of the aorta and curves forward 
 behind the heart to enter the stomach. It is smooth in outline and 
 the opaque mass passes readily through it with a momentary pause 
 at the arch and a longer delay at the cardia. 
 
ESOPHAGUS 153 
 
 Pathological Esophagus. — The esophagus may be greatly dilated 
 in cardiospasm or benign stricture. In the former, a glass of hot 
 water may relax the spasm and allow part or all of the meal to enter 
 the stomach. There is no discoverable irregularity in outline and 
 the shadow ends at the cardia in a smooth, funnel-shaped mass. 
 Dilatation of the esophagus occurring as a result of cardiospasm may 
 
 Fig. 128. — Dilated gas-filled esophagus. There is a small amount of barium in the 
 lower part. Plate was taken with the patient upright. 
 
 be so great that the margins of the esophagus overlap the lung field 
 on the right side. In these cases there may be a delay of the meal 
 above the cardia for hours or days. Malignant tumors of the cardia 
 of sufficient extent to cause obstruction can, as a rule, be recognized 
 by irregularities in outline of the barium mass in the lower esophagus 
 or stomach. 
 
154 
 
 G ASTRO-INTESTINAL TRACT 
 
 Changes in Position. — The esophagus may be displaced by medias- 
 tinal tumors, aneurysms, effusion, fibrosis or diseases of the spine. 
 
 Fig. 129. — Spasm of the middle third of the esophagus suggesting malignant 
 
 disease. 
 
 Outline. — Irregularities in outline are most commonly due to 
 carcinoma which produces a persistent defect that is annular and 
 ragged or mottled. It is most commonly found in the lower half of 
 the esophagus. Scar tissue within the esophagus, ulceration or the 
 ingestion of corrosives results in multiple constrictions through its 
 
Fig. 130. — Diverticulum of the esophagus. 
 
 Fig. 131. — Malignant disease of the esophagus at the middle third. 
 
156 
 
 GASTRO-INTESTINAL TRACT 
 
 course. The contraction of extra-esophageal fibrous tissue may 
 result in constriction or sacculation. 
 
 Diverticula. — Diverticula may be found anj-wliere in the course 
 of the esophagus, most commonly the upper and lower ends. They 
 appear as rounded pouches which overflow into the esophagus 
 through an opening at one side. It may be necessary to view the 
 patient from several angles to bring this opening into profile. They 
 remain partially filled after the remainder of the meal has passed on. 
 The liquid meal is to be preferred, as solid masses may not enter 
 the pocket. In rare cases the meal may be seen to enter a descending 
 bronchus as a result of broncho-esophageal fistula, usually due to 
 
 carcnioma. 
 
 STOMACH. 
 
 In the standing position the normal stomach hangs more or less 
 centrallv in the abdomen with the lesser curvature above the level 
 
 Fig. 132. — Normal stomach. 
 
 of the crests of the ilia. The greater curvature lies at a variable 
 distance below the lesser. The form and position of the stomach 
 
STOMACH 
 
 157 
 
 are determined by the architecture of the individual, the tone of 
 the gastric wall, the tension of the abdominal muscles, the pressure 
 of neighboring organs and the amount of the meal. Thin individuals 
 with a narrow costal arch have long central stomachs which hang 
 low in the pelvis. In broad, fat individuals with a wide costal arch 
 and in those of strong muscular development the stomach is high 
 
 Fig. 133. — Hyperperistalsis in an othenvise normal stomach. 
 
 ttnd transverse. In asthenic states it is low and, because of the lack 
 of tone, the meal settles in the lower pole, allowing the walls of the 
 cardia to collapse. In the prone position the stomach swings up 
 under the liver, h'ing more transversely. When empty, its walls 
 are in apposition except at the cardia which is dilated by the 
 gas bubble. As the stomach fills, the meal collects in a funnel- 
 shaped shadow below the gas bubble and gradually fills out the 
 
158 
 
 G ASTRO-INTESTINAL TRA CT 
 
 body and antrum. In atonic stomachs the meal passes rapidly to 
 the lower pole which enlarges out of proportion to the body. 
 
 The outline is smooth except for indentations due to peristalsis, 
 and a variable amount of irregularity on the greater curvature due 
 to pressure from the colon and spleen. Small transient indentations 
 occur on the margins of the antrum near the pylorus. They are 
 most common on the lesser curvature and are without significance. 
 
 Fig. 134. — Normal stomach deformed by pressure. Plate taken \Yith patient prone. 
 
 Normal peristalsis begins at about the middle of the lesser curva- 
 ture with a shallow depression corresponding to it on the greater 
 curvature. The wa\'es tra^'el toward the pylorus without inter- 
 ruption. They become progressively deeper as they pass forward 
 and may bisect the barium mass at the upper limits of the antrum. 
 If the pylorus opens, the antrum then contracts as a whole, forcing 
 its contents into the duodenum. If not, the waves move on to 
 
STOMACH 
 
 159 
 
 the pylorus. Peristaltic waves occur at intervals of about twenty 
 seconds, varying with the patient and the meal used. Ordi- 
 narily no more than two or three waves are visible on a stomach 
 at the same time. They are increased in number and depth in the 
 prone position and may be strongly affected by mental states, being 
 increased by rage or inhibited by fear or nausea. 
 
 Fig. 1.3.5. — Tracing of normal stomach. 
 
 Pathological Stomach. — The stomach is increased in size when 
 dilatation has occurred as a result of pyloric obstruction or in con- 
 ditions where there is a general loss of muscle tone. It is diminished 
 in size (1) as a result of increased tone from strong muscular develop- 
 ment or as a reflex from disease of the duodenum, gall-bladder or 
 appendix, and (2) as a result of infiltration of the wall as seen in 
 ulcer, carcinoma, adhesions, s^^hilis and linitis plastica. 
 
160 
 
 GASTRO-INTESTINAL TRACT 
 
 Changes in Position. — The stomach is displaced upward and to 
 the right where there are adhesions to the liver as a result of gall- 
 bladder disease or from the presence of a large accumulation of gas 
 in the splenic flexure or tumors in the left upper quadrant. In some 
 cases of appendiceal disease or adhesions the lower pole is swung 
 o\-er toward the right iliac fossa. It may be displaced and rotated 
 upward on its long axis in case of adhesions to the anterior abdominal 
 wall. General gaseous distention of the intestine or fluid in the peri- 
 toneal cavity crowds the stomach upward against the liver. Displace- 
 
 Pylonis 
 
 Fig. 136. 
 
 Jncisuixr. 
 
 -Tracing of stomach, showing a small ulcer on lesser curvature near the 
 pylorus. There is no visible crater. 
 
 ment doAvnward (ptosis) is of no importance unless accompanied by a 
 six-hour residue or definite clinical evidence of abnormal function. 
 It may be shifted downward and to the left by enlargement of the 
 liver or tumors in the right upper cpjadrant. In i)yloric obstruction 
 where dilatation has occurred the stomach shadow often appears 
 farther to the right than normal, but this is due to dilatation of the 
 antrum and is not a true displacement of the entire stomach. 
 
 Changes in Outline. — Changes in outline occur (1) as a result of 
 spasm. This may be localized as seen in the narrow contractions 
 
STOMACH 
 
 161 
 
 near the pylorus or in the upper portion of the body of the stomach 
 where the greater curvature is drawn in toward the lesser over a 
 space of a few millimeters. These spasms may be reflex or be due 
 to the irritation of a small ulcer or new growth at that level. Spasm 
 may also be extensive, obliterating the entire antrum, for example. 
 Here again it may be entirely reflex or be due to an associated lesion 
 
 Fig. 137. — Tracing of stomach, showing penetrating ulcer of lesser curvature. 
 
 Patient prone. 
 
 of the stomach wall, which is often a difficult matter to decide. 
 Functional spasms usually are transitory so that repeated observa- 
 tions of the patient will frequently settle the matter. Antispas- 
 modics, such as belladonna or papaverin, may be emploj^ed, but 
 they are not conclusive because of the fact that at times they relax 
 the spasm associated with a lesion of the wall as readily as those 
 due to functional causes; so that the question of the presence or 
 11 
 
162 
 
 GASTRO-INTESTINAL TRACT 
 
 absence of a lesion must depend upon other evidence than that of 
 spasm. (2) As a result of gastric lesions. Under this heading 
 come the contracted, rigid, smooth lesser curvatures with absence 
 of peristalsis seen in ulcer and carcinoma; the presence of the 
 crater of a penetrating or perforating ulcer projecting from the gas- 
 tric outline on the lesser curvature or posterior wall; marked 
 
 Fig. 138. — Stomach sho-wing penetrating ulcer of lesser curvature. Patient standing. 
 
 irregularities of carcinoma which vary according to the size, shape 
 and position of the tumor. These deformities are usually either 
 annular or due to the presence of irregular masses invading the 
 barium mixture, leaving ragged holes or markings suggesting finger 
 prints. We may also have the local contractions due to an ulcer 
 with its associated spasm ; or the extensive defects of lues, suggest- 
 
STOMACH 
 
 163 
 
 ing ulcer or carcinoma. Another deformity is that which occurs 
 as the result of contraction of scar tissue in the gastric wall, produc- 
 ing a so-called hour-glass stomach. This deformity is constant in 
 all positions. (3) Defects due to extragastric causes such as tumors 
 or pressure as, for example, the gall-bladder which produces a 
 rounded depression in the region of the pylorus, or pancreatic tumors 
 which cause irregularity of the greater or lesser curvature, are not 
 
 Fig. 139. — Tracing of stomach, showing large ulcer on lesser curvature. 
 
 constant in all positions of the patient. An enlarged liver may cause 
 defect in the antrum by compressing it against the spine. In plates 
 taken in the prone position the pressure of the spine against the 
 abdominal wall commonly causes a break in the barium shadow 
 overlying it. Perigastric adhesions, particularly those about the 
 pyloric end of the stomach, may produce ragged defects suggesting 
 carcinoma but as a rule they are not constant in all positions. 
 (4) Any solid material in the stomach, such as food masses, foreign 
 
164 
 
 GASTRO-IXTESTIXAL TRACT 
 
 bodies, hair balls, and the like, may cause defects in the barium 
 mass resembling malignant disease. However, these irregularities 
 shift with changes in position of the patient and there is no inter- 
 ference with peristalsis. Papillomata produce a defect similar to 
 that seen in large foreign bodies, but there is little displacement of 
 
 Fig. 140. — Tracing of stomach, showing large saddle ulcer. 
 
 the defect with change in position of the patient, peristalsis is not 
 interfered with, and they are constant on repeated examinations. 
 
 Changes in Peristalsis. — Increase in the depth or speed of waves 
 may be due to reflex or irritative causes or compensatory to a 
 diseased pylorus. In the early stages of pyloric obstruction the 
 waves are deep and vigorous. They may bisect the stomach, giving 
 
STOMACH 165 
 
 it the appearance of a row of balls. The waves also start higher and 
 more are visible at the same time. Peristaltic waves are lost in 
 achylia, in the stage of decompensation of pyloric stenosis, in infil- 
 
 FiG. 141. — Tracing of stomach, showing ulcer at fundus and large ulcer of the lesser 
 curvature invohing the pylorus. 
 
 tration of the gastric wall, and in nausea, fear or faintness. They 
 are irregular where they encounter areas of infiltration in the gastric 
 wall or strands of adhesions and possibly in some functional dis- 
 turbances. Peristalsis is reversed in carcinoma and tabes. 
 
Fig. 142. — Penetrating ulcer of the lesser curvature and ulcer of the duodenum. 
 
 Fio. 14.3. — Large saddle ulcer causing hour-glass stomach. 
 
STOMACH 
 
 w: 
 
 Incjsura 
 
 Fig. 144. — Cancer high on the lesser curvature. Note the large area involved and the 
 absence of a definite projection. 
 
 Incisura. Pijlomis 
 
 Fig. 145. — Malignant disease of the lesser curvature. 
 
168 GASTRO-INTESTINAL TRACT 
 
 Motility. — The normal stomach empties in three to six hours, 
 depending upon the amount and composition of the meal, the tone 
 of the stomach and its functional activity. If it empties in less than 
 three hours, ach^^ia, an incompetent pylorus, duodenal ulcer or 
 gall-bladder disease is suggested. If there is a definite residue 
 (one-quarter of the original meal) beyond six hours and the patient 
 has taken no food or drugs in the meantime, one must suspect a 
 
 Fig. 146. — Tracing of the stomach, showing annular constriction of the media ckie to 
 
 cancer. 
 
 lesion in the stomach, reflex irritation of the pylorus (duodenum, 
 gall-bladder, appendix) or obstruction in the intestine below. In 
 rare instances delay may be due to acute illness, marked ptosis or 
 the action of certain drugs. 
 
 Carcinoma. — Because of the insidious onset of carcinoma, the 
 patients do not appear for examination until there is a well-estab- 
 lished lesion so that few early ones are found. The characteristic 
 findings are defects in outline, absent, sluggish, irregular or reversed 
 
STOMACH 169 
 
 peristalsis, esophageal or gastric stasis (or early gastric emptying) 
 and loss of flexibility of stamach wall. The appearances seen vary 
 considerably with the t}^e of growth and with its location. Car- 
 cinoma of the cardia is often difficult to visualize. In these cases 
 it is helpful to watch the first mouthfuls of barium entering the 
 stomach. The jet will be irregular instead of smooth and there 
 may be delay at the cardia. There will also be rigidity and deformity 
 of the fundus which does not change on deep inspiration. For this 
 observation the patient should lie on his back. 
 
 Fig. 147. — Extensive malignant disease of the media and antrum. 
 
 Large growths in the body and antrum are usually characteristic. 
 There is a ragged annular defect which is constant at all times and 
 in all positions. If the tumor is palpable it will be found to coincide 
 with the defect. Peristalsis is absent in the region of the growth 
 and may be irregular, sluggish or reversed elsewhere. Stasis is usual. 
 The dift'erentiation is from ulcer, lues, adhesions and extragastric 
 tumors. Typical ulcers and t\T)ical carcinoma are easily distin- 
 guishable but borderline cases are often hard to identify. Carcino- 
 
170 
 
 GASTRO-INTESTINAL TRACT 
 
 matous ulcers may, like benign ulcers, be limited to one wall and 
 show a rigid area of infiltration with the pocket of a crater project- 
 ing from it. However, the crater is usually larger in carcinoma and 
 
 Pl/lOT'U S 
 
 FiG. 148. — Extensive annular involvement of the media and antrum due to 
 malignant disease. 
 
 Fig. 149. — Malignant disease of the pyloric end of the stomach. 
 
STOMACH 
 
 171 
 
 peristalsis will be diminished or irregular, while in ulcer it is apt 
 to be increased. Stasis may occur in both cases but is perhaps 
 more frequent in ulcer. Spasms and incisurae are much more 
 common in ulcer. 
 
 In lues the deformity is generally more irregular and the patient 
 is not so sick as he would be if the lesion were carcinomatous. The 
 defect is out of proportion to the symptoms. 
 
 Fig. 150. — Malignant disease of the cardia, with metastasis in tlie lungs. 
 
 The defects in adhesions and extragastric tumors are usually 
 not constant in all positions. 
 
 Diffuse infiltration of the stomach wall occurs in scirrhous car- 
 cinoma, lues and linitis plastica (which may be one form of lues). 
 The signs are those of infiltration — a smooth, rigid outline with 
 absence of peristalsis and usually a contracted, rapid emptying 
 stomach. 
 
 Pyloric Carcinoma.- — In well-established cases there is a definite 
 funnel-shaped defect and if the pj'lorus is involved, the outlet 
 
172 
 
 GASTRO-INTESTINAL TRACT 
 
 becomes rigid and the stomach may empty rapidly. Dilatation of 
 the stomach is rarely present. In early carcinoma at the pylorus 
 there may be a funnel-shaped defect which is not due to the actual 
 lesion, probably as a result of associated spasm. 
 
 Ulcer, — In general, ulcers are more readily found the closer they 
 are to the pylorus. Stasis is of more significance the nearer the 
 lesion lies to the sphincter, i. e., if there is pyloric deformity and no 
 
 Fig. 151. — Tracing of stomach, showing typical deformity of cap due to duodenal 
 
 ulcer. 
 
 residue, it is not due to ulceration but to some other condition, most 
 commonly carcinoma or adhesions. The recognition of an ulcer 
 depends upon the presence of a crater which can be filled with 
 barium and brought into profile and upon the presence of associated 
 spasm, increased peristalsis and usually stasis. In some cases the 
 crater and spasm are absent although careful observation may reveal 
 the presence of a small area of induration indicated by a break in 
 peristalsis, or there may be no discoverable abnormality aside from 
 
Pylorus 
 
 Fig. 152. — Tracing, showing type of duodenal ulcer. 
 
 Fig. 153. — Tracing, showing type of duodenal ulcer. 
 
174 
 
 GASTRO-INTESTINAL TRACT 
 
 Fig. 154. — Tracing of stomach, showing the deep, vigorous peristalsis of duodenal 
 
 ulcer. 
 
 Fig. 155. — Tracing of the stomach, showing stoma and position of bismuth in email 
 bowel after gastro-enterostomy. 
 
STOMACH 
 
 175 
 
 a residue. However, the latter are not usually surgical ulcers so that 
 failure to identify them is not of as great importance. Ulcers may 
 be divided into mucous, indurated, penetrating and perforating. 
 
 The mucous t;>"pe is usually indicated by an incisure opposite 
 the lesion and may or may not have accompanying hA-perperistalsis 
 and stasis. They are often missed. 
 
 Fig. 156. — Duodenal ulcer shoviing typical deformity. 
 
 In the indurated form, one sees an area of infiltration on the 
 lesser curvature which, if extensive, may cause considerable shorten- 
 ing of this curvature. There will be a break in peristalsis at 
 the site of the lesion, h^-perperistalsis and stasis. Spasm is not 
 usually present. \Yhen it does occur it takes the form of local 
 incisurse opposite the active edge. They may cause irregularity of 
 the greater curvature from contraction of scar tissue which extends 
 out around the body of the stomach. If they occur at the pylorus 
 there is failure of the antrum to contract and stasis is marked. The 
 
176 GASTRO-INTESTINAL TRACT 
 
 first swallow of barium may collect in a small pool at the site of the 
 lesion due to the slight spasm which holds up its progress at first 
 but which disappears as the stomach fills. 
 
 Penetrating ulcers have all the signs of the indurated form and, 
 in addition, a mass of barium projecting from the rigid area which 
 corresponds in size and shape with the crater of the lesion. Although 
 they are often found on the posterior wall surgically, they usually 
 appear on the lesser, curvature during the roentgen examination. 
 A lateral ^'iew may at times be necessary to adequately visualize 
 these lesions and should be a part of the routine examination which 
 as a matter of fact should include careful observation from every 
 
 Fig. 157- — Free gas between the upper surface of the liver and the diaphragm 
 following perforation of a duodenal ulcer. 
 
 angle in at least three positions — prone, supine or standing. These 
 protrusions must be differentiated from the duodenojejunal flexure 
 which is often projected just above the lesser cur\'ature. Rotation 
 of the patient and deep inspiration will usuall}^ enable one to deter- 
 mine whether or not the mass is actually projecting from the gastric 
 shadow or is independent of it. 
 
 Perforating ulcer shows, in addition to the signs of a penetrating 
 ulcer, the presence of a gas bubble outside the stomach wall above 
 the mass in the crater. 
 
 Syphilis. — Its radiographic appearance is practically that of car- 
 cinoma except that mottling of the barium mass and stasis are 
 
STOMACH 111 . 
 
 uncommon. The extent of the lesion is out of proportion to the 
 patient's s}Tnptoms. The age of the patient, the history and the 
 laboratory findings must be relied upon for corroborative evidence. 
 Appropriate treatment improves sjTQptoms and may or may not 
 affect the roentgen picture. 
 
 Fig. 158. — Postoperative ulcer of the stomach (recurrent). The constriction is 
 probably the result of the operation. The projection just below it is the crater of a 
 new ulcer. 
 
 Linitis Plastica. — ^Linitis plastica is believed by some observers to 
 be a late stage of a luetic process. It is a fairly rare condition in 
 which the gastric wall is infiltrated by dense fibrous tissue which 
 12 
 
178 
 
 GASTRO-INTESTINAL TRACT 
 
 contracts the stomach down to a sniall, rigid tube high up under 
 the liver, and through which the meal pours in a few minutes. 
 
 Foreign Bodies. — Hair balls and metal articles are occasionally 
 reported. Whether or not they are in the stomach may be deter- 
 mined by changing the position of the patient, by inflating the 
 stomach with air and the routine barium meal. Hair balls present 
 a characteristic appearance and the barium adheres to them, out- 
 lining their structure for some time after the meal has passed on. 
 
 Fig. 159. — Specific stomach. 
 
 Polypi. — Polypi of the gastric wall are comparatively rare. They 
 may be multiple and when demonstrable, appear as smooth, rounded 
 holes in the barium shadow which remain constant with changes 
 in the position of the patient. Peristaltic waves are not interfered 
 with. The condition must be differentiated from foreign materials 
 in the stomach, such as food masses and from extragastric tumors. 
 
STOMACH 
 
 179 
 
 Their constancy is the best evidence. In the late stages, if extensive, 
 they may cause obstruction and be mistaken for mahgnancy. 
 
 The stomach after gastro-enterostomy is usually smaller and 
 higher. It empties rapidly, depending somewhat upon the size of 
 the stoma. There is little peristalsis visible. When seen it usually 
 passes over the entire lower part of the stomach to the pylorus, 
 forcing the barium mixture through unless it has been closed at 
 
 Fig. 160. — Dilatation of the jejunum due to obstruction from malignant disease. 
 
 the operation or by disease. Usually the stoma can be demon- 
 strated and its size, position and contour noted. A loop of the 
 jejunum passing from behind the stomach shadow ma}' lead to errors. 
 The observations to be made in the order of their importance are 
 emptying time ; shape and position of the stoma ; type of peristalsis ; 
 size of stomach; whether or not food leaves through the pylorus, 
 and the appearance of the duodenal loop. 
 
180 GASTRO-INTESTINAL TRACT 
 
 DUODENUM. 
 
 The normal first part of the duodenum is a smooth, rounded, 
 triangular shadow, at times connected with the stomach by a thin 
 line of barium in the pyloric canal when the sphincter is open. Its 
 relation to stomach, gall-bladder and liver varies with the type and 
 position of the patient and the size and shape of the stomach and 
 liver. It has a peristalsis of its own and its filling and emptying 
 are controlled both by the pyloric sphincter and a constrictive action 
 of the junction of the first and second portions. The rapidity of 
 filling and emptying depends largely upon the character of the meal, 
 being much more rapid in the case of watery and carbohydrate 
 mixtures than when proteins are present. It may be considerably 
 enlarged in atonic individuals. Enlargement may also occur as a 
 result of adhesions or bands about the duodenum or ulcer of the 
 second portion. It may be contracted as a result of spasm, scar 
 tissue in the wall or adhesions about it. Defects in outline ma}' be 
 due to pressure as, for example, smooth rounded depression due to 
 the gall-bladder and the small indentation on the inner margin due 
 to the bile duct. Scars and the spasm from ulcers cause irregular 
 deformities which produce the familiar coral-shaped shadow. 
 Rarely, as a result of perforation of such an ulcer, there may be a 
 pocket filled with barium between the duodenum and the liver or 
 colon. In some cases of perforation, free gas has been demonstrated 
 in the peritoneum above the liver. Adhesions usually produce slight 
 irregularities which are not constant. Spasm may produce exten- 
 sive changes in the shape of the duodenal bulb. It is usually reflex 
 from a lesion of the gall-bladder or the appendix. Yery rapid empty- 
 ing where the meal shoots through the cap rapidly is seen in gastric, 
 pyloric and duodenal ulcer. Delayed emptying may be due to 
 obstruction in the duodenum or the intestine lower down, but usuall}^ 
 occurs reflexly as a result of gall-bladder or appendiceal disease. 
 
 Ulcer. — The signs of ulcer are deformities in outline, changes in 
 motility already mentioned, in addition to changes in gastric per- 
 istalsis and motility. The deformities in outline must be differen- 
 tiated from those due to spasm as a result of gall-bladder or appendix. 
 The deformity of ulcer is constant, whereas that due to spasm will 
 vary or disappear at different examinations. It is probable that a 
 part of the deformity seen in duodenal ulcer is due to local spasm 
 accompanying the lesion. 
 
ILEUM 181 
 
 Adhesions. — Adhesions may produce slight irregularities in the 
 cap which are not constant with change in position of the patient 
 and there is usually fixation of the bulb. Constricting bands may 
 be fomid am'^\'here in the course of the duodenum. E^'idence of 
 their presence is seen in dilatation and delay in motility, a common 
 form of which is the pendulum movement of masses of barium to 
 and fro in the second and third portions. The meal passes as a 
 flocculated mass through the second and third portions of the 
 duodenum with considerable rapidity so that they are less well 
 outlined than the first portion. The entire second and third por- 
 tions are well outlined only when there is a rapidly emptying 
 stomach or in cases of obstruction from adhesions or pancreatic 
 disease. Delay in any portion of the duodenum, pendulum move- 
 ments of the barium mass, visible and reverse peristalsis are sug- 
 gestive of spasm or obstruction. Ulcer is rare in this portion of the 
 duct although craters have been seen. The ampulla of Vater may 
 be dilated and appear as a definite spot of barium a few millimeters 
 in diameter along the descending portion. Diverticula are occa- 
 sionally seen. They appear as rounded masses in close proximity 
 to the duodenum. Duodeno-gall-bladder fistulte have been dem- 
 onstrated. 
 
 JEJUNUM. 
 
 The jejunum normally appears as coils of fine, feathery flakes 
 of the meal due to the rapidity of its progress. It is never outlined 
 except in pathological conditions, the most common of^which are 
 peritonitis, acute or chronic, and obstruction from bands or tumors. 
 A tumor sufficient to cause obstruction is nearly always palpable. 
 In peritonitis and obstruction the flocculent appearance is lost and 
 the coils are dilated. Gastrojejunal ulcers may occasionally be 
 made out at the site of gastro-enterostomy. They appear as per- 
 sistent irregularity in outline in the region of the stoma which are 
 sometimes rather diflficult to visualize. Changes in gastric peris- 
 talsis and motility are the rule. 
 
 The roentgen evidences of gastrojejunal ulcer are gastric stasis, 
 increased gastric peristalsis, deformity of the stoma, and localized 
 tenderness. 
 
 ILEUM. 
 
 The Qormal ileum is seen as a coil of intestine containing dense masses 
 of barium lying low in the pelvis with a loop running up to terminate 
 
182 GASTRO-INTESTINAL TRACT 
 
 in the cecum. Palpation is unsatisfactory except in its terminal 
 portion owing to its depth in the pelvis. It is smooth in outline 
 with transverse contractions which are continually changing. It 
 may begin to fill within an hour after the meal has reached the 
 stomach and is entirely emptied by eight to ten hours after eating. 
 The head of the meal should have passed through it at six hours. 
 Dilatation occurs as a result of obstruction from adhesions or bands. 
 Disease in the ileocecal region usually causes fixation and tender- 
 ness of the terminal ileum. A delay of over six hours in entering the 
 cecum or beyond ten hours for complete emptying of the ileum is 
 suggestive of disease in the ileocecal region, in which case there is 
 usually an associated fixation and tenderness of the terminal ileum. 
 
 APPENDIX. 
 
 The normal appendix fills and empties during the presence of 
 barium in its vicinity and should be visible if persistently and care- 
 fully looked for. It is freely movable and not tender and should 
 be empty when the cecum has emptied. It may present one or more 
 constrictions which are without significance. When it is or has 
 been the seat of disease, it either never fills or fills irregularly and 
 contains a residue after the cecum is empty. There may also be 
 tenderness and fixation of cecum and terminal ileum, stasis in the 
 ileum, stasis and hyperperistalsis in the stomach, spasm of the 
 duodenum, and at times stasis in the tip of the cecum after a meal 
 and after enema. An incompetent ileocecal valve is often associated 
 with such an appendix. Stones and foreign bodies are sometimes 
 demonstrated in appendices and may be mistaken for ureteral stones. 
 
 CECUM. 
 
 The normal cecum is smooth with transverse constrictions and 
 is freely movable vertically and laterally but varies greatly in size, 
 position and mobility. A filled terminal ileum is often necessary 
 to identify it positively. It may be dilated in cases of obstruction 
 in the distal colon or in spastic constipation. It may be contracted 
 by extensive adhesions about it. Changes in outline which are best 
 demonstrated by enema are due to adhesions, to carcinoma which 
 produces large, irregular defects, or to inflammatory masses as a 
 result of tuberculosis or a chronic appendix, which may produce large 
 defects resembling carcinoma, but (iareful observation will usually 
 
COLON 
 
 183 
 
 show them to be outside the colon. The normal cecum is never 
 empty when barium is present in both ileum and ascending colon. 
 
 COLON. 
 
 The colon varies greatly in size and po3?cion from hour to hour 
 and in different individuals. The outline is smooth and broken by 
 haustrel segmentations. The meal normally reaches the splenic 
 flexure in twelve to eighteen hours and the colon is entirely clear 
 
 Fig. 161. 
 
 -Carcinoma of the transverse colon. On the opposite side there is 
 narrowing of the gut, due to periostitis. 
 
 in from twenty-four to seventy-two hours. ]\Io^'ements of the colon 
 are: (1) haustrel churning, that is, formation and reformation of 
 haustrel contractions and (2) antiperistalsis or anastalsis. A con- 
 traction ring exists at about one-third of the distance between the 
 
184 
 
 G ASTRO-INTESTINAL TRACT 
 
 hepatic and splenic flexures and from this point antiperistaltic 
 Avaves run slowly backward to the cecum. (3) Pendulum move- 
 ments where large masses of contents swing back and forth through 
 short distances; they are usually soon followed by (4) mass move- 
 ments where haustrel markings disappear and large masses of barium 
 are rapidly propelled through a considerable portion of the colon. 
 In outlining the colon by enema it takes a few minutes to complete 
 
 Fig. 162. — Hirschprung's disease. Idiopathic dilatation of the colon. 
 
 the filling of the rectum and sigmoid, after which the fluid should run 
 over readily to the cecum. The pelvic loop of the sigmoid as it 
 distends should rise well out of the pelvis. If it is retained in the 
 pelvis, pelvic adhesions should be suspected. 
 
 Variations. — The position of the colon may be reversed so that 
 the ascending colon lies on the left side in cases of transposition 
 of viscera and it may not rotate completely during the process of 
 
COLON 185 
 
 development, or the ascending colon may not be completely formed 
 so that the cecum lies in the region of the gall-bladder. The sig- 
 moid is subject to great ^'ariation in length and amount of omentum. 
 In cases of so-called redundant sigmoid it may be found an}"\vhere 
 iti the abdomen. 
 
 Changes in Size. — The colon may be dilated as a result of con- 
 genital malformations, so-called megacolon or Hirschprung's dis- 
 ease, or as a result of obstruction from bands or tumors. The 
 'caliber of the transverse and descending portions is uniform!}' 
 diminished in spastic constipation. 
 
 Changes in Position. — Changes in position are not important unless 
 they are permanent and fixed as, for example, sigmoid to the gall- 
 bladder region or the appendix region. 
 
 Changes in Outline. — In observations after barium meals the 
 colon will often show irregular defects due to the presence of fecal 
 matter. They are not permanent and in case of doubt an opaque 
 enema will rule out pathology. Defects are seen best after enema. 
 The common ones are the annular, ragged, funnel-shaped deformi- 
 ties due to carcinoma and the constrictions caused by bands of 
 adhesions. Multiple small buds are sometimes seen along the course 
 of the colon, particularly in its descending portion, which represent 
 barium-filled diverticulae. They may be overlooked if the only 
 observation of the colon is twenty-four hours after the meal. The 
 barium-filled colon may overlap and obscure them so that where 
 their presence is suspected the patient should be seen after the colon 
 is empty, as small residues may remain in the diverticulse for se^■eral 
 days after the colon is clear as small, round, dense masses scattered 
 along the course of the colon. They are sometimes brought out by 
 an enema when a meal has failed to reveal their presence. It has 
 been noted that there is a complete absence of segmentation in 
 severe cases of colitis. 
 
 Changes in Motility. — Decreased emptying time occurs in achylia, 
 in conditions which produce a rigid, incompetent pylorus, and in 
 colitis. Increased emptying time or constipation appears usually 
 in three forms, spastic, atonic and rectal. The spastic type is the 
 result of increased tone of the transverse and descending colon 
 shown by a diminution in caliber and changes in haustrel segmen- 
 tations which are fewer in number and increased in width. The delay 
 in these cases may be extreme, barium remaining in the colon as 
 late as a week after the meal. The atonic t}'pe is characterized by 
 a large, flabby colon and is comparatively rare. It may be seen in 
 
186 GASTRO-'INTESTINAL TRACT 
 
 asthenic states where there is a general loss of tone. In the rectal 
 type there are large masses of barium high up in the rectum and 
 sigmoid occupying most of the pelvis. There is, of course, more or 
 less dela}^ in cases of obstruction due to adhesions or malignancy. 
 
 EECTUM. 
 
 The rectum appears as a smooth, S-shaped mass, occupying a 
 considerable portion of the pelvis. Defects in outline are due to 
 carcinoma which show the ragged, annular lesions typical of the 
 disease, llceration due to lues or tuberculosis may be evidenced 
 by more or less infiltration of the wall which becomes rigid. The 
 diameter of the intestine is diminished rather uniformly throughout 
 the area of the lesion. Pressure from inflammatory masses or tumor 
 in the pelvis may deform or displace the rectal shadow. 
 
 Fig. 163. — This plate shows a fairly typical group of gall-stone shadows. 
 
 GALL-BLADDER. 
 
 Visualization of the gall-bladder is a matter of thorough, careful 
 technic and a certain amount of luck. The patient must suspend 
 respiration completely and the exposure and position of the central 
 
GALL-BLADDER 187 
 
 ray may be just right for the particular patient. It is an exaggera- 
 tion to say that every gall-bladder which can be visualized is patho- 
 logical. However, it is undoubtedly true that a large proportion 
 of pathological gall-bladders can be visualized by careful work. 
 The shadow of the gall-bladder is rounded and sharply margined; 
 
 Fig. 164. — The indefinite ring-like shadow between the eleventli and twelfth 
 vertebrae is that of a single large gall-stone. 
 
 it varies greatly in size and position; it may be found an\'^vhere 
 from the costal margin to the crest of the ilium. Gall-stones may 
 be recognized if they contain a sufficient amount of calcium salts, 
 which unfortunately is true in only 20 to 30 per cent, of the cases. 
 They appear as single or multiple shadows which may be the 
 typical faint ring, a dense homogeneous mass, or a mottled area 
 
188 GASTRO-INTESTINAL TRACT 
 
 of density due to many small stones packed together. Great care 
 must be taken to resist the tendency to make positive diagnosis 
 of gall-stones from any faint shadows in the gall-bladder region. 
 Shadows of stones are often very faint but they at least should 
 show definite rings and lie entirely within the limits of the gall- 
 bladder before they can be diagnosed as stones. The proper 
 
 Fig. 165. — The large indefinite shadow near the spine is not a gall-stone, as nothing 
 was found at operation. It is probably a retroperitoneal gland. 
 
 significance of the negative diagnosis should be realized and 
 insisted upon at all times. A negative diagnosis is of no positive 
 value, for stones may be present and cast no shadow. Further- 
 more, the patient's symptoms may be due more to associated 
 pathology in the gall-bladder than to the stones. Patients occa- 
 sionally refuse a needed operation because stones have not been 
 demonstrated by the roentgen method. They should be warned 
 
BIBLIOGRAPHY 189 
 
 in the beginning that gall-stones may not show. When gall-bladder 
 disease is suspected, a routine gastro-intestinal examination should 
 
 Fig. 166. — Calcified retroperitoneal glands resembling a gall-stone. 
 
 always be done to determine the incidence of adhesions and reflex 
 gastric disturbances such as spasm or stasis. 
 
 BIBLIOGRAPHY. 
 
 Cannon, W. B.: The mechanical factors of digestion, New York, Longmans, 1911. 
 
 Williams, F. W. : Roentgen rays in medicine and surgery. New York, 1903. 
 
 Carman, R. D., and Miller, A.: Roentgen diagnosis of disease of the alimentary 
 canal, Philadelphia, 1917. 
 
 Holzknecht: G.: Recent advances in the Roentgen examination of the digestive 
 tract, Berl. klin. Wchnschr., 1911, No. 4; Arch. Roent. Ray, .July, 1912. 
 
 Holzknecht, G.: Roentgen diagnosis of the stomach. Arch. Roent. Ray, 1911, 
 xiv, p. 206. 
 
 Holzknecht, G.: Der normale Magen nach Form, Lage und Grosse, Mitt. a. d. 
 Lab. f. Rad. Diag., 1906, i, p. 72. 
 
 Holzknecht, G.: Die normal Peristaltik des Colon, Miinchen. med. Wchnschr., 
 1909, ha, part 2, p. 2401; Arch. Roent. Ray, 1909-10, xiv, p. 273. 
 
 Holzknecht, G.: See p. 2. 
 
 Holzknecht, G., and Luger, A.: Zur Pathologic u. Diagnostik des Gastrospasmus, 
 Mitt, a, d. Grenz. der Med. u. Chir., 1913, xx^-i, p. 669. 
 
190 GASTRO-INTESTINAL TRACT 
 
 Holzknecht, G., and Sgalitzer, M.: Papaverin zur roentgenologischen Differential- 
 diagnose z-ndschen Pylorospasmus und Pylorusstenose, Mimchen. med. Wchnschr., 
 1913, Ix, p. 1989. 
 
 Ringer G., and Holzknecht, G.: Radiologische Anhaltspunkte zur Diagnose der 
 chronischen Appendizitis, Miinchen. med. Wchnschr., 1913, ii, p. 26.59. 
 
 Hertz, A. F. : Constipation and allied disorders, London, 1909. 
 
 Hertz, A. F.: Chronic intestinal stasis, British Med. .Jour., 1913, i, p. 817. 
 
 Hertz, A. F. : AT-ray diagnosis of gastro-intestinal conditions, with special refer- 
 ence to appendicitis, Arch. Roent. Ray, 1914, xix, p. 249. 
 
 Case' J. T.: Stereoroentgenography of the alimentary canal, 4 parts, Troj', New 
 York, 1914-15. 
 
 Codman, E. A.: Diagnosis of diseases of the stomach and intestines by the x-ray, 
 British Med. Surg. Jour., 1912, clx^-i, p. 155. 
 
 Leonard, C. L.: Radiography of the stomach ajid intestines, Am. Jour. Roent., 
 1913, i, p. 5. 
 
 Beclere (Paris) : Les Rayons de Roentgen et le diagnostic des affections thora- 
 ciques, Paris. 
 
 Beclere: Rapport sur I'exploration radiologique dans les affections chlrurgicales 
 do I'estomac et de I'intestin, Tr. Assn. Frangaise de Chir, October, 1912. 
 
 Holzknecht, G.: Das norniale roentgenologische Verhalten des Duodenum, 
 Zentralbl. f. Physiol, 1909, xxiii, p. 974. 
 
 Case, J. T.: Roentgenologic aspects of intestinal stasis, Med. Clinics, Chicago, 
 1915-16, i, p. 829. 
 
 Keith, A.: Interpretation of certain a--ray signs of intestinal stasis, Proc. Roy. 
 Soc. Med., Electrotherapeutic Section, 1915. 
 
 Hertz, A. F.: Ileocecal sphincter, Jour. Physiol., 1913-14, xlvii, p. 54. 
 
 Hertz, A. F., and Ne'v\i;on, A.: Normal movements of the colon, Jour. Physiol., 
 1913-14, xlvii, p. 57. 
 
 Barrett, G. M.: Linitis plastica. Jour. Am. Med. Assn., 1916, Ixvii, p. 276. 
 
 Cole, L. G.: The diagnosis of post-pyloric (duodenal) ulcer by means of serial 
 radiography. Lancet, 1914, R. 44, p. 1239. 
 
 Imboden, H. M.: Roentgen diagnosis of lesions of the vermiform appendix. 
 Am. Jour. Roent., 1915, ii, pp. 581-91. 
 
 Pf abler, G. E. : The Roentgen ray in the diagnosis of gall-stones and cholecystitis. 
 Jour. Am. Med. Assn., 1914, cxiii, pp. 304-6. 
 
 Barclay, A. E.: The stomach and esophagus, Macmillan Company, New York. 
 
 Caldwell, E. W. : The safe interpretation of roentgenograms of the gall-bladder 
 region. Am. Jour. Roent., 1915, ii, pp. 816-819. 
 
 Schwarz, G.: Roentgen shadow, with chronic gastritis, Wien. klin. "Wchnschr., 
 1916, xxix, p. 1554. 
 
 McMahon, F. B., and Russell, D. C: Chronic colitis and its roentgenologic 
 findings. Jour. Lab. and Clin. Med., ii, p. 328. 
 
 Basch, Seymour: Diverticulum of the duodenum. Am. Jour. Med. Sc, 1917, 
 clxxx, p. 83.3. 
 
 Geis: Acute tuberculosis of the stomach, Long Island Med. Jour., 1916, p. 84. 
 
 Sailer, J.: Linitis plastica, Am. Jour. Med. Sc, 1916, cli, p. 321. 
 
 Le Wald: Pyloric stenosis. Am. Jour. Obst., 1916, p. 1162. 
 
 Baetjer, F. H., and Friedenwald: Roentgen ray in gastric cancer, Johns Hopkins 
 Hosp. Bull., 1916, xx^-ii, p. 221. 
 
 Kerley, C. G., and Le "Wald, L. T.: Digestive disorders in children. Jour. Am. Med. 
 Assn., 1916, IxAdi, p. 1569. 
 
 Homans, J.: Congenital transduodenal bands, British Med. Surg. Jour., 1916, 
 clxxv, p. 665. 
 
 White, F. W.: Syphilis of the stomach, British Med. Surg. Jour., 1917, clxx\'i, p. 11. 
 
 Eusterman, G. B.: Sj'philis of the stomach. Am. Jour. Med. Sc, 1917, cliii, p. 21. 
 
 Smithies, F.: -SjTjhilis of the stomach. Am. Jour. Syph., 1917, i, p. 100. 
 
 Cadwallader, R.: Hirschpi-ung's disease. Arch. Ped., 1916, xxxiii, p. 665. 
 
 Basch: Primary benign gro\si;hs in the stomach, Tr. Am. Gast.-Intest. Assn., 
 1915, xviii, p. 37. 
 
 Stewart, W. H.: The value of the roentgen examination in obstruction of the 
 esophagus. Arch, of Diag., 1913, ^ri, pp. 309-314. 
 
 Mills, R. Walter: "The Relation of Bodily Habitus to Visceral Form, Position, 
 Tonus and Motility." Amer. Jour. Roent,, April, 1917. 
 
CHAPTER IX. 
 GEXITO-URIXARY TRACT. 
 
 Preparation of the Patient. — The preliminary preparation of the 
 patient is a matter of opinion. If it is thought advisable, a vege- 
 table cathartic or oil should always be recommended. Mineral 
 salts and enemata are particularly to be avoided, the former because 
 of their tendency to fill the intestine with fluid and the latter because 
 they are seldom entirely expelled and air is usually introduced along 
 with them. Fluid or air in the intestine may entirely obscure the 
 kidneys and cause a confusing shadow. Excellent plates may often 
 be obtained with no preparation. 
 
 Technic. — Examinations should always include both kidneys, the 
 course of the ureters and the bladder. Suspicious shadows and most 
 positive findings should be checked up with a second examination 
 on another day. This work requires plates of the best technical 
 quality. Any evidence of respiration or other motion on a roent- 
 genogram should cause its rejection. Plates of the bladder area 
 should be made in both anteroposterior and postero-anterior posi- 
 tions. The ideal plate should be of moderate density, thin rather 
 than over-exposed and, as Leonard pointed out long ago, should 
 show clearly the last two ribs, the transverse processes of the 
 vertebrae and the margin of the psoas. 
 
 THE KIDNEYS. 
 
 The normal kidney is of the familiar form, in length approximately 
 equal to three vertebral bodies — the twelfth thoracic and first and 
 second lumbar — and of smooth, regular contour. The right lies 
 1 to 2 cm. lower than the left, and is less frequentl}' seen. "S'isibility 
 depends upon the amount of fat around it. Kidneys are not particu- 
 larly movable in the normal individual. At the most they will 
 drop not over 1 cm. in the change from the supine to the standing 
 position. In young children they are lower than in adults. The}' 
 lie close to the margin of the psoas and are crossed by the shadows 
 of the last two ribs. 
 
192 
 
 GENITO-URINARY TRACT 
 
 Changes in size of the kidneys are not diagnostic. The shadow 
 may have been distorted or enlarged by the size of patient or posi- 
 tion of tube; or a kidney may be hypertrophied as a result of disease 
 in its fellow, while on the other hand, the shadow may be of normal 
 size but the kidney be badly damaged. 
 
 Changes in shape are due to tumors, cysts, or infections and 
 anatomical variations. They may be found in the pelvis, they may 
 fuse across the vertebrae, there may be only one kidney present 
 and an additional ureter may be attached to a kidney. 
 
 Fig. 167. — Position and outline of normal kidneys, v/ith the patient standing. 
 
 Changes in density will be found extremely luireliable in diag- 
 nosis. While it is true that in rare eases tuberculosis of the kidney 
 may be suspected from the presence of a mottled shadow of increased 
 density, in general, mottling will be found to be due to intestinal 
 contents. The principal value of the roentgen examination lies 
 in the detection of stone. In good hands, probably SO to 90 per 
 cent, of all kidney and ureteral (not bladder) stones will show. 
 Their visibility depends upon the technic, preparation and size of 
 patient and the composition and size of the stone. The first two 
 
THE KIDNEYS 
 
 193 
 
 factors may be controlled by repeated examinations and in regard 
 to the last point, the order of visibility is as follows: phosphates 
 and cystine very dense, oxalates next and urates last, which have 
 little if any greater density than that of the soft tissues. Stones 
 which lie in large inflamed kidneys may be so obscured by the 
 general density about them that they are not visible. Furthermore, 
 the shadow of a stone may overlie a rib or transverse process and 
 
 Fig. U 
 
 -Tuberculosis of the kidney. The shadow of the enlarged kidney can be 
 indistinctly seen. There is a small stone in the upper calix. 
 
 be overlooked. It sometimes happens that a stone previously 
 invisible will receive a coating of thorium during pyelography and 
 become evident. They usually occur in the region of the pelvis 
 and lower calices.. They may be round, although they are usually 
 irregular and sometimes assume the form of a cast of the pelvis in 
 which they are located. It must not be forgotten that a single 
 shadow may represent multiple stones. Discrete shadows scattered 
 through the periphery of the kidney shadow suggest a kidney dis- 
 13 
 
194 
 
 GEN I TO-URINARY TRACT 
 
 Fig. 169. — Large branching calculi in both kidneys. 
 
 Fig. 170. — Unusual type.s of kidney stones. The faceted atones in the right suggest 
 gall-stones, but the position and -nide curve of the catheter prove they are in the 
 kidney pelvis. 
 
THE KIDXEYS 195 
 
 tended by back pressure with stones separated by fluid. Large 
 dendritic stones mean that the kidney has suffered severely. 
 
 Shadows which may be confused with stones are: (1) those due 
 to material in the bowel, fecal masses, fruit pits, enteroliths, opaque 
 salts, such as bismuth and barium (particularly residues in diver- 
 ticulse of the colon), Blaud's pills, salol capsules. The appendix 
 often lies in close relation to the right ureter and foreign bodies 
 or enteroliths within it may be mistaken for ureteral calculi. (2) 
 Gall-stones which can usually be differentiated by their structure 
 and shifting position with reference to the kidney area on plates 
 taken in the anteroposterior and postero-anterior diameters. (3) 
 Calcified glands which have a spongy appearance usuallv sufficient 
 to identify them. They occur along the course of the root of the 
 mesentery, in a line from the left kidne}" to the anterior right sacro- 
 iliac, and in the neighborhood of the iliac vessels, differentiated by 
 shifting position. (4) Tuberculous foci in the kidneys may calcify 
 and give shadows resembling those of stone. (5) Calcification in 
 carcinomatous masses in the pancreas or glands may be a rare cause 
 of confusion. (6) The tip of a transverse process may be so much 
 more dense than the rest of it that it may suggest a stone. (7) 
 Small areas of density in the spleen may overlie the upper portion 
 of the kidney. (8) Calcification in a blood clot or about a foreign 
 body may simulate a stone if it overlies the kidncA'. (9) Mention 
 must also be made of the shadows cast by fibromata, scars and even 
 dressings on the back which may be recorded on the plate as areas 
 of increased density. (10) Artefacts in plates due to thin spots m 
 the emulsion or small areas which are unequally dcA'eloped may be 
 a source of confusion. 
 
 Pyelography. — Pyelography is not a procedure to be undertaken 
 without due consideration and caution. SeA'ere reactions cannot be 
 entirely avoided although a careful technic will do much to prevent 
 them. The most important single precaution to be obserA'ed is to 
 allow the solution to flow in very slowly under a slight gravity 
 pressure and to stop as soon as the patient complains of pain in 
 the kidney. Perhaps the best medium to use is a 15 per cent. 
 thorium solution, as it is cleaner, more fluid and less toxic than the 
 silver salts. 
 
 The outline of the kidney pelvis as obtained by this method 
 varies greatly. The normal pelvis is somewhat lily-shaped with 
 the ureter corresponding to the stem. The pelvis presents a more 
 or less rounded border, into which the ureter blends on the inner 
 
196 
 
 GEN I TO-URINARY TRACT 
 
 Fig. 171. — Large stone in the urinary bladder. 
 
 Fig. 172. — Injected kidney pelvices. The abnormal shape is due to anatomical 
 
 variation. 
 
THE KIDNEYS 197 
 
 margin. Arising from its outer edge are a variable number of pro- 
 cesses projecting into the kidney substance (the major calices) from 
 the tips of which arise small further projections called minor calices, 
 (with cupping between). The pelvis may be more or less globular 
 or consist entirely of two or more branches. The errors which must 
 be guarded against are incomplete filling of the pelvis, usually due 
 to spasm of the ureter or pelvis brought on by too rapid disten- 
 tion, compression from neighboring organs, extrarenal tumors and 
 rotation of the kidnev. 
 
 Fig. 173. — Hydronephrosis, demonstrated by injection with thorium. 
 
 Anomalies. — Aberrant positions of the kidneys and multiple 
 ureters are perhaps best brought out by this method which is more 
 accurate than plain roentgenology with or without opaque catheter. 
 
 Hydronephrosis. — Hydronephrosis shows all degrees of change 
 from blunting of the minor calices to the formation of a large sac, 
 depending upon the site of the obstruction and the length of its 
 existence. With obstruction near the kidney the characteristic 
 early change is blunting of the minor calices. With obstruction 
 near the bladder, on the other hand, dilatation of the pelvis and a 
 certain amount of rounding of its outline is the characteristic find- 
 
198 
 
 GEN I TO-URINARY TRACT 
 
 ing. In the later stages of the process both major and minor calices 
 may disappear and the thorium collect in a pool in the sac with 
 remains of the kidney. The discovery of a stone in the ureter is 
 confirmatory evidence of the process in the pelvis. 
 
 In inflammatory conditions the chief change is in the major 
 calices which are apt to have irregular, moth-eaten edges and to be 
 increased in length and width. In the later stages they may show 
 rounded dilatations at their extremities. The form of the pelvis 
 varies according to the amount of destruction of the kidney sub- 
 stance and the amount of distention of the pelvis. 
 
 Fig. 174. — The injected pelvis of an infected kidney. 
 
 Tuberculosis. — The characteristic change here is lengthening of 
 the major calices with pronounced bulbous dilatation at the tips 
 and the occurrence of rounded masses of thorium in the cortex, 
 representing cavities communicating with the pelvis. Stricture of 
 the ureter may prohibit the filling of the kidney pelvis. 
 
 Growths. — Extrarenal and parenchymal tumors may cause 
 deformities in the pelvis and calices which are similar in all respects. 
 It is not always possible in the presence of a distorted pelvis showing 
 an irregular loss of calices to say whether it is due to incomplete 
 
URETERS 199 
 
 filling, extrarenal tumor or a growth in the cortex. The amount of 
 deformity produced in the pelvis depends upon the size and loca- 
 tion of the tumor. A very characteristic picture is the irregular 
 prolonged extension of one or more calices to a considerable distance 
 beyond the usual limits in a normal kidney. When the whole 
 kidney is involved, the pelvis may be reduced to a small mass with 
 irregular strands of thorium stretching out from it in a spider-like 
 pattern. Polycystic kidneys produce a somewhat similar picture 
 as well as enlargement of the kidney outline, but here the defects 
 in the pelvic shadow are not so irregular and their margins show the 
 rounded indentations of the neighboring cysts. Furthermore, the 
 process here is usually bilateral. The ureter is long and curves over 
 the enlarged lower pole of the kidney which may extend far enough 
 inward to throw the shadow of the ureter over the spine. 
 
 Papillomata. — Papillomata in the pelvis may produce round holes 
 in the thorium shadow. Stones in the pelvis or calices produce an 
 intensification of thorium shadow at that point. 
 
 URETERS. 
 
 The course and condition of the ureters may be very well out- 
 lined provided they can be kept filled with thorium during exposure. 
 This may be a somewhat difficult matter in the normal ureter if the 
 catheter is too small to occlude the lower end. Injection has these 
 advantages over the use of radiographic catheters: the ureter lies 
 in its true course and does not conform to that of the rather rigid 
 catheter, and changes in diameter and irregularities in outline are 
 well brought out. Apparent kinking due to the angulation in the 
 ureter produced at the tip of the catheter does not occur, whereas 
 true kinks are readily recognizable. Abnormalities are fairly 
 common, as has already been mentioned, consisting of multiple 
 ureters. Irregularities in outline are usually the result of infection, 
 most commonly of tuberculous origin which usually appears first 
 in the lower portions of its course. Dilatations may be true diver- 
 tlculse which contain stones or the enlargement above an obstruc- 
 tion as a result of pressure from tumors or adhesions, the latter 
 being particularly common following infections of the vas deferens 
 in the male and pelvic cellulitis in the female. 
 
 The course of the ureter is downward across the transverse pro- 
 cesses of the lumbar vertebrae and sacro-iliac joints to the pelvis, then 
 curving inward and forward toward the bladder. There are four 
 
Fig. 175. 
 
 -Small stone in the lower end of the ureter. Its transverse position shows 
 that it is near the mouth of the ureter. 
 
 Fig. 176. — A calcified mesenteric gland suggesting a stone in the ureter. 
 
Fig. 
 
 177. — The same cvTse as Fig. 176. The radiofiraphic fathetcr demonstrates that 
 the shadow is well outside the course of the ureter. 
 
 Fig. 178. 
 
 -Large stone in dilated ureter. The catheter is obstructed, 
 ureter is made visible by the injection of thorium. 
 
 The dilated 
 
202 GENITO-URINARY TRACT 
 
 points of narrowing where stones are prone to lodge: (1) the uretero- 
 pelvic junction, (2) where they cross the ihac vessels, (3) just out- 
 side the bladder, (4) the papilla within the bladder. Stones w^ill 
 be found most commonly at (1) and (3). They are easily over- 
 looked when lodged near the iliac vessels, because their shadow is 
 projected on to that of the sacrum. They may be projected b}^ 
 an increased tilt of the tube. The shadows of ureteral calculi are 
 oval or enlongated and are irregular in outline and density. Their 
 long axis lies in the direction of the course of the ureter. Shadows 
 which may be confused with them, in addition to those enumerated 
 before, are h^'pertrophic changes upon the vertebrae or pelvic bones, 
 arteriosclerosis of the pelvic arteries, calcified fibroids, calcified 
 ovaries, dermoid cysts and phleboliths. Phleboliths are small, cir- 
 cular or oval, sharply outlined calcifications usually multiple, which 
 occur in the pelvis in the region of the ischial tuberosities. They 
 are calcified thrombi on the distal side of the valves ia the plexus 
 of veins in the pelvic cellular tissue about the bladder and rectum. 
 They are very common and are constantly being mistakea for 
 ureteral calculi. The distinguishing characteristics of a calculus are 
 that it is not so sharply outlined, that it is more apt to be oval 
 than round, and that it lies in the course of the ureter which passes 
 above and internal to the area where phleboliths lie. Furthermore, 
 phleboliths seldom occur singh'. 
 
 In case of doubt the patient should be examined with an opaque 
 catheter in the ureter, preferably stereoscopically, in order to deter- 
 mine the presence or absence of obstruction as well as the relation 
 of the suspected shadow to the ureter. 
 
 BLADDER. 
 
 The outline of the partially filled bladder may be made out in 
 many pelvic plates but may be readily visualized by filling it with 
 air or dilute thorium. Stones in the bladder are occasionally not 
 visible because a large percentage of them are urates. Important 
 characteristics of bladder stones are that they are of fairly large 
 size, are oval, and lie with their long axis transversely in the pelvis. 
 
 The bladder may be outlined by thorium (us'ually 10 per cent.) 
 or by air. Large diverticulse are usually well brought out by 
 moderate distention with thorium. They appear as knobs on either 
 side or behind the main shadow and may be larger than the bladder 
 itself. Trabeculation of the bladder wall is sometimes suggested 
 by irregularity of the outline, particularly along the sides. In some 
 
BLADDER 
 
 203 
 
 Fig. 179.- 
 
 -Diverticulum of the bladder, demonstrated by fillinc 
 collargol. 
 
 the bladder with 
 
 Fig. ISO. 
 
 -Diverticulum of the bladder, demonstrated by means of the radiographic 
 catheter. 
 
204 
 
 GEN I TO-URINARY TRACT 
 
 cases, particularly of tuberculosis, distention of the bladder may 
 cause the solution to run up a dilated, irregular ureter and visualize 
 it and the kidney pelvis when catheterization is impossible. In 
 children where it is difficult to catheterize the ureters, they may 
 sometimes be similarly filled by distention of the bladder in cases 
 of obstruction at the neck of the bladder due to congenital valves 
 in the region of the verumontanum. Congenital anomalies are 
 sometimes encountered, such as hour-glass bladder and patent 
 urachus which gives a thin line of solution extending upward toward 
 .the umbilicus. 
 
 Fig. 181. — Papillomatous tumor of the bladder, on which there is a deposit of 
 
 calcium. 
 
 Tumors may be extensive enough to produce defects in the 
 thorium shadow, although it is unusual. A better method for their 
 demonstration, which is equally useful in the case of stone, is to 
 inflate the bladder with air and secure stereoscopic plates. Hyper- 
 trophied prostates may be well outlined by inflating both the bladder 
 and the rectum with air. 
 
REFERENCES 205 
 
 MALE GENITALS. 
 
 Small multiple calculi occur in the prostate and may be mistaken 
 for urinary concretions. The vas deferens and seminal vesicles, 
 when injected with silver solution, show a certain amount of dis- 
 tortion as a result of vesiculitis. This procedure will probably 
 never come into extensive use. 
 
 FEMALE GENITALS. 
 
 Calcification is often seen in fibroids in the form of round, irregu- 
 larly calcified masses, often multiple and occupying any portion 
 of the pelvis. In rare cases the ovaries may be calcified. They are 
 oval, flattened, spongy masses suggesting glands lying internal to 
 and above the ischium. They may be mistaken for ureteral stones. 
 Attempts have been made to inject the uterus and tubes with opaque 
 solution but the technic is still undeveloped. 
 
 REFERENCES. 
 
 Cabot, Hugh: Modern Urology, Philadelphia. 
 
 Beer, E. : Relative values of the roentgen rays and the cystoscope in the diagnosis 
 of vesical calculi, Jour. Am. Med. Assn., 1913, Ixi, p. 1376. 
 
 Braasch: Jour. Am. Med. Assn., October 9, 1915. 
 
 Cabot, Hugh: Jour. Am. Med. Assn., 191.5, Ixv, p. 1233. 
 
 Holland: XVIIth International Congress of Medicine, London, 1913, Section 22, 
 Radiologic P- ii> PP- 87-100. 
 
 Keen, Pfahler and Ellis: Jour. Am. Med. Assn., 1914, viii, p. 1047. 
 
 Dodd, W. J.: Roentgenologj^ of the urinary tract. Modern Urology, Philadelphia. 
 
 Braasch, W. I.: Pyelography, W. B. Saunders Company, Philadelphia, 1915. 
 
 Hyman, A., and Jaches, L.: The roentgenographic diagnosis of pro.static enlarge- 
 ment bj' means of air inflation of the bladder, Surg., Gvnec. and Obst., 1914, xix, 
 p. 407, 
 
INDEX. 
 
 Abnormal fusing malformations, 32 
 Abnormality of heart, congenital, 124 
 
 in outline of vertebrae, 36 
 Abscess, ah'eolar, 91 
 
 bones, 52 
 
 of lung, 141 
 
 mediastinal, 128 
 
 perivertebral, 128 
 
 subdiaphragmatic, 131 
 Absence of long bones, partial or com- 
 plete, 20 
 Achondroplasia, 78 
 Acromegaly, 75 
 Actinomycosis of the bone, 62 
 
 of lung, 149 
 Adhesions, duodenal, 181 
 
 perigastric, 163 
 
 of pleura, 135 
 Alveolar abscess, 91 
 Aneurysm, 125 
 Anomalies of bones, 29 
 
 of dentition, 90 
 
 of genito-urinary tract, congenital, 
 197 
 
 of kidnev, 197 
 
 of ribs, 28 
 Anthracosis, 149 
 Antispasmodics, gastric, 161 
 Aorta, diffuse dilatation of, 125 
 Aortic cUsease, 124 
 Aortitis, specific, 125 
 Appendix, normal, 182 
 
 pathological, 182 
 Arch, dilatation of, 124 
 Arthritis, atrophic, 99 
 
 gonorrheal, 101 
 
 hypertrophic, 97 
 
 pyogenic, 100 
 
 villous, 104 
 Atomic colon, 185 
 Atrophic arthritis, 99 
 Auricular fibrillation, 124 
 
 BARirM meal for examination of gastro- 
 intestinal tract, 152 
 
 Bladder, diverticute of, 202 
 
 outline of, 202 
 
 stones, characteristics of, 202 
 Bone abscess, non- virulent, 52 
 
 virulent or fulminating type, 
 52 
 
 blisters in sj-phihs, 58 
 
 cysts, 63 
 
 changes in density of, 50 
 in outhne of, 50 
 in phosphorus poisoning, 62 
 
 diffuse density of, 50 
 
 diminution in size of, 50 
 
 disease of, 50 
 
 gumma of, destruction due to, 59 
 
 leprosy in, 62 
 
 normal, 50 
 
 oidiomycosis of, 62 
 
 signs of pathological process in, 34 
 
 spong}^, areas of increased density 
 in, 23 
 texture of, 50 
 
 spotted density of, 50 
 
 syphihs of, 57, 59, 104 
 congenital, 59 
 
 tuberculosis of, 101 
 
 tumors of, rarer, 71 
 
 typhoid in, 61 
 Bones, anomalies of, 29 
 
 detached, 29 
 
 diminution in size of, 50 
 
 fusion of, 30 
 
 margins of, rovighening of, 20 
 
 size of, increase in, 50 
 
 supernumerary, 30 
 Brain tumor, 84 
 
 Bronchial glands, calcification of, 21 
 Bronchiectasis, 142 
 Bronchitis, 141 
 Bronchopneumonia, 140 
 Bronchostenosis, 143 
 Bursae, calcification of, 109 
 
 Calcification of bronchial glands 21 
 of bursae, 109 
 of costal cartilage, 20 
 of larynx, 20 
 
208 
 
 INDEX 
 
 Calcification of mesenteric glands, 21 
 of ovaries, 205 
 of pineal glands, 86 
 syphilitic, 58 
 Calcifications, 20 
 Carcinoma of cardia, 168 
 metastatic, 70 
 of pylorus, 171 
 of skull, 69 
 of spine, 69 
 
 of stomach, characteristic findings 
 in, 70 
 Carcinomatous ulcers of s'tomach, 170 
 Cardia, carcinoma of, 168 
 Caries sicca, 56 
 Carpal centers, time of appearance of, 
 
 32 
 Cecum, change in outline of, 185 
 
 normal, 182 
 Chahcosis, 149 
 Charcot joints, 97 
 
 Chest, glands of, enlargement of, 111 
 technic in examination of, 120 
 time of exposure for examination 
 
 of, 121 
 tumors of, 112 
 Chondrodystrophy fetalis, 78 
 CoUes' fracture, 39 
 Colon, atonic, 185 
 
 change in motility of, 185 
 in outline of, 185 
 in position of, 185 
 in size of, 185 
 examination of, barum enema in, 
 
 184 
 normal, 183 
 spastic, 185 
 
 method of examination by barium 
 enema, 184 
 Congenital abnormality of heart, 124 
 anomahes of genito-urinarv tract, 
 
 197 
 dislocations of hip, 48 
 elevation of scapula, 29 
 syphilis of bone, 59 
 Costal cartilage, calcification of, 20 
 Cyst of lung, echinococcus, 147 
 Cysts, bone, 63 
 dermoid, 114 
 
 Dactylitis (spina ventosa), 56 
 
 (syphihtic), 57 
 Defective plates, errors due to, 25 
 Defects in outline of rectum, 186 
 Delayed union, 32 
 Dentition, anomalies of, 90 
 
 table (Thoma), 90 
 Dermoid_cysts, 114 
 
 Diaphragm, changes in mobility of, 129 
 in outline of, 129 
 in position of, 130 
 
 normal, 129 
 Dilatation of ileum, 182 
 Dislocations, before and after reduc- 
 tion, 49 
 
 of first cervical vertebra, 45 
 
 of hip, congenital, 48 
 Displacement of sacro-iliac joint, 47 
 
 of semilunar cartilage in carpus, 47 
 
 of upper cervical vertebrte, 45 
 Diverticulse of bladder, 202 
 Duodenal adhesions, 181 
 
 diverticulse, 181 
 
 scars, 180 
 
 spasm, 180 
 
 ulcer, 180 
 Duodenum, defects in outline of, 180 
 
 irregularities in outline of, 180 
 
 normal, 180 
 Dysplasia, periosteal, 78 
 
 E 
 
 Echinococcus cyst of lung, 147 
 Elevation of scapula, congenital, 29 
 Emphysema, 111 
 Empyema, 132 
 Encapsulated fluid, 133 
 Enchondromata, 62 
 Epiphyseal ossification, 31 
 
 separations, 47 
 Epiphyses, tuberculosis of, 53 
 Esophagus, change in position of, 154 
 
 dilatation of, 128 
 
 diverticulse in, 158 
 
 examination of, 152 
 
 pathological, 153 
 Extragastric defects, 163 
 Extrarenal tumors, 198 
 
 Failure of union, 32 
 Fibromata of skin, 24 
 Fluoroscopic examination of heart and 
 great vessels, 118 
 of gastro-intestinal tract, 151 
 of hmg, 131 
 Foreign bodies in lung, 142 
 
 examination for, 142 
 in stomach, 173 
 Fracture, CoUes', 39 
 
 lines, obliteration of, 34 
 Pott's, 42 
 Fractures, classification of, 37 
 
 lines mistaken for (nutrient artery), 
 19 
 
INDEX 
 
 209 
 
 Fractures of skull, 35 
 
 of teeth, importance of roentgen 
 examination in, 91 
 Fragilitas ossium, 78 
 Functional spasms (gastric), 161 
 Fusion of bones, 30 
 
 G 
 
 Gall-bladder, examination of, posi- 
 tion for, 186 
 pathology of, 188 
 position for examination of, 186 
 Gall-stones, detection of, 187 
 Gangrene of lung, 143 
 Gas in intestinal tract, 25 
 Gastric antispasmodics, 161 
 
 outline, significance of irregulari- 
 ties of, 162 
 peristalsis, changes in, 164 
 
 normal, 158 
 spasm, 160 
 Tllcer, 172 
 wall, polypi of, 178 
 Gastro-intestinal tract, examination of, 
 method of, 151 
 position for, 151 
 fluoroscopic examination of, 
 
 151 
 syphihs of, radiographic ap- 
 pearance of, 176 
 ulcers of, penetrating, 176 
 perforating, 176 
 Gastrojejunal ulcers, 181 
 Genito-urinary tract, anomalies of, 
 congenital, 197 
 examination of, preparation 
 
 of patient for. 191 
 phlebohths in, 202 
 technic in examination of, 191 
 tumors in, method of demon- 
 strating, 204 
 Glands of chest, enlargement of. 111 
 Gonorrheal arthritis, 101 
 Gout, 97 
 Great vessels, examination of, 114 
 
 normal, 123 
 Gumma of bone, destruction due to, 59 
 
 Heart, abnormahty of, congenital, 124 
 block, 124 
 dilatation of, 124 
 examination of, 114 
 fluoroscopic examination of, 118 
 measurements of normal (Claytor 
 
 and Merrill), 126 
 normal, 123 
 
 14 
 
 Heart, normal, measurements of (Clay- 
 tor and Merrill), 126 
 
 valves, diseases of, 124 
 Hemophilia, 106 
 Hemorrhages, subdural, 85 
 Hip, dislocations of, congenital, 48 
 
 fractures, failure of union in, 45 
 Hydrocephalus, 83 
 Hydronephrosis, 197 
 Hypernephroma, 72 
 Hypertrophic arthritis, 97 
 Hypertrophy of prostate, 204 
 
 Ileum, dilatation of, 182 
 
 normal, 181 
 Impacted teeth, 90 
 Intestinal tract, gas in, 25 
 
 Jaw, osteomyelitis of, phosph<:>rus 
 
 poisoning and, 95 
 Jejunum, normal, 181 
 
 pathological, 183 
 Joint lesions, symmetrical, 60 
 unilateral, 60 
 
 sacro-ihac, displacement of, 47 
 Joints, Charcot, 97 
 
 tuberculosis of, 53 
 Juxta-epiphyseal lesion in syphilis, 60 
 
 Kidney, anomalies of, 197 
 change in density of, 192 
 in shape of, 192 
 in size of, 192 
 normal, 191 
 pelvis, outline of, 195 
 
 of papillomata in, 199 
 tuberculosis of, 198 
 Kidneys, polycystic, 199 
 
 Larynx, calcification of, 20 
 
 Leprosy in bone, 62 
 
 Linitis plastica, 177 
 
 Lipomata, 114 
 
 Lobar pneumonia, 139 
 
 Lumbar curve, exaggerated, 28 
 
 Lumbosacral junction, articulation at, 
 
 variations in, 28 
 Lung, abscess of, 141 
 
 fields, examination of position for, 
 131 
 
210 
 
 INDEX 
 
 Lung fields, position for examination 
 of, 131 
 fluoroscopic examination of, 131 
 foreign bodies in, 142 
 
 examination for, 142 
 gangrene of, 143 
 metastatic malignancy of, 145 
 normal, 132 
 
 pathological changes in, 132 
 primary malignancy of, 144 
 syphilis of, 143 
 tuberculosis of, 135 
 miliary of, 138 • 
 
 M 
 
 Mastoids, 90 
 Mediastinal abscess,'_128 
 
 masses, 111 
 
 tumors, 125 
 Mesenteric glands, calcification of, 21 
 Metastatic carcinoma, 70 
 Mucoceles, 89 
 
 Multiple cartilaginous exostoses, 63 
 Myeloma, 72 
 Myxoma, 73 
 
 N 
 
 Nutrient artery, 19 
 
 Odontoma, 95 
 
 Oidiomycosis of bone, 62 
 
 Orthodiagraphy, 116 
 
 Os calcis, separation and delayed union 
 
 in epiphysis of, 48 
 Ossification center of tibial tubercle, 
 
 delayed union of, 48 
 Osteitis deformans, 65 
 
 fibrosa, 63 
 Osteochondritis deformans (Perthe's 
 disease), 106 
 
 desiccans, 106 
 Osteogenesis imperfecta, 78 
 Osteomalacia, 79 
 Osteomata, 62 
 Osteomyelitis, characteristics of, 51 
 
 of jaw, due to phosphorus poison- 
 ing, 95 
 Osteopsathyrosis, 78 
 Osteosarcomata, 67 
 Ovaries, calcification of, 205 
 Oxycephalus, 84 
 
 Facet's disease (osteitis deformans), 
 65 
 
 Papillomata in kidney pelvis, 199 
 Parenchymal tumors, 198 
 Pericarditis, adherent, 124 
 
 with effusion, 124 
 Perigastric adhesions, 163 
 Periosteal dysplasia, 78 
 
 sarcoma, 68 
 Periostitis, syphilitic, 57 
 Peristalsis, changes in gastric, 164 
 
 normal gastric, 158 
 Perivertebral abscess, 128 
 Perthe's disease, 106 
 Phleboliths, 22 
 
 in genito-ui'inary tract, 202 
 Phosphorus poisoning, change of bone 
 in, 62 
 osteomyelitis of jaw and, 95 
 Pineal glands, calcification of, 86 
 Plates of symmetrical parts, importance 
 
 of, 48 
 Pleura, adhesions of, 135 
 
 thickening of, 132 
 Pleural effusion, 130, 132 
 Pneumoconiosis, 149 
 Pneumonia, lobar, 139 
 
 unresolved, 141 
 Pneumothorax, 132, 133 
 Poisoning, phosphorus, change of bone 
 in, 62 
 osteomyelitis of jaw and, 95 
 Polycystic kidneys, 199 
 Polypi, 89 
 
 of gastric wall, 178 
 Pott's fracture, 42 
 Prostate, 205 
 
 Prostatic hypertrophy, 204 
 Pulmonary tuberculosis, 135 
 Pulp stones, 91 
 Pyelography, 195 
 Pylorus, carcinoma of, 171 
 Pyogenic arthritis, 100 
 Pyorrhea, 91 
 
 R 
 
 Rectum, defects in outline of, 186 
 
 normal, 186 
 
 ulceration of, 186 
 Renal calculus, detection of, 192 
 Ribs, anomalies of, 28 
 Rickets, 75 
 
 Roentgen anatomy, importance of, 33 
 Round-celled sarcoma, 67 
 
 Sacro-iliac joint, displacement of, 47 
 Salivary calcuh, 95 
 Sarcoma, periosteal, 68 
 
 round or spindle-celled (medul- 
 lary), 67 
 
m' 
 
 INDEX 
 
 211 
 
 Scapula, elevation of, congenital, 29 
 Scars, duodenal, 180 
 Scorbutus, 76 
 
 differential diagnosis in, 77 
 Sella turcica, 85 
 
 faulty technic in securing 
 
 views of, 86 
 importance of stereoscopic 
 views in examination of, 85 
 Semilunar cartilage, displacement of, 47 
 Seminal vesicles, 205 
 Shadows due to metallic salts, 25 
 
 in genito-urinary tract other than 
 renal calcuh, 195, 198 
 Sinuses, frontal, 86 
 
 position for examination of, 86 
 variations of, 89 
 Skin, fibromata of, 24 
 
 warts of, 24 
 Skull, carcinoma of, 69 
 
 fractures of, 37 
 Spasm, duodenal, 180 
 
 gastric, 160 
 Spindle-celled sarcoma, 67 
 Spine, carcinoma of, 69 
 
 syphiHs of, hypertrophic changes 
 
 in, 61 
 tuberculosis of, 55 
 Stomach after gastro-enterostomy, 179 
 carcinoma of, characteristic find- 
 ings in, 70 
 change in outhne of, 160 
 
 in position of, 160 
 examination of, position for, 156 
 foreign bodies in, 178 
 motility of, 168 
 normal, 156 
 pathological, 159 
 ulcers of, 169 
 
 carcinomatous, 169 
 Subdiaphragmatic abscess, 131 
 Subdural hemorrhages, 85 
 Supernumerary bones, 30 
 Synovitis, 109 
 
 Syphihs of bone, 57, 59, 104 
 congenital, 59 
 of gastro-intestinal tract, (radio- 
 graphic appearance), 176 
 juxta-epiphyseal lesion in, 60 
 of lung, 147 
 
 of spine,hypertrophic changes in,61 
 Syphihtic calcification, 58 
 dactylitis, 57 
 periostitis, 57 
 
 Teeth, 90 
 
 fractiires of, importance of roent- 
 gen examination in, 91 
 
 impacted, 90 
 
 unerupted, 90 
 Tele-roentgenology, 1 18 
 Teratomata, 112 
 Thickening of pleura, 132 
 Thoracic wall, pathological processes 
 
 in. 111 
 Thymus, enlarged. 111 
 
 normal. 111 
 Thyroid, interthoracic. 111 
 
 normal. 111 
 Tibial tubercle, separation of, 48 
 Tuberculosis of bone, 101 
 
 of joints and epiphyses, 53 
 
 of kidney, 198 
 
 of lungs, 135, 138 
 mihary, 138 
 
 of spine, 55 
 Tubes (female genitals), 205 
 Tumors of bone, rarer, 71 
 
 brain, 84 
 
 of chest, 112 
 
 extrarenal, 198 
 
 mediastinal, 112 
 
 parenchymal, 198 
 Typhoid in bone, 61 
 
 Ulcer, duodenal, 180 
 
 gastric, 172 
 Ulcers of gastro-intestinal tract, pene- 
 trating, 176 
 perforating, 176 
 gastro jejunal, 181 
 of stomach, 169 
 
 carcinomatous, 169 
 Unerupted teeth, 90 
 Unresolved pneumonia, 141 
 Ureteral calculus, distinguishing char- 
 acteristics of, 202 
 Ureters, course of, 199 
 dilatation of, 199 
 irregularity in outline of, 199 
 Uterus, 205 
 
 Vas deferens, 205 
 
 Vertebra, first cervical, dislocations of, 
 
 45 
 Vertebrae, upper cervical, displacement 
 
 of, 45 
 Vertebral bodies, extra, 26 
 Villous arthritis, 104 
 
 Table of dentition (Thoma), 90 
 
 of ossification centers, 30 
 Tabulation of findings in common bone 
 
 lesions for differential diagnosis, 80 ' Warts of skin, 24 
 
 W 
 

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