ANNALS OF ROENTGENOLOGY* VOL'II THE PATHOLOGICAL GALL-BLADDER ARIAL W. GEORGE, M.D. RALPH D. LEONARD. M.D. 6®®®®®®®®®®®®®®®®®®®e Presented by Francis Leix, D. 0. COLLEGE OF OSTEOPATHIC PHYSICIANS ^ I I I l b AND SURGEONS • LOS ANGELES, CALIFORNIA fa I THE PATHOLOGICAL GALL-BLADDER ANNALS OF ROENTGENOLOGY VOLUME TWO ANNALS OF ROENTGENOLOGY A SERIES OF MONOGRAPHIC ATLASES EDITED BY JAMES T. CASE, M. D. Ex- President of The American Roentgen Ray Society Volumes Published I. MASTOIDS— By Frederick M. Law, M. D., New York II. THE PATHOLOGICAL GALL-BLADDER— By Arial W. George, M.D., and Ralph D. Leonard, M.D., Boston Volumes in Preparation: III. DIGESTIVE DISTURBANCES IN INFANTS AND CHILDREN— By Charles G. Kerley, M. D., and Leon T. LeWald. M. D., N. Y. IV. SKULL FRACTURES— By William H. Stewart, M. D., N. Y. V. DIVERTICULA OF THE ALIMENTARY TRACT— By James T. Case, M. D., Battle Creek VI. NASAL ACCESSORY SINUSES— By Frederick M. Law, M. D„ N. Y. VII. BRAIN TUMORS— By Charles H. Frazier, M. D., and Henry K. Pancoast, M. D., Phila. VIII. THE URINARY TRACT— By Hugh H. Young, M. D., and Charles A. Waters, M. D., Baltimore Order of publication and volume numbers subject to change. Other volumes to be announced. PAUL B. HOEBER, Publisher 67-69 East 59TH Street New York City ANNALS OF ROENTGENOLOGY A SERIES OF MONOGRAPHIC ATLASES EDITED BY JAMES T. CASE, M.D. Ex-President of The American Roentgen Ray Society VOLUME TWO 4- THE PATHOLOGICAL GALL-BLADDER ROENTGENOLOGICALLY CONSIDERED BY Arial W. George, M.D. AND Ralph D. Leonard, M.D. •*• PAUL B. HOEBER 67-69 East Fifty-ninth Street NEW YORK ANNALS OF ROENT GENOLOGY . VOLUME TWO THE PATHOLOGICAL GALL-BLADDER ROENTGENOLOGIC ALLY CONSIDERED ONE HUNDRED AND THIRTY- FIVE ROENTGEN RAY STUDIES ON FORTY-FOUR FULL PAGE PLATES, THREE OF WHICH ARE PHOTOGRAPHIC AND TWO TEXT ILLUSTRATIONS BY ARIAL W. GEORGE, M.D. AND RALPH D. LEONARD, A. B., M.D. BOSTON, MASSACHUSETTS NEW YORK PAUL B. HOEBER 1922 ' Copyright, 1922 By PAUL B. HOEBER Published January', 1922 All Rights Reserved Printed in the United States of America DEDICATED TO DR. PERCY BROWN OUR FRIEND AND COLLEAGUE EDITOR'S Hvl I \< I IT is tnii much to expect thai any man can be a specialist in all ol the branches ol medicine in which roentgenology plays a useful part. True, one finds here and there an exception who, because oi a specially fortunate scries ol events and an unusually large clinical experience, is endowed with great usefulness as a roentgenologist w ith a broad view point ; hut t he average physician working with the roentgen rays, even il he restricts Ins practice to the use of this newer diagnostic and therapeutic arm, feels keenly his lack ol training and experience m main ol the branches ol medicine in which his roentgenologic aid is sought. Again and again in the presence of a case in one ol the less familiar lines, he will lind himself longing to make com- parison with roentgenograms ol some proven cast' ol a similar nature, won- dering what roentgenologic pitfalls he must avoid, lie ma\ recall having seen some similar case in a postgraduate course but his memorj of the plate details is too hazy lor reliance. The scope ol the roentgenologist's judgment is measured by the expe- rience he can kill hack upon. It is to supply a diagnostic guide rich in the fruit of experience of leading authorities in special fields of .v-ra\ that the Editor and the Publisher have conceived the production of this series ol monographic atlases, to bring to the roentgenologist at homea postgraduate course from the very men whom he would seek in personal \isit, and to leave with him an invaluable series ol master roentgenograms which he may Study and with which he may make comparisons as often as desired. Battli Creek, Michigan. JAMES I. CASE. i\ 22923 PREFACE IT was with a great deal ol trepidation thai we attempted to compile the materia] that is presented in this monograph, realizing the manj prob- lems involved in the study ol the pathological gall-bladder. But we felt by presenting, in our own way, the problems which have come to us in the [study of this subject, that perhaps it would become simpler for others who wish to take- up this work. The importance of the studj of the pathological gall-bladder l>\ the x-ray is so great that this alone must be our apology for offering these facts. All our colleagues who have attempted to carry on this work realize with us the difficulty in trying to reproduce photographically the more definite findings of the photographic plate or him, and we realize better perhaps than anyone that the plates that are reproduced in this monograph are not as excellent as they can be made, but represent the cases as we, with our facilities, were obliged to take them. One must keep constantly in mind that we are dealing frequently with almost negligible shadow values. We have come to expect even in the most definite cases, hardly discernible shadows on the x-ray plate or him, and when attempt is made to reproduce these, they are, in a good many instances, ol no value for this purpose. The writers have tried to approach the problem from every angle met with in their experience, giving as definitely as possible the ways and means by which they interpret the plates or films of t he upper right quadrant and classifying the many apparently simpler facts which have later become important in the diagnosis. Purposely, the writers have tried to choose for this monograph the dillicult plates ol gall-stones and ol the pathological xi PREFACE gall-bladder, trying to cover the problem in its most difficult aspect, rather than choosing the plates that show stones and the gall-bladder without a great deal of effort. It is the ambition of the writers that this monograph on the subject of the pathological gall-bladder will arouse interest in those who have not been interested, and renew the interest of those who have been discouraged by failures. If these facts which are set forth in the following pages accom- plish this, the writers will feel amply repaid for bringing this study before their colleagues. It is hoped that this work will be received in the same spirit in which it is offered by the writers, though they realize more than anyone can that it will fall far short of what they hoped for, and what necessarily the future must hold for this special study. To obtain the clinical material for carrying on this investigation would have been impossible without the help of our medical and surgical colleagues. It has been their untiring interest, in spite of our failures, in individual cases, and their readiness to grasp the possibilities of this study and not the least their appreciation of the need of such assistance that has made this work possible. The writers wish to express their appreciation of the help of these friends. To Dr. Leo Pariseau we must express our heartiest thanks for the French translation, and to Dr. I. Gonzalez Martinez, for the Spanish translation; and to Mr. Paul B. Hoeber, our publisher, we express our thanks for his untiring interest and help in the work. 43 Bay Street Road, A. W. GEORGE. Boston, R. D. LEONARD. December, 1921. CONTENTS CHAPTER PAG1 I. 1\ I ROD! CI [ON I II. Technique 4 Preparation of the Patient Films Intensifying Screens rube and liable — Standard Position Potter-Bucky Diaphragm Exposure I Inkling of the Breath- Number of Plates or Films Opaque Meal. III. [nterprei \ I I(i\ 15 Interpretation of the Films Direct Evidence Classification Differentia) Diagnosis — The Visible Pathological Gall-BIadder Position of the (.all- Bladder Shadow — Differential Diagnosis [ndired I vidence Deformities Due to Pressure— Second u \ Changes Due to Adhesions Fixation ol Organs -Spastic Changes in the Stomach— Changes in the Gall-BIadder. IV. Conclusions Statistics ; 5 Roentgen Plates of Pathologicai Gall-Bladders Thai May or May Not Contain Gall-Stones I. Pathological Gall-Bladders Containing Gall-Stones (Plates I XII) 37 II. The Visible Pathologic \i G \i i -Bi \ddi k i Plates \lll XXV) 89 III. The Pa lhological Gall-Bladder : Indirect Evidence (Plates XXVI XI.IVi .137 Mil THE PATHOLOGICAL GALL-BLADDER roentgenological.lv considered Chapter 1 INTRODUCTION IT N [910 we had the privilege of visiting the various gastro- intestinal clinics of Europe It was obvious to an\ observer who hoped to make an accurate studj "I the lesions oi the -1 irastro-intcstinal tract licit the continental method of study was lacking in something to make it complete. No effort was being made to solve the gall-stone problem, except ill some slight experimental way. It was openly taught that gall-stones could not be demonstrated in a great majority of cases. On returning to this country and seeing the work of Lewis Gregory Cole, to whom more than any other individual we are indebted for the stimulation to carry on this work, we observed that in his direct studj oi the duodenum by the plate method, he was incidentally visualizing gall-stones in a large number of cases. It was clear that the reason for this [ay in the fact, that by perfecting his plate technique to such a point as to bring out the slight changes in the duodenum, he thereby made clear the hunt and obscure shadows ol any gall-stones which happened to be present. Hence, when we took the opportunity to study ulcer of the duodenum by our modification <>t Cole's method, we also began to see gall-stones w ith increasing frequency. At once our interest became centered on the gall-stone problem. We became ambitious to show as many Stones as possible, and became curious as to what percentage of all gall-stones could be demonstrated. We made sc\cral attempts at a statistical study. While realizing a1 the time how figures lie and that such studies were almost valueless, > et we hoped, b\ presenting these statistics, to arouse in other roentgenologists an active interest in this 2 THE PATHOLOGICAL GALL-BLADDER problem. We expected, by stimulating a universal study of the right upper quadrant, to arrive, as time went on, at a higher percentage of correct diagnoses. This work was carried on until 1917. At this time we began to realize that there was a certain, and possibly a large percentage of cases actually having gall-stones, in which the character of the gall-stones was such that it was almost a physical impossibility to visualize the stones on the photo- graphic plate. We were, therefore, forced to seek other evidence, besides the mere demonstration of stones, whereby a diagnosis of diseased gall-bladder could be established. Our attention was called in certain cases to a shadow in the right upper quadrant, having the size, shape, and position of the gall- bladder. This shadow, we inferred, represented a gall-bladder full of stones, no single stone being of sufficient density to cast a shadow. Occasionally, a patient showing this shadow would be found at operation to have only a chronically inflamed gall-bladder without any stones. We then appreciated for the first time that the pathological gall-bladder might, under certain conditions, cast a shadow, even when no stones were present. Our observation as to the demonstration of the pathological gall-bladder we have considered the greatest step in advance toward the solution of the gall-bladder problem. Since 191 ~ the emphasis in our work has been placed on the visualization of the pathological gall-bladder and the demonstration of the results of gall-bladder disease on the surrounding organs. In the earlier study of gall-stones by the use of the x-ray, one should not overlook the early demonstration of gall-stones by Beck of New York and Thurstan Holland of England. There have been a few roentgenologists who have from time to time emphasized the study of gall-stones by the roentgen method. Principally, among these investigators have been Cole of New York, Case of Battle Creek and Pfahler of Philadelphia, who have been of help to us personally in carrying on this work. Dudley Roberts of New THE PATHOLOGICAL GA1 I -Bl UDDER York in the last few years has made a definite studj oi the pathological gall-bladder and gall-stones. Knox ol England has |>ecn a meat stimulus to all to continue this work. His experimental work on the varying densities and types oi gall-stones should be studied caret u lb by all those who an interested in these problems. It is because ol our appreciation of his work that we have omitted any consideration along these lines in this monograph, as it would be impossible to improve at the present time upon what Knox has already pul dished. Our work would have been much simpler il more ol our colleagues had taken it up and given us t he bench t ol their obserx at ions; but there has been SO little published upon this particular aspect of the stud\ of the- biliar\ tract that it has required a good deal ol time on our part to accumulate facts and observations which would be ol value. Considerable material has been published in the last ten years upon the experimental study of gall-stones, most ot which has been studied outside the bodj or b\ placing the stones in different media, such as water, wood, paper and beef; and it has been the opinion of the writers that there has been no definite analogy between the experimental study ol gall-stones in this way as compared with the study of gall-stones in the living. It would have been a very discouraging problem it the facts which have been deducted from the experimental studj of gall- stones were criteria of what we should find in the living. Chapter II TECHNIQUE THERE is nothing mysterious or complicated in the technique of roent- genographing a patient for gall-bladder disease. The simplest way is always the best way; hence, we have discarded in our method of procedure anything which has seemed an unnecessary complication. Preparation of the Patient As most of our gall-bladder examinations are made in conjunction with a general gastro-intestinal study, we allow nothing to be done in the way of preparation which would interfere with the study of the stomach or intes- tines. This rules out any violent purgation because of its effect on the motility of the intestinal tract, it being our endeavor to study patients in their usual habits of living. A cleansing enema, however, is desirable, in that it thor- oughly cleans out the hepatic flexure area of the colon in the region of the gall-bladder, while not interfering with the subsequent intestinal motility. More important is the requirement that the patient present himself for examination with an empty stomach. As our patients come in the morning, we recommend that they omit the breakfast. If this seems too much of a hardship, a little liquid such as tea, coffee, milk or bouillon may be taken at least two hours previous to the examination. This will obviate any tendency to faintness, particularly when the patient comes to the office from some distance. We are particular about the stomach being empty, for a food-filled antrum or duodenum may produce shadows simulating the gall-bladder or gall-stones. It goes without saying, that all drugs should be omitted for at least two days previous to the examination. This is particularly true of medicine containing bismuth. It is surprising how long bismuth may adhere to the HIE PATHOLOGICAL GALL-HI ADDER intestinal walls and it in the hepatic flexure region maj produce confusing shadows in the right upper quadrant. \\ hen all is said and done, il shadows appear on t lie him which are suspicious but indefinite, one should not hesitate tn repeal the examination on another day. I'll MS The ,\-ra\ evidence.' of gall-bladder disease is of such a character as to require the use ol films or plates for its demonstration. Our earlier work was done, ol course, entirely with glass plates. I he advent ol the duplitized him about three years ago entirely superseded the use ol plates in our office, since which time we have found no disadvantage in their use either for gall- bladder or genera] \-ra\ work. In this connection, it ma\ be said that throughout the text the words "plate" and "him" are used almost synonymously. Fluoros- copy has been of no practical value in this line of work; in fact, in some ways it has seemed an actual detriment to the perfection ol gall- bladder diagnosis. Except by remote, indirect methods, there is nothing within the power of the fluoroscope to give the least information regarding the pathological gall-bladder. If all observers in this country had used the lluoroscope exclusively, a demonstration ol gall-stones would have been the rarest observation, and the visualization of the gall-bladder unknown. Some ol our colleagues who have had the best opportunities tor studying large numbers of gastro-mtcst mal cases, have been of the hast assistance in the solution ol this problem, because their observations were' confined mainlj to the fluoroscope. Intensifying Screens From the very beginning, the intensifying screen has been the founda- tion for our gall-bladder work. Without its use but little progress would have been made. It was found to be essential in obtaining that additional bit ol 6 THE PATHOLOGICAL GALL-BLADDER contrast so necessary to bring out the slight variations in the density of the gall-stones. It is just at this point that many men have failed to achieve gratifying results. The difference in density between a gall-stone or gall-bladder and the surrounding tissue is so slight that it is frequently not detected on a straight plate or film, but may become visible when the intensifying screen is used. Those who persist in using straight films or plates (without the intensifying screen) will overlook a large percentage of gall-stones and pathological gall-bladders. For years we have used the single screen and plate and have continually been bothered by the grain of the screen which seems to be accentuated in the plate. Furthermore, any defect in the screen is clearly reproduced on the plate, and many of these defects produce shadows simulating gall-stones. We attempted to eliminate these sources of error by using in each case a series of screens, so that before stating that gall-stones were present, the same shadows must be obtained throughout the series of plates. With the development of the "double intensifying" screen and dupli- tized film, the sources of error from screen grain and defects are practically done away with. The defects of one screen are apparently offset by the good screen on the other side of the film. We feel today that not only is a screen necessary for gall-bladder work, but the best work requires a double screen used with a duplitized film. The double screen seems to increase twofold the advantages of the single screen and proportionately to diminish its faults. Tube and Table Experience has shown us that uniformly better results are obtained while using some type of Coolidge tube. The right degree of penetration, being of fundamental importance, can always be obtained with this tube. It is true that occasionally a very brilliant plate is obtained with the gas THE PATHOLOGICAL GALL-B1 ADDER tube, but on account of the uncertainty of the vacuum the duplication oi excellent plates is difficult. Other things being equal, the finer the focus the better the detail. As our technique requires a rather high milhamperage a too-line focus tube ma\ heat up. For general routine work the medium focus Coohdge tube has proved satisfactory, as well as the hue Incus radiator type. No speeial form of tube-stand is required. We prefer a small cone and diaphragm. The cone which we routinely use measures 5 ' . inches in length, with a 3 1 -j- inch diaphragm. 1 he same is true ol a table. As no unusual posi- tion of the patient is necessary, an ordinarj horizontal table answers all purposes. In our office wooden tables are used, which incidentally do awaj with any static discharge. Si \\d \kd Posn n>\ We use a standard position. All cases are taken prone, the patient lying on the screen with the tube above. The screen is placed beneath the right upper quadrant so that it is bisected by the right costal margin. The most practical sized screen to use is the 8- by 1 0-inch. It is possible to use a 6 1 j- by S 1 .-inch or possibb a smaller one, but in using a screen that is too small one ma\ overlook a gall-bladder it it is m an abnormal position. The tube is placed above, the central ray perpendicular to the plate, using the smallest circle and cone which at a given distance will cover the plate. This is centered midwaj over the costal margin so that the exposure will give as much area above the costal margin as below it (Figs. I and 2). The distance ol the tube from the 1 1 1 111 and screen varies. I sing a medium-locus tube, distance becomes ol importance in bringing out sharp- ness of detail. \\ ith a line-locus tube, distance is ol less importance so far as detail is concerned; this also is the ease for the radiator-type tube. The following rule holds true in gall-stone work just as in other \-ra\ work. II the 8 THE PATHOLOGICAL GALL-BLADDER object being roentgenographed is an appreciable distance from the film, the tube must be a correspondingly greater distance away in order not to produce a distorted shadow. For instance, in a stout individual, where there may be several inches of abdominal fat between the gall-stone and the film, the Fig. i. tube should be quite a distance away in order not to destroy the shadow by the divergence of the rays. Under ordinary circumstances, the tube should not be tilted or the angle changed. We are endeavoring to demon- strate a shadow as being constant in a series of films. If, now, the angle at THE PATH01 OGICA] GA1 I -Bl M)l)l R which the films are taken is changed, we thereby introduce a new variable factor which will cause a variation in the shadows on the film. 1 1 \\ e observ e on any one him a shadow which is suggesth e oi gall-bladder disease, we en- deavor to visualize this shadow more clearlj 1>\ changing the penetration and time oi exposure, and not In changing the angle oi the tube. Fig. 2. However, it max occasionally be necessary to change the angle of the tube in east's where apparent gall-stone shadows lie within the shadow produced In the spine. I his condition ma\ occur where there is a scoliosis, particularly with the curve toward the right. Postoperative eases may also present tins condition as a result oi adhesions. Too much emphasis cannot be laid on this point of placing the tube so as to cover the area wanted and keeping it there, varying the technique only as may be required to improve the quality of the film. The patient must io THE PATHOLOGICAL GALL-BLADDER be instructed to lie in one position (prone) and maintain that position throughout the entire examination. He should turn the head only from side to side, rather than turn the body to make his position more comfortable. It sometimes seems advisable to change the screens under the patient by using a funnel or by putting them beneath the table, so as not to disturb the position of the patient. The disadvantage of this technique is that it is necessary to place the screen as close as possible to the patient. Every additional fraction of an inch that is interposed between the anterior abdominal wall of the patient and the intensifying screen adds to our difficulty by destroying detail. POTTER-BuCKY DlAPHRAGM The use of the Potter-Buckey diaphragm has materially helped in the study of all portions of the body to which it is applicable, and it has seemed from our experience that it should be of distinct advantage in the study of the right upper quadrant. This is particularly true in the muscular and well- nourished individuals. Unquestionably, when one understands the technique of the movable grid, more detail is brought out of the soft parts than without its use, especially in making visible the kidney, for example. The study of the visible gall-bladder also is simplified to a certain extent by its use, but one must understand the use of the grid and also realize that there is a certain amount of distortion that naturally comes from the use of this apparatus. Gall-stones which are difficult to make visible under ordinary routine tech- nique, if care is used will stand out more brilliantly and with more contrast with the use of the grid. Its greatest help to us individually has been in the differentiation between gall-stones and renal stones, especially when using the lateral position. Shadows due to calcium which may or may not be gall- stones and with the ordinary technique would be difficult to make visible in the lateral view, seem to be clearer and more easily discernible when using the diaphragm. Tin: iwtiioi ()(,ic\i cam -i'.i \i)Di u We have not attempted to hm' the Potter-Buckej diaphragm routinely m the normal or the average-sized person. I he distance between the Mini and the patient's abdominal wall and the necessarily slightlj longer exposure required, are disturbing factors in obtaining the most satisfactorj plati It is hoped that as we gain more experience in the use oi the Potter-Buckej diaphragm in thestudj of gall-bladder disease, we maj find its use of increa - ing \ alue. PNE l MOPER] K)\l I \1 It has not been our privilege to utilize the pneumoperitoneal injections lor the study oi the biliary tract. We have realized that it is possible to make clearly visible all gall-bladders, almost without exception, with the gas injection method; and undoubtedly stones which under ordinary circum- stances would not be visible in the roentgen plate, can at least be suspected with the injection method. Its routine use lor the studj ol the gall-bladder lias not been attempted by us. It is onI\ m the studj lor other conditions that occasionally we meet with conditions ol the gall-bladder not suspected clinically <>r possibly not seen m a previous roentgen examination. It is imt the wish ol the writers to deprecate the value ol this method, but more to urge that the ordinary methods be better developed before one considers this new method, solely lor the purpose ol studying the biliary tract. I ndoubtedly one will meet with cases in this study which would make the use ol the pneumoperitoneum imperative, but the large majority ol these cases that cannot be settled either by accepted clinical methods or by care- ful roentgen study would necessarily seem to indicate surgical exploration. ExPOSt hi The correct degree ol penetration is ol the utmost importance in pro- ducing the ideal gall-bladder him. Individuals vary so greatlj that no fixed exposure rule can be given; suffice it to say, that in a given case that ia THE PATHOLOGICAL GALL-BLADDER degree of penetration should be used which will just pass through the patient. In other words, use the "softest" possible ray that will penetrate to the film. For some patients a 219-inch spark gap might be sufficient, while for stouter individuals 3 1 2 to 4^ inches may be necessary. It should always be borne in mind that we are dealing with very slight variations in density, so that the slightest degree of over-penetration may obliterate many of these faint shadows. The length of exposure requires attention as well as the degree of penetration. The exposure time should not be unduly prolonged — a second and a half at the longest. Too prolonged an exposure gives opportunity for motion on the part of the patient. Movement caused by respiration, muscle tremor, or even arterial pulsation might be enough to obliterate the shadows of gall-stones or of the gall-bladder. Holding of the Breath An important factor, therefore, in exposing the plate is the correct holding of the patient's breath. While this would seem to be a simple matter, yet it is one of the most difficult things in which to instruct patients and have them carry out accurately. A plate or film perfectly exposed as to time and penetration, becomes valueless if there is the slightest motion on the part of the patient. We take a good deal of time in explaining to patients how to hold their breath. We do not attempt to have them hold it after a deep inspiration, for we have found that they are gradually expelling the air during the exposure. We, therefore, instruct them to stop breathing the instant we give the signal, attempting neither to inspire nor expire. This, for the moment, gives them no desire to inhale or exhale, and during that brief interval the exposure is made. We cannot emphasize too strongly the importance of a correct holding of the breath, for we have observed that a large number of our failures in diagnosis have been due to motion at the time of exposure. THE PATHOLOGICAL GALL-BLADDER 13 Number oi Plates or Films One should not limit oneseli to an\ fixed number oi plates or films. Each patient is a rule unto himself. Repeated films must be made until a satisfactory degree ol detail is obtained. For some patients two or thre< exposures maj be sufficient, others maj require ten, a dozen, or even more. Our routine is to make one exposure, estimating the time and pen* na- tion best suited for the type oi patient. I his him is then developed under the personal supervision oi the operator, who determines whether a ch; should be made m the next exposure to produce a more satis factor J him. In laet, each him is developed and examined before the next one is taken. We have found it a waste ol time and energy to take lour or five films at a time and have them all developed at once. 1 his process of alternately exposing and developing is continued until the operator is conhdent that the best detail possible lor that particular patient has been obtained. A satisfactory gall-bladder him should show at least the twelfth and eleventh ribs and the lower dorsal and upper lumbar vertebrae (Plate XIV, big. 43). On account ol the lack ol penetration, spine detail is usually not obtained. The transverse processes, however, should be clearly seen. The lower edge and the lower portion ol the outer edge of the li\er should be visible. A portion ol the right kidney should also be seen on a satisfactory him. I he kidney shadow will be somewhat enlarged bom distortion, since the exposure is made w it h the hi m on the anterior abdominal wall. Occasion- ally, however, the kidney shadow is not seen on the film. This may be due to the laet oi Us occupying an unusually low position or from some unknown cause. When the kidney shadow is visible, it simplifies the inter- pretation ol the film. W hen the source ol a suspicious shadow on thi' film is being considered, the kidney being definitely identified is thus eliminated as a possible cause. i 4 THE PATHOLOGICAL GALL-BLADDER Opaque Meal Finally, after obtaining a sufficient number of gall-bladder films, the patient is given a barium meal. Films or possibly the fluoroscopic examina- tion after such a meal may reveal any of the secondary or indirect evidence pointing to gall-bladder disease. The meal consists of 500 c.c. of buttermilk to which has been added 80 gm. of the specially prepared barium sulphate. Any other of the accepted media could be used. We have used buttermilk for the past ten years; all our observations have been made with this meal, and as yet we have found no reason to make a change. Chapter 111 INTERPRETATION Km rpr] i \ i io\ in i in Films HAVING obtained lilms as near technically perfect as possible, the next problem is to interpret the evidence winch these lilms present. \\ luK' there is greal room for improvement in our technique, there is still greater opportunity for perfecting our interpretations, rhere is more in the dims today than we can read. Only In continuous study ol the \-ra\ evidence and checking up after operation or autopsj can progress be made. It must be borne in mind that todaj the roentgenologist is not interested simply m the demonstration ol gall-stones, but in the broader held ol gall- bladder disease. We, therefore, study the films for other evidences of gall- bladder disease, besides the mere visualization oi stones. Direct Eviden( i For our convenience in teaching, we have divided the x-ray evidence ol a pathological gall-bladder into two general groups: direct and indirect. Under direct evidence let us consider, first, the demonstration oj gall-stones. Stones will show on the plate il there is sufficient difference m density between the stone or group ol stones and the surrounding tissue. Il is only this differ- enct in density which the x-ray detects and nothing man. In general, the more lime salts a stone contains, the greater its density and the more casik demonstrated. Unfortunately, the ordinary stone contains onl\ a small amount ol calcium, the bulk ol the stone being composed ol cholcstcrin and bile pigment. \\ e roughk classify gall-stones according to their X-ray appearance. Visible Gall-Stones. The majority ol gall-stones visualized on the x-ray him present the so-called peripheral shadow (Plate III, Fig. 9). The stone appears as a ring. This appearance may be explained by the fact 16 THE PATHOLOGICAL GALL-BLADDER that the periphery contains more lime than the central portion; on the other hand, any more or less translucent spherical body when viewed by trans- mitted light will present this "ring" appearance. Laminated stones may be found (Plate X, Figs. 30 and 31). Their shadows are similar to the cross section of a tree-trunk where the growth rings are visible. This peculiar picture is undoubtedly due to different layers of salts being gradually deposited on the surface of the stone from time to time, some of the layers containing more calcium than others. Dense homogeneous shadows are occasionally seen (Plate V, Fig. 15). This type of shadow represents a stone containing much calcium evenly distributed throughout. Such a stone may resemble a kidney stone and therefore requires more care in the differential study. Fairly dense shadows may be found which suggest a mass of small stones or a collection of "sand," rather than one large solitary stone. In- spissated bile may at times be dense enough to cast a shadow on the plate (Plate VIII, Fig. 23). Experimentally, the so-called "negative" stones may be demonstrated. These stones are of less density than the surrounding tissue and appear on the film as dark areas (being more easily penetrated by the x-ray). While theoretically such stones can be demonstrated in a patient, practically it is a rare occurrence. Such shadows, when seen, must be differentiated from small collections of gas in the stomach or intestine. Stones may vary in number from one up to hundreds. Some of the single stones may grow to a large size. The whole gall-bladder may be filled with one large stone. Some of these large stones measure 3 inches or so in the longest diameter. All gradations in size are found, down to collections of minute specks, which are commonly called "sand." We do not find the great variety in the shape of gall-stones that is seen in kidney stones. In general, gall-stones are not extremely irregular, being I 111 PATHOLOGICAL GALL-BLADDER usually rounded. When several stones are present, thej become faceted and produce a polygonal shadow, frequently triangular (Plate \lll. Fie. 26). '6 Ci vssu u \ 1 io\ With the permission of the author, we have adapted the classification of gall-stones as devised In Dr. Dudley Roberts. This classification we consider one of the most practical up to the present time; at least from an x-ray viewpoint. 1. The Radial Cholesterin Stone. This rare type of single stone occurs in gall- bladders which show evidence of dilatation without inflammation. It-- structure is peculiar, in that it is composed of pure cholesterin crystals that radiate from the center to the surface. This stone is less dense than all surrounding tissue, and can be visualized only as a negative shadow, that is, a round or oval dark spot. 2. The Combination Stone. When inflammation develops in a gall-bladder which contains a radial cholesterin stone, the inflammatory exudate causes a deposit of lime salts on the stone, and this layer shows as a ring or oval shallow. It sometimes happens that the lime is unequally deposited and onlj a segment is visualized. 3. Cholesterin-Bilirubin Calcium Stones. This rather common type is fairly large, from two to live in number, frequently faceted and nested in the neck ot the l>l R 23 casionally a gall-bladder shadow may be in such relation to the lower surface of the liver thai its shadow appears to show through tin' liver substance. In stout individuals it frequently lies in the outer hall oi the right upper quadrant; in thinner patientSj it lies nearer the median line, occasionally partlj overlying t he spine. The level of the gall-bladder will, of course, vary with the position ol the lower edge of the liver. Here again, in well-nourished individuals, its shadow will be seen high upon the right sick'; in thin people or patients with general ptosis, it may be seen well down in the right Hank, and occasionally below the crest ol the ilium. Shape \\i> Size of mii G all-Bladder Shadow The ordinary gall-bladder as seen in the x-ray plate or film is oval in shape, the long diameter being vertical or inclining toward the median hue in thin individuals. Frequently, in the well-nourished, its long diameter ma\ be nearb horizontal. I he lower pole or lower edge ol the gall-bladder is usually the more clearly seen, the upper pole being obscured by the density ol the liver t issue. The gall-bladder shadow presents a marked variation in size in different individuals. We have observed chronic gall-bladders, which are contracted about a single stone, practically containing no bile and w it h thickened w alls, the whole mass being no larger than an English walnut. On the other hand, with complete obstruction of the cystic duet, the lower pole ol the bladder may reach the brim ol the pelvis, the whole sausage-shaped mass measuring over 8 inches in length (Plate XXII, Fig. 71). Dim i hi ntiai Di ^.GNOSIS There are several conditions likely to be mistaken lor the gall-bladder shadow. Perhaps the most confusing is the kidnej shadow. It is a good rule 24 THE PATHOLOGICAL GALL-BLADDER to hesitate before interpreting a shadow in the right upper quadrant as a gall-bladder unless the outline of the kidney is also clearly visualized. There is opportunity for error in reporting a gall-bladder without a visible kidney, for the chances are that the shadow seen is the kidney rather than the gall- bladder. One helpful point is the distinctness with which the inner edge of the gall-bladder is usually seen in contradistinction to the inner edge of the kidney. The anatomical structure of the kidney is such, with the pelvis on the inner side, that this margin is not clearly seen. At times the kidney may be displaced or rotated so that the pelvis is more or less posterior. Its shadow under these circumstances is very confusing, as the inner edge of the kidney then resembles the edge of a somewhat enlarged gall-bladder. If the kidney outline is not clearly seen in the front view, the patient may be turned on his back and a routine "kidney plate" made. This will frequently give the size and position of the kidney and enable one to differ- entiate it from the gall-bladder. An unusual contour of the liver edge may occasionally be confused with a gall-bladder shadow. This, however, is not likely to be a common abnor- mality and in practice rarely has to be considered in the differential diagnosis. The so-called Riedefs lobe may simulate very closely a gall-bladder shadow. The differential point is: If we are dealing with a Riedel's lobe, its outline is continuous with, and of the same density as, the liver edge. The shadow produced by the gall-bladder, however, usually appears distinct from the liver edge and of different density from the liver tissue. It is interesting to note that some authors consider the presence of a Riedel's lobe as evidence of pathology in the biliary system. Stomach and intestinal contents may occasionally be of such a nature as to cast a shadow on the film. If these shadows happen to be in the right upper quadrant, they may be confused with a possible gall-bladder shadow. I 111 I'M IIOI OGICAL GAI 1 -Bl \l)l)l U 25 This is particularly true oi a "food-filled" duodenum, the duodenal cap frequenl K having more or less the shape ol a gall-bladder, and with a similar smooth margin. Food is, ol course, continually passing through the duo- denum, so that a food shadow will be inconstant. 11ns is the importanl differentia] point. II at the end of an examination, there is still doubt as to whether a certain shadow is the gall-bladder or food in the duodenum, the patient may be asked to return on another day, taking the precautionary measure ol an emptj stomach. Fecal material in the hepatic flexure ma\ also be confusing when one is looking lor a gall-bladder shadow . I his ma \ be ruled out in the same general w;i\ as a food-filled duodenum. In addition, a study ol the twenty-four-hour filled film will definitely identify the hepatic flexure, this portion ol the colon being filled with barium at that time. II the shadow suggesting the gall-bladder is still seen, one would be warranted in considering it positively a gall-bladder shadow . Certain tumor masses in rari' eases ma\ produce shadows in the right upper quadrant likelj to be confused with pathological gall-bladders. ( lancer of t In- head of the pancreas or ol the pyloric end ol the stomach is the most common. The differential diagnosis depends on the lack ol a discrete margin to a shadow produced by a growth ol the pancreas or stomach, the margin ol the shadow ol an enlarged gall-bladder being usually sharp and clean cut. Furthermore, in cases ol malignant tumors ol sufficient size to cast a shadow on the plate, there will be enough indirect evidence to make the diagnosis clear. The character ol the deformitj ol the stomach and duodenum due to cancer in the right upper quadrant is almost pathognomonic. Iii rare cases it ma\ be ol help in a differential diagnosis to examine a patient alter a pneumoperitoneum. We have not used this method to any extent in our ow n practice. 26 THE PATHOLOGICAL GALL-BLADDER Indirect Evidence The direct evidence of gall-bladder disease is obtained from plates and films made directly of the gall-bladder region. The evidence consists, in general, as we have seen, of a demonstration of gall-stones or of the patho- logical gall-bladder. The indirect evidence of gall-bladder disease is obtained by a study of the various organs surrounding the gall-bladder. These organs, of course, are not visible without a barium meal. The search for indirect evidence is, therefore, always made after a barium meal. Deformities Due to Pressure The most common type of indirect evidence is the deformity of the duodenum or stomach due to pressure from the gall-bladder (Plate XXVIII, Fig. 8-; Plate XXXII, Fig. 98; Plate XXXIII, Figs. 100 and 101). This pressure deformity has a characteristic appearance, which is best understood by a study of the films or plates. The value of this type of evidence lies in the fact that in our experience this deformity is never produced by a normal gall- bladder. This may be explained by the theory that the tension within the normal gall-bladder is less than the tension within the food-filled duodenum or stomach. In other words, the normal gall-bladder is more easily compressed than the stomach. Hence the stomach or duodenum when brought into con- tact with the normal gall-bladder will compress the gall-bladder, rather than be deformed itself by the gall-bladder. When pathological changes take place in the gall-bladder — thickening of the walls, increased fluid, or stones — then the pressure within the gall- bladder may become greater than the pressure within the stomach. Under these circumstances, the stomach or duodenum will be compressed by the gall-bladder and the typical "pressure delect" produced. The deformity is usually seen in the first or second portion of the duodenum, but it may involve the greater curvature of the stomach, near the pylorus (Plate THE IWTIIOI OGICAL G A I 1 -P.I \I)I>1 R 27 XXXII I, Figs. 1 on and 101 1. 1 hedeformitj is in the nature oi an indentation on tlu' viscus, 1 lu' indentation apparently being produced l)\ some smooth, rounded object, rhere is usuallj no"irreguIantj in the outline ol t lu- duod< - mini or stomach 111 the area involved, the margin being smooth and the indentation in the form ol a concave curve. I he arc of the curve is more or less constant, represent ing thai port ion ol the gall-bladder thai is in contad with t he duodenum or stomach. When involving the duodenum, the deformitj is usuallj on its outer edge. In a centrally situated gall-bladder, the inner edge ol the duodenum max he involved. Occasionally the superior angle may be flattened In the gall-bladder. Such a situation produces a more or less rectangular shape ol the duodenum, and m marked cases produces a much "flattened" cap, tin- vertical diameter being greatlj narrowed. Tins particular deformity ol the cap is seen most frequently in the lateral position. As we have just stated, the margin oi this deformity is usually smooth. In rare cases, however, it will have a somewhal "scalloped" appearance (Plate XXXIII, big. 102) due to pressure oi sunn actual stones within the gall-bladder. The second portion ol the duodenum will at times show the effect ol gall-bladder pressure (Plate XXXIX, big. Il6). The pressure deformity shows the same characteristic type ol curve as seen in the Inst portion. I he deformity ol this part ol the duodenum is usuallj associated with fixation due to adhesions, which will be discussed later. When involving the stomach, the pressure dclormitx is in the antrum on the greater curvature ( Plate WW I, b igs. [ 09 and 110). 1 1 ere again the curve has the same characteristic arc. I Ins deformitj is seen best withthe patient in the prone position, when, particularly In stout individuals, the antrum is forced into t he right upper quadrant, thus coming into contact with the gall-bladder. Usually in the uprighl posit ion, the stomach falls awaj from 28 THE PATHOLOGICAL GALL-BLADDER the right upper quadrant and the pressure defect of the gall-bladder becomes obliterated. Occasionally, however, the antrum of the stomach may be fixed by adhesions in the right upper quadrant, so that even in the upright position the gall-bladder pressure will still be seen. In the interpretation of these curved pressure defects, one should bear in mind that while an enlarged gall-bladder is almost always the cause of the deformity, still there are rare exceptions that should be borne in mind. An abnormal contour of the under surface of the liver might produce a similar deformity; likewise, an enlarged or freely movable kidney. Various rare forms of new growth, particularly of the cystic type, or where the tumor mass has a rounded and smooth surface, might cause pressure similar to an enlarged gall-bladder. In this last class are the cystic conditions of the head of the pancreas. Secondarv Changes Due to Adhesions We now come to the consideration of other changes in adjacent organs (aside from those caused by pressure) that are secondary to gall-bladder disease. Practically all these changes may be classified under the general heading of adhesions. We shall be considering, therefore, the various mani- festations of the results of gall-bladder adhesions on other organs. First Portion of the Duodenum. The organ most frequently affected by gall-bladder adhesions is the first portion of the duodenum. The character of the changes produced in the first portion by adhesions group themselves into more or less definite types of filling defect. Perhaps the most common— and one must be familiar with the surgical picture to appreciate this type of filling defect — is as if strings were pulled backward and forward over the anterior surface and pulled down upon the first portion, giving a more or less toothed appearance (Plate XXXV, Fig. 107). One simple and not very reliable differentiation between this condition and ulcer is that adhesions play their [Ill PATHOLOGICAL (.Ml -Bl \l)l)l K jo most deforming role a i the time when the stomach is lull rather than when it is partially empty. In general, the ulcer picture is nol so characteristic im- mediately after the injection oi a meal as a little wink' later in the examina- tion, rhe ulcer-filling defect becomes more definite up to a certain poim in the emptying oi the stomach, while the deforming defects from gall-bladdei adhesions gradually disappear as the stomach empties and relaxes. 1 he second type ol deformity from adhesions involving the firsl portion oi the duodenum is the complete obliteration oi the normal outline oi the duodenum, the lumen becoming tubular in character, as though gripped In a firm band oi adhesions a cent i meter or more in width. I his condition, too, may be confused with the chronic indurated obliterative type oi ulcer i Plate XXXIV, Fig. 105). The third type oi filling defect commonly met with is a combination ol the ulcer picture and ol adhesions, and it becomes dillicult to determine by an\ means except surgerj whether the deforming delect lound in the duo- denum is due primarily to ulcer or to adhesions, or to both. Second Portion <ntrary to one's expect at ions, lor this portion is usuallj considered to be more or less retroperitoneal. The most common deformity is an apparent picking up ol t he descending or second portion ol the duodenum, displacing it and fixing it toward the right 'Plate XXXIX, Figs. n6 and m _ i. This lateral displacement fre- quently produces an appearance on the film or plate as though the fundus oi the gall-bladder were outlined l>\ the duodenum. This deform ii\ is the result ol pressure plus an adhesion fixation. Occasionalb one linds a simple narrow ing at one point ol the duodenum. 3 o THE PATHOLOGICAL GALL-BLADDER This type of deformity is usually due to one single band of adhesions lying across the duodenum (Plate XL, Fig. 120). Jejunum. Another opportunity to observe secondary manifestations of gall-bladder disease may be found in the study of the jejunum. Occasion- ally one finds, in the right upper quadrant, loops of jejunum filled with gas, showing on the films previous to the ingestion of the barium meal. If this phenomenon is confirmed when the jejunum is filled with barium, it becomes an important diagnostic point (Plate XXXIV, Fig. 105 and Plate XLII, Fig. 125). Barring the rare possibility of a congenital malposition of the small intestine or a chronic tubercular peritonitis, one must conclude that these loops of jejunum are displaced and fixed by adhesions from the pathological gall-bladder. Colon. An important organ to examine for changes due to gall-bladder disease is the colon in the region of the hepatic flexure. The most character- istic changes in the hepatic flexure are a catching up and "pulling out" ot a small portion of the wall of the colon. The resulting deformity has the ap- pearance of a sacculation in which there is usually a collection of gas, the main lumen of the colon being filled with the barium meal (Plate XXIV, Fig. 77). This projection or sacculation is, of course, due to an adhesion from the gall-bladder, and therefore is always located close to the gall-bladder. This particular type of deformity is almost pathognomonic of gall-bladder disease. There may be a general deformity of the hepatic flexure due to more extensive gall-bladder adhesions. From the fact that these general adhesions are in the right upper quadrant, we are usually safe in considering them as coming from the gall-bladder. However, one must bear in mind that there may be other sources for these adhesions — a long retrocecal appendix, omen- tal adhesions, or tubercular peritonitis. There is, however, a more or less characteristic deformity of the hepatic flexure and proximal portion of the THE PATHOLOGICAL (,\l I -HI \I)DI R 51 transverse colon, frequently seen as a result ol gall-bladder disease, rhis deformity consists oi a "picking up" and fixing ol the transverse colon al a point a few inches distal I nun the hepatic flexure I Plate \l 1 1. Fig. 127). This product's a more or less sharp angulation ol the transverse colon, and we have conic to speak ol it as a "pseudohepatic flexure." Finally, we have the simple displacement ol the hepatic flexure from an enlarged gall-bladder. I Ins displacement is usually downward and toward the median line (Plate XXII, Fig. 71). Kidney. In the differential diagnosis it is rarelj necessarj to consider a displacement due to an enlarged or low kidney. Fortunately, the kidnej does not usually displace the hepatic flexure. When it does, however, the colon usually goes clow nw aid and to the outer side. Fixation or One, \\s Quite commonly one will observe no deformity in the outline of the various organs which could be ascribed to adhesions, but there will be a fixation oi the part. 1 he organ may be "fixed" in its normal position or dis- placed and fixed, the fixed portion always being close to the gall-bladder. for instance, the pyloric vnd ol the stomach ma\ be huind far over to the right side and li\ed. A similar situation may involve the hepatic flexure. This fixation may be demonstrated by palpation under the fluoroscopic screen, or by taking films with the patient prone and standing. In the latter method, the " fixed " portion will ha\ e a constant relation to the gall-bladder in both positions. Sp vstic Ch VNGES l\ I III Stom \< 11 1 In pathological gall-bladder, like the chronic appendix, max produce reflexly various spastic manifestations in the stomach. These spastic changes in general do not differ from reflex spasms due to other causes. There is, how ever, one type of spasm thai in our experience is so commonlj associated 32 THE PATHOLOGICAL GALL-BLADDER with gall-bladder disease that we have come to consider it when present as fairly reliable evidence. This type of spasm affects the antrum of the stomach. Usually the distal third of the stomach becomes uniformly contracted, pro- ducing a tubular outline an inch or so in diameter, the proximal two-thirds maintaining its normal diameter (Plate XLIII, Fig. 129). Changes in the Gall-Ducts Finally, the changes observed in the gall-ducts are very important indirect evidences. We have noticed from time to time a small speck of barium retained close to the second portion of the duodenum but not within its lumen (Plate XLI, Fig. 123). The small shadow could frequently be seen twenty-four hours after the barium meal. At first we considered this to be a small congenital diverticulum attached to the second portion of the duodenum; but repeated occurrences of this condition, with the shadow always bearing a constant relation to the duodenum, have led us to conclude that we are dealing with barium in the ampulla of Vater. We believe that under certain conditions the ampulla becomes dilated or relaxed so as to allow the entrance of barium into it. This dilatation might be the after-effect of the passage of a large gall-stone or some chronic in- flammatory condition. Possibly some interference with the normal How o! bile or pancreatic secretion may allow this phenomenon to take place. We consider the barium-filled ampulla to be practically pathognomonic of some form of gall-bladder or pancreas disease. This consideration is based on the fact that in every case coming to operation where this phenome- non was observed, a pathological condition was found either in the gall- bladder, in the ducts, or in the pancreas. Again, we have never been able to demonstrate a barium-filled ampulla of Vater in a normal individual, either after an exhaustive film examination or with palpation under the fluoro- scopic screen. Chapter I \ CONCLUSION IN conclusion, let us remind the reader that the value ol the v-ray in the diagnosis oi gall-bladder disease depends, first, on careful attention to the details ol technique. 1 he methods for preparing the patient and foi making the exposures are not complicated <>r involved. On the contrary, they arc extremely simple, but Frequently lack ol attention in some appar- ently unimportant detail is what stands between success and failure. Secondly, the diagnosis ol gall-bladder disease is not limited to the demonstration ol gall-stones. I he diagnosis is made on a great mass ol direct and indirect evidence. I he degree ol positiveness ol the diagnosis depends on the amount ol evidence. II gall-stones are visible, the diagno- sis is positive. On the other hand, il the entire examination reveals only one minor type ol indirect evidence, such as a suggestive pressure defect on the duodenum, then oiiI\ a presumptive diagnosis can he made'; or, as we fre- quently report, "the evidence is consistent with gall-bladder disease." Finally, we have endeavored not to elaborate some scientifically proved method ol diagnosis, but rather to report our progress toward the ultimate solution ol one ol the most dilhcult problems before the medical profession. II this modest work should by chance stimulate some one to "carry on" in this pioneer held ol roentgenology, we shall rest content. Statisi k s The writers realize the inaccuracy ol statistics as well as anyone. The following figures are offered, however, as something ol a guide. I hey repre- sent a summary ol a scries ol cases which were referred to us and on w Inch we reported m turn to the consultant, from January i, [920 to November 1, 1920, making a total ol ten months. During this time we Imd, on going oxer our records, that we passed an opinion in 746 cases either on the positive or negative aspect ol the gall-bladder examination. In some instances we ii 34 THE PATHOLOGICAL GALL-BLADDER knew the cases were referred for distinctly definite lesions of the stomach, the physician expecting from the clinical evidence to find ulcer or cancer. Nevertheless, in these cases, in an effort to base our knowledge of gall-bladder disease upon the surgical findings from as great a number of cases as possible, we reported to the consultant any suggestive shadows that seemed abnormal in the gall-bladder. We hoped that the surgeon would at least casually investigate the gall-bladder and help us to determine more quickly the value of certain signs which seemed definite from a purely roentgenographic point of view. In order not to include any personal equation in compiling these statis- tics, we gave all our reports and the letters received from the medical men and surgical consultants who replied to our request for the surgical findings, to a disinterested individual. She compiled them simply from a statistical point of view, using her judgment in interpreting the reports as to whether they were positive or negative. Out of a total of 746 cases reported on during this period of time, 128 were operated upon and reported to us as to the sur- gical findings. These eases are included in the statistics. Some medical men did not answer our letters. Undoubtedly, some eases have been operated upon, or will be, of which we have no knowledge. Of the 128 operative cases, eight diagnoses were proved wrong on the negative aspect and seven on the positive, making the percentage of correct diagnoses 88.4 with a percentage of error of 1 1.6 per cent. Reported between January 1, 1920 and November 1, 1920. (Total of positive and negative opinions). "46 cases Operative findings reported on 128 cases Correct interpretation in X-ray examination 114 cases Errors 15 cases Percentage (correct) 88 . 4 per cent. Percentage (incorrect) 1 1 . 6 per cent. ROENTGEN PLATES OF PATHOLOGICAL GALL-BLADDERS THAT MAY OR MAY NOT CONTAIN GALL-STONES PATHOLOGICAL GALL-BLADDERS CONTAINING GAI L-STON1 S l\ the studj ol the individual case for the detection oi gall-stones, the difficulty in demonstrating or making visible the gall-stones is partlj a physical problem, but mostlj lack oi care in the essential details ol the x-ray examination, loo much emphasis cannot be laid upon the necessity oi immobilizing, not only the part to be taken, but the respiratorj motions. The slightest amount oj breathing in itsell will make invisible even a fairlj definite calcium stone (Plate X, Figs. 30 and 51). We feel that stones ol reasonable size and density are usually visible eventually, with perseverance as to the number oi films and extreme care in the amount of milliamperage and voltage used, and, most ol all, with attention to the immobilization oj tin part. Secondary in importance is the examination ol the whole region in which the gall-stones max be found. One must not overlook any part of the right upper quadrant, sometimes going down to and below the crest of the ilium. One never knows where the stone may be found. Errors may arise and have occurred in the writers' experience, through superficial skin defects, such as moles, warts, etc., through scars on the anterior abdominal wall and on the back, through calcified mesenteric glands, foreign bodies in the colon, calcification oi the liver, calcification of the pancreas, irregular calcification of the costal cartilage, stones and calcified areas within the right kidney, and rarely through myositis ossificans of the deep muscles. In the type of stone that In its chemical make-up is not dense enough or oi atomic weight sufficient to cast a shadow either of the periphery or ol the nucleus, w c are able at tunes to make visible the mass b\ its increased density. Occasionally, even in difficult types of stones, it is 57 PLATE I Visible gall-stones. This examination was made with the Potter-Bucky diaphragm. PLANCHE I Calculs biliaires radiographics avec I'antidifTuseur Potter-Bucky. PLANCHA I Calculos visibles. EI exanien se hizo con el antidiiusor Potter-Bucky. GEORGE 6? LEONARD GALL-BLADDER PLATI I ANNALS Ol reiENOLOGY, VOL. I! i [SHI D BY PATHOLOGICAL ( , Al I -Bl.ADDLUs 39 possible to make one individual stone stand out even in a collection oi a larger number oi in\ isible stones. 1 he position oi the patienl on the plate and in relation to the tube (Figs. 1 and 2) is oi the utmost importance, and an efforl should be mack' to obtain a series oi films oi the right quality in the same position, rathei than to change the position oi the patient in relation to the tube. The fatter will [ead to uncertainty and error. LES VESICULES BILIAIRES M AI.ADI S II CALCU- LEUSES Dans la recherche des calculs biliaires on se heurte, sans doute, a des difficultes d'ordre physique, mais la plupart des obstacles peuvent etre surmontes avec une technique soignee. On ne saurait trop insister sur la necessite d'immobiliser non seulemenl la region, mais aussi les visceres, en suspendant la respiration. Le plus jaible mouvement respiratoire peut effacer un calcul qui, sans cela, serait bien visible (planche X, figs. 50 e1 31). Nous nous croyons en droit d'affirmer que tout calcul de taille ou de consistance raisonnables pent se montrer si Ton ne se rebute pas, si Ton ne neglige pas les details de la prist' du cliche, et, surtout, m Von immobilise le sujet. On ne negligera pas, non plus, d'explorer toute la zone ou peut se trouver une vesicule. Non seulement il faut balayer tout I'hypochondre droit, mais, parlors, descendre, [usqu'a la crete iliaque et meme plus bus. On ne sait jamais OU pent se blottir un ealeul. Une cause d'erreur possible, a not re connaissance, e'est la presence de verrues, loupes ou autres excroissances cutanees. Des cicatrices de la paroi abdominale ou dorsale, des ganglions mesenteriques cretaces, des corps 4 o PATHOLOGICAL GALL-BLADDERS etrangers du colon, des calcifications du foie ou du pancreas, des depots calcaires dans Ies cartilages costaux, des calculs ou des depots calcaires dans Ie rein droit, exceptionellement la myosite ossifiante, tout cela pent simuler Ie calcul biliaire. Quand Ies calculs pris individuellement n'ont pas une composition chimique permettant d'en obtenir une ombre, Ieur groupe- ment pent constituer une masse assez dense pour Ieur permettre de se reveler sur Ie cliche. Parfois, meme dans un amas de calculs pen visibles, un d'entre eux se montrera clairement. La position du malade et de I' ampoule (figs, i et 2), est tres importante. Mieux vaut obtenir une serie de plaques de bonne qualite photographique sans rien deplacer, que de modifier sans cesse I' orientation du tube; cette derniere pratique engendre des hesitations et des erreurs. INVESTIGACION DE LOS CALCULOS BILIARES No hay duda de que la investigacion de Ios calculos biliares, si no es metodica, tropieza con serias dificultades de orden fisico, que, sin embargo, el empleo de una tecnica cuidadosamente reglada podra veneer el mayor numero de veces. En ninguna otra ocasion son tan necesarias e imperiosas, como en esta, la inmovilidad de la region examinada y la suspension absoluta de la respiracion. EI mas breve movimiento respiratorio puede, por si solo, velar y haeer, desde Iuego, invisibles hasta las imagenes de calculos moderada- mente ricos en calcium que, sin esta circunstancia, habrian aparecido nitidos en Ios roentgenogramas (Plancha X, Figs. 30 y 31). Nosotros creemos no incurrir en error al sostener que ordinariamente es posible obtener la imagen de cualginer calculo de tamaho y consistencia medianos, con tal que se impresionen varias peliculas, se consuma elcorrecto numero de miliamperios a un voltaje adecuado y rio se descuide, ante todo, la inmovilizacion del sujeto. PATIIOI.OGICAI GAI L-M \DDL ; RS 41 Es asimismo importante extender la exploracion a toda la zona en la cual puedan encontrarse calculos biliares. No solo debe de examinarse todoel hipocondrio derecho sino que, a veces, es necesario descender nasta, \ aun por debajo, de la cresta iliaca, puesto que nunca se sabe donde fijamente esta el calculo. Nuestra experiencia nos ha advertido de varias causas tic error posible, tales sou: la presencia de verrugaSj unares, angiomas \ otras excrecencias cutaneas; las cicatrices en la pared abdominal y en la espalda; los ganglios mesenteric! >s cretaceos; Ins cuerpos ex1 ranos del colon; Ins depositos calcareos en el higado \ el pancreas; la calcificacion irregular de Ids cartilagos costales; los calculos \ los depositos calcareos en el rinon derecho \ , excepcionalmente, la miositis osificante de los musculos profundos. Cuando la composicion quimica de los diversos calculos de un grupo, considerados aisladamente, es tal que ni su peso atomico ni su densidad Ie permiten proyectar una sombra, bien sea de la periferia, bien del nucleo, del calculo, ocurre sin embargo, que su agrupamiento puede constituir una masa bastante densa para revelarse claramente en el disc. A veces tambien sucede que en un paquete de calculos poco visibles mm, entre todos, da una imagen netamente visible. La posicion del enfermo con relacion a la placa fotografica \ a la ampolla radiogena (Figs. 1 > 2) dc gran importancia. Valem as obtener una serie de peliculas de buena cualidad en la misma posicion de sujeto y ampolla, que alterando las relaciones de uno 3 otra; esto ultimo conduce a la incertidumbre v al error. PLAIT. II PLANCIII II PLANCHA II PLATE II Fig. 3. Woman, aged thirty-five. A mass of stones in the gall-bladder and one in the cystic duct. Illustrates the type of dense gall-stones containing more calcium than the usual gall-stone, and, in the experience of the writers, the only instance in which the stones cast such a definite shadow as is found in this case. Also illustrates the location of the gall-bladder in thin and poorly nourished men or women, especially in women. By the relation of the gall-bladder, though the stomach is not illustrated, one can seehow the pressure of these stones, even though they should prove to be a negative shadow, would cause de- formity of either the stomach or duodenum, either by fixation of a portion of the stomach or of the gall-bladder, or by pressure against the stomach or the second portion of the duodenum. If all gall-stones were of the density of these stones, they would be as easily recognized by the x-ray as kidney stones. This is the unusual type of very dense gall- stones, rarely seen. Fig. 4. A large number of gall-stones. Fig. 5. The gall-bladder full of almost pure bilirubin lime stones. PLANCHE II Fig. 3. Femme de 35 ans - Un amas de calculs dans la vesicule, un autre dans le canal cystique. Nous avons ici des calculs exceptionnellement riches en calcium, portant les ombres les plus nettes que les auteurs aient rencontrees. Le cliche montre aussi la situation ordinaire de la vesicule chez des sujets maigres ou denourris, generalement du sexe feminin. Par la seule position de la vesicule, bien que I'estomac ne soit pas visible, on se rend compte des tiraillements et des compressions que la vesicule biliaire peut exercer sur I'estomac ou sur la seconde partie du duodenum. Si tous les calculs biliaires avaient la densite de ceux figures ici, on les decelerait aussi facilement que des calculs renaux. On en rencontre rarement d'aussi opaques. Fig. 4. Nombreux calculs biliaires. Fig. 5. La vesicule remplie de calculs a base de bilirubinate de chaux presque pur. PLANCHA II Fig. 3. Mujer de 35 anos; Grupo de calculos en la vesicula y uno en el conducto cistico. Pertenece a una variedad excesivamente rica en calcio, y es el unico ejemplar en que los autores han podido obtener imagenes tan densas y precisas. EI clise muestra la situacion de la vesicula en sujetos flacos y mal nutridos, principalmente mujeres. Si bien no ensena la imagen del estomago, en cambio la posicion anormal de la vesicula da buena idea de como la presion ejercida por dichos calculos, aunque hubieran sido de los que originan sombras negativas, es causa importante y frecuente de deformaciones en las imagenes del estomago y del duodeno, ora fijando un segmento del estomago a la misma vesicula biliar o bien comprimiendo contra el estomago la segunda porcion del duodeno. Si todos los cal- culos biliares tuvieran la densidad de estos, su reconocimiento seria tan facil como el de los renales; pero raras veces suelen ser tan opacos. Fig. 4. Numerosos calculos biliares. Fig. 5. Vesicula biliar repleta de calculos de bihrubmato de cal casi puro. PLATE [] k m Fig. 3- Fig. 4. Fig. 5. PLATE II PLANCHE III PLANCIIA 111 PLATE III Fig. 6. Unusual arrangement of calcium shadows which suggest one single stone, possibly several stones. At operation, this proved to be one single stone. Fig. 7. Same case as shown in Fig. 6. Barium-filled stomach showing the relation of the shadows to the stomach. Fig. 8. X-ray of the gall-bladder region of a woman, showing several faint peripheral shadows due to gall-stones. Fig. 9. Two gall-stones in a woman, aged sixty. Illustrates one type of the character- istic peripheral calcium stone. The nucleus has very little density, if any. Easily recognized in plates and characteristic of gall-stones rather than of mesenteric glands or renal stones. The difficulty in demonstrating this type of stone is mostly in the patient's breathing or moving; otherwise it can be demonstrated without difficulty en the plate or film. PLANCH E III Fig. 6. Ceci pouvait etre du a un seul calcul ou a un amas compact. A ['operation: un calcul. Fig. 7. Rapport des ombres figurees plus haut avec I'estomac rempli de baryum. Fig. 8. Radiographic de la region vesiculate d'une femme, montrant plusieurs ombres annulaires tres faibles, dues a des calculs bilaires. Fig. 0. Deux calculs biliaires chez une femme de 60 ans. C'est la un des types du calcul a. couches concentriques avec cortex riche en chaux. On les differencie aisement d'avec les ganglions mesenteriques ou les calculs du rein. Si I'immobilisation du patient est assuree et la respiration suspendue, on doit pouvoir mettre de tels calculs en evidence. PLANCHA III Fig. 6. Imager bizarra de un calculo abundante en sales de calcio. Pudo ser producida tambien por un grupo compacto; pero la intervencion quirurgica demostro que no habia mas que uno. Fig. 7. El mismo caso de la figura 6. Muestra las relaciones de dicho calculo con la silueta del estomago. Fig. 8. Roentgenograma de la region biliar de una mujer presentando varias soni- bras anulares muy tenues debidas a calculos biliares. Fig. 9. Dos calculos biliares en una muier de 60 aiios. Son imagenes tipicas, facil- mente reconocibles y caracteristicas, de calculos biliares con nucleo de escasa densidad y periferia rica en sales de calcio. Se las diferencia sin trabajo de los ganglios mesentericos y de las piedras renales. Los principales obstaculos a su demostracion roentgenografica son la respiracion y los movimientos del enfermo. Si ambas cosas se evitan, el resultado satisfacto- rio es frecuente. I'l Ml Fu;. 6. Fig. -. Fig. 8. Fig. q. PLATI l\ PI.ANCIIb: IV PLANCIIA IV PLATE IV Fig. io. Woman, aged fifty-five; weight, 261 pounds. Two definite stones found with- out difficulty. At operation, 2 stones were found the size shown in the film and several smaller ones that were not visible on the plate. Fig. 11. Collection of small gall-stones within a small gall-bladder. At the time of operation several surgeons were unable to palpitate these stones through the gail-bladder wall. Under ordinary circumstances the surgeon would not have considered gall-stones, illustrating that all gall-bladders must be opened to determine the presence or absence of gall-stones. Fig. 12. Gall-bladder just below the liver; small in size but rather dense in shadow- producing qualities, suggesting the probability ot the pathological gall-bladder containing stones. Confirmed at operation. PLANCHE IV Fig. 10. Femme de 55 ans pesant 119 kilos. Deux calculs facilement decelables. A P operation on en trouva d'autres plus petits que la radio-graphie avait meconnus. Fig. 11. Amas de petits calculs dans une petite vesicule. A I'operation, plusieurs chirurgiens presents ne purent les sentir a travers les parois. Us se seraient crus en droit de nier leur presence. II laut done ouvrir une vesicule si Ton veut etre sur de ee qu'elle contient. Fig. 12. La vesicule situee immediatement sous le foie. Une ombre aussi nette, en depit de ses dimensions restreintes, fit dire que la vesicule devait etre malade et contenir des calculs. Confirmation operatoire. PLANCH A IV Fig. 10. Mujer de cincuenta y cinco aiios, que pesa 261 Iibras. Dos calculos facil- mente reconocibles. La operacion los encontro del mismo tamano que habian aparecido en la pelicula y ademas varios otros pequeiios no sospeehados. Fig. 11. Coleccion de pequeiios calculos dentro de una vesicula pcquena. Durante la operacion varios cirujanos presentes no pudieron sentirlos a traves de las paredes de la vegiguilla. En circunstancias iguales se comprende que pueda negarse su presencia. De ahi la necesidad de abrir siempre la vesicula para asegurarse si contiene o no calculos. Fig. 12. Vesicula situada inmediatamente por debajo del higado. A pesar de su exiguo tamano, como la sombra roentgeniana era tan densa, pensamos que se trataba de una vesicula enferma y con calculos. La operacion confirmo las sospechas. I'l \l I l\ Fig. io. Fig. ii. 'IG. 12. PLATE V PI.ANCIII-. V PLANCHA Y PLATE V Fig. 13. Illustrates the presence of gall-stones in a woman, aged twenty-three, and also illustrates, in the absence of visible stones, that the position of the stomach (plate made in the routine prone position) suggests always the possibility of fixation and pressure against the antrum (A), indicating the possibility of the gall-bladder being the cause of this deformity. Surgically proved to have 37 small stones. Fig. 14. Group of gall-stones of uniform size and density. Note dense peripheral shadows with very little shadow in the nucleus of each stone. Fig. 15. A well-nourished individual showing two of the common multiple-faceted stones. Easily recognized unless obscured by breathing. Stones of this type should always show on the plate or film. Fig. 16. Collection of small stones of low atomic weight, the gall-bladder slightly pressing against the antrum of the stomach. PLANCHE V Fig. 13. Calculs chez une femme agee de 23 ans. Le cliche demontre en plus que I'aspect de 1'estomac radiographic dans le decubitus abdominal pourrait suggerer des calculs merae si leur ombre etat absente. II est tiraille et I'antre pylorique, "A," est deformepar une compression exterieure. A 1'operation, 37 petits calculs. Fig. 14. Un groupe de calculs biliaires de forme et de composition identiques. Noter que le centre est beaucoup plus transparent que la peripheric Fig. 15. Deux calculs d'un type tres commun, dits calculs a facettes, radiographics chez un patient assez corpulent. On Ies decelera assez facilement si Ton a soin d'interdire tout mouvement, respiratoire 011 autre. Fig. 16. Un amas de petits calculs a poids atomique tres faible. La vesicule deforme un peu I'antre pylorique sur lequel elle appuie. PLANCHA V Fig. 13. Calculos biliares en una mujer de 23 anos. EI roentgenograma demuestra tambien que el aspecto y posicion del estomago, con el sujeto en decubito abdominal, podria, aim en la ausencia de imagenes calculares visibles, sugerir el diagnostico de adhe- rencias y deformacion del antro pilorico (A) ocasionadas por colecistitis calculosa. La opera- cion descubrio 3^ pequenos calculos. Fig. 14. Grupo de calculos biliares de tamafio y densidad uniformes. Notese que el cent m de cada calculo es mucho mas transparente que la periferia. Fig. 15. Dos ejemplares de una variedad de calculos muy comun, Ilamada en lacetas, obtenidos en sujeto de complexion robusta. Su diagnostico roentgenografico es facil, a con- dicion de prohibir durante la exposicion toda clase de movimiento. Fig. 16. Coleccion de calculos pequenos y de escaso peso atomico; la vesicula biliar comprime \ deforma Iigeramente el antro pilorico. 'I \ I I \ Fig. 13. Fig. 14. Fig. t$. Fig. if>. PI Ml VI PLANCH I VI PLANCH A VI PLATE VI Fig. 17. Collection of stones of uniform size and density. Periphery of the stones dense. The fact that there was an increased density about these stones was explained at the time of operation by the density of the bile in which these stones were contained. Fig. 18. Group of small stones; outline of gall-bladder. Fig. 19. Same case as Fig. 18, showing barium-filled stomach, taken in upright posi- tion. The outline of the gall-bladder is clearly seen. The stones were contained in a dense, dark, tarry bile, the bile casting, relatively, almost as much shadow as the nuclei of the stones. This case illustrates: (1) that the gall-bladder can be visible with or without stones; (2) that the position of the gall-bladder varies in this instance with the position ol the stom- ach when filled; (3) that the stomach is fixed more to the right than in a normal case. PLANCH E VI Fig. 1 7. Collection de calculs ayant meme forme et densite. La peripheric est plus opaque que le centre. Une ombre plus dense que les calculs semble Ies entourer. Elle s'expliqua a I'operation par la presence d'une bile tres epaisse, plus opaque aux rayons X que Ies calculs eux-memes. Fig. 18. Amas de petits calculs; vesicule profilee. Fig. 19. Le malade de la figure 18, son estomac rempli de baryum et radiographic debout. La vesicule est bien visible. Les calculs baignaient dans une bile epaisse et poisseuse presqu'aussi opaque qu' eux. On voit: (1°) que la vesicule est demontrable, qu'ellecontienne 011 non des calculs; (2 ) que, dans ces cas, Iorsqu'on remplit l'estomac, la vesicule se deplace avec Iui; (3 ) que l'estomac est phis a droite qu'il doit 1'etre. PLANCHA VI Fig. i~. Coleccion de calculos con tamaiio y densidad uniformes. La periferia es mas opaca que el centro. Una sombra mas densa que los calculos parece rodearlos. La operacion probo que era engendrada por bills muy espesa. Fig. 18. Grupo de calculos pequeiios. Visible el perfil de la vesicula. Fig. 19. El mismo caso de la figura anterior, pero con el estomago Ileno de bario y el roentgenograma de pie. El contorno de la vesicula se distingue netamente. Los calculos estaban banados por bilis oscura, espesa y pegajosa casi tan opaca como sus nucleos. Este caso sirve para demostrar: (1) que la imagen de la vesicula puede verse, contenga o qo calculos; (2) que en este sujeto la posicion de la vesicula varia con la del estomago lleno de bario y (3) que el estomago ocupa un sitio mas hacia la derecha que en las personas normales. PLAT! \ I Fig. it. Fk Fig. 19. PLAIT Ml PLANCHE VII PLANCH A VII PLATE VII Figs. 20, 21, 22. Variety and location of types of stones found in the study of patho- logical gall-bladders which contain stones. They should never be overlooked, as they are always visible if searched for. At times, unless due care is taken in regard to the breathing of the patient during examination, one may easily overlook these types, especially those shown in Figs. 16 and 21. PLANCHE VII Figs. 20, 21, 22. Divers types de calculs dans des positions differentes. On Ies decouv- rira toujours si Ton s'en donne la peine. lis pourraient demeurer invisibles si la respiration du sujet n'etait pas suspendue, particulierement ceux des figures 16 et 21. PLANCHA VII Figs. 20, 21 y 22. Diferentes tipos y situacion diversa de calculos coino suelen encon- trarse en el estudio de la colecistitis calculosa. Ordinariamente visibles, podrian, no obstante, pasar inadvertidos, si el enfermo no suspende la respiracion durante el examen, sobre todo Ios de Ies figs. 16 y 21. IM.ATI VII Fig. 20. Fig. 21 Fig. 22. PLATE V PLANCHE VIII PLANCHA VIII PLATE VIII Fig. 23. Outline of the pathological gall-bladder with bile in one cf the ducts. One can see in this duct several stcnes of negative value, so far as shadow is concerned. Fig. 24. Same case as shown in Fig. 23, three months later, after repeated gall-bladder attacks. Duct empty at this time; A, gall-bladder more sharply defined. At operation, a gall-bladder full of small stones was found. Fig. 25. A rather uncommon type of gall-bladder full of bilirubin lime stcnes. They were found to be very small and so friable that they were removed with a good deal of difficulty. Fig. 26. Three multiple-faceted stones. PLANCHE VIII Fig. 23. Profil d'une vesicule malade et d'un des canaux rempli de bile. Ce dernier contient plusieurs petits calculs portant des ombres negatives c'est-a-dire plus transparent^ que leur entourage. Fig. 24. Meme malade (Fig. 23), 3 mois apres. II a eu plusieurs crises. Cette fois, Ies canaux bihaires sont vides, mais la vesicule, "A," est plus evidente. A I'operation on la trouva pleine de petits calculs. Fig. 25. Une vesicule remplie de calculs a base de bilirubine-chaux. lis etaient si petits et si friables qu'on cut du mal a Ies extraire sans Ies detruire. Fig. 26. Trois calculs a facettes multiples. PLANCHA VIII Fig. 23. Contorno de la vesicula enferma y de uno de Ios conductos Ileno de bilis. D entro del conducto hay varios calculos con imagen negativa, es decir menos opaca que la bilis circundante. Fig. 24. EI mismo caso de la fig. anterior 3 meses despues, durante Ios cuales tuvo varios colicos. EI conducto esta vacio, pero la vesicula (A) es mas evidente y en la operacion se la encontro Ilena de pequenos calculos. Fig. 25. Caso no frecuente. Vesicula Ilena de calculos al bilirubinate de cal. Eran tan pequenos y friables que se extra jeron con suma dificultad. Fig. 26. Tres calculos de facetas multiples. PLAT] \ III Fig. 23. Fk;. 24. Fig. 25. IG. 26. PI. A I I IX PLANCIIP IX PLANCHA IX PLATE IX Fig. 27. One large gall-stone. The gall-bladder and the stone are causing pressure against the antrum of the stomach. This stone was not recognized in the gall-bladder plates or films but was visible during the barium meal. Confirmed at operation. Fig. 28. Plate of the gall-bladder region in a large woman, made with the Potter- Bucky diaphragm; brought out more definitely than is possible with the ordinary method. Calcium shadows found near the right transverse process of the second lumbar vertebra. Fig. 29. One large gall-stone. PLANCH E IX Fig. 27. Un gros calcul. La vesicule comprime I'antre pylorique. On meconnut ce calcul lors des premiers examens et il ne fut decouvert qu'au cours des examens au baryum. Confirmation operatoire. Fig. 28. Cliche de la region vesiculaire fait avec 1'antidiffuseur Potter-Bucky, chez une grosse femme. Calculs a composition calcaire, visibles pres de I'apophyse transverse de la deuxieme Iombaire. L'antidiffuseur a donne dans ce cas des images meilleures que celles possibles avec la technique ordinaire. Fig. 29. Un gros calcul biliaire. PLANCH A IX Fig. 27. Un calculo voluminoso. La vesicula y la piedra comprimen el antro pilorico. Paso inadvertida en los roentgenogramas directos de la region; pero se le descubrio al llenar el estomago con bario. Confirmado quirurgicamente. Fig. 28. Placa de la region biliar de una mujer corpulenta, hecha con el antidifusor Potter-Bucky. Calculos a base dc calcio visibles cerca de la apofisis transversa de la segunda lumbar. El antidifusor produjo imagenes mejores que las que hubiera dado el metcdo habitual. Fig. 29. Un calculo biliar voluminoso. I'l Ml l\ Fig. 2-. Fig. 28. Fig. 29. PLATE X PLANCHi; X PLANCHA X PLATE X Fig. 30. One large laminated gall-stone in a woman, aged thirty; removed. Fig. 31. Same case as Fig. 30. Illustrates a plate made with the same technique and in the same position but in which the stone was not visible, due to the patient not holding her breath. Illustrates the care that must be used in observing this one detail of gall-bladder examination. A stone as dense as this one seems to be in Fig. 30, is not visible in any way in Fig. 31 ; it is entirely obliterated by motion. Fig. 32. Plate of a large individual showing group of small stones and pressure of the gall-bladder upon the first portion of the duodenum. This is the type of pressure defect which should always open the question of a possible pathological gall-bladder which may or may not contain stones, since it is the only organ in this region that can produce a deformity of this size and shape, with the remote possibility of an extra lobe of the liver or an increase in a portion of a lobe of the liver. This plate is used not so much to show the stones as to show the characteristic effect of the pressure of the gall-bladder upon the first portion of the duo- denum. Fig. 33. Case referred as a palpable tumor, possibly of the proximal portion of the transverse colon or hepatic flexure. A'-ray examination showed gall-stones in a large gall- bladder with fixation of the gall-bladder to the bowel. Condition confirmed by operation to have been due to a large gall-bladder containing stones. PLANCHE X Fig. 30. Un gros calcul a couches concentriques, en pelurc d'oignon. Femme de 30 ans, operee. Fig. 31. Mime cas (fig. 30). Ce cliche a etc fait dans la meme position et avec la meme technique que precedemment. Mais le calcul est invisible, Ie malade n'ayant pas suspendu sa respiration. On voit I'importance de ce dernier detail, puisqu'un calcul aussi visible que celui de la fig. 30 a pu s'evanouir completement. Fig. 32. Cliche d'un patient corpulent montrant un groupe de petits calculs et la pression exercee par la vesicule sur la premiere portion du duodenum. Une deformation de ce genre doit toujours faire soupconner la vesicule, car elle seule peut la produire, l'occurrence d'un lobe hepatique hypertrophic ou surnumeraire ctant \ raiment exceptionnelle. Fig. 33. Le malade avait une masse palpable dans 1'hypochondre droit, qui pouvait bien etre une tumeur du colon a la coudure hepatique ou a la portion initiale du transverse. La radiographic montra des calculs dans une grosse vesicule adherente a 1'intestin. Confirma- tion operatoire. PLANCHA X Fig. 30. Calculo de grandes dimensiones y capas concentricas en una mujer de 30 anos; opera da. Fig. 31. EI mismo caso de la 30. Roentgenograma hecho con tecnica y posicion iguales al anterior, pero el calculo es invisible, porque la enferma no suspendio la respiracion He ahi demostrada la importancia de ese requisito: un calculo bien visible se esfuma con el movimiento. Fig. 32. Placa de un individuo corpulento, mostrando un grupo de pequenos calculos v la compresion que la vesicula ejerce sobre el primer segmento del duodeno. Deformaciones como esta deben sugerir siempre la posibilidad de una vesicula biliar enlerma, puesto que es el unico organo de la region capaz de producirla con forma y tamano semejantes; rara vez podran atribuirse a la prcsion de un lobulo hepatico hipertrofiado o supernumerario. EI objeto principal de este roentgenograma es el de mostrar esa caracteristica deformacion. Fig. 33. EI enfermo presentaba un tumor palpable en el hipocondrio derecho, que bien podria ser un neoplasma de la acodadura fiepatica o de la porcion inieial del colon transverso. EI examen roentgenografico descubrio calculos biliares en una vesicula grande, adherida al intestino; y la operacion confirmo ese diagnostico. PLAT] \ Fie. 30. Fig. ji. Fig. 32. Fig. 33- PLATE XI PLANCHE XI PLANCH A XI PLATE XI Fig. 34. Case referred for probable gall-stones. Plates showed a group of small shadows unquestionably due to calcium. Diagnosis: Probable collection of small stones. Operation: Drainage of gall-bladder; no evidence of the stones. Plates made several weeks after operation showed no evidence of these shadows. Conclusion: Either these stones were being passed through one of the ducts at the time of the x-ray examination, or they were lost during drainage. Fig. 35. Palpable tumor in upper right quadrant, in an elderly woman, found to be due to 3 large gall-stones and several small ones. This plate illustrates the size, position, and pressure of the gall-bladder upon the colon, which one occasionally observes. Fig. 36. One stone of unusual shape, and of more or less uniform density. Fig. 3". Group of small stones with very little calcium, showing as much of the out- line of the gall-bladder as of the stones. Extremely low penetration is necessary to make these stones visible. PLANCHE XI Fig. 34. Diagnostic clinique: Cholelithiase probable. La radiographic montra un groupe de petites ombres evidemment dues a. de la chaux. On en conclut a la presence proba- ble de calculs. La vesicule fut cuverte, on n'y trouva pas de calculs et on la draina. Des cliches pris plusieurs semaines apres ne portaient plus Ies ombres suspectes. II faut conclure que Ies calculs etaient en voie d'expulsion lors de la radiographic ou bien qu'ils sont passes inappercus dans Ies pansements. Fig. 35. Masse palpable dans 1'hypochondre droit chez une vieille femme. Elle etait due a trois gros calculs biliaires et plusieurs petits. Le cliche montre la forme et la position de la vesicule amsi que la pression sur le colon qu'elle exerce parfois. Fig. 36. Un calcul non homogene; sa forme est exceptionnelle. Fig. 37. Groupe de calculs pauvres en chaux. lis ne sont pas plus visibles que Ies parois de la vesicule. PLANCH A XI Fig. 34. Diagnostico clinico: probable colehtiasis. La radiografia demuestra un grupo de pequenas sombras, producidas evidentemente per sales de cal. Diagnostic! roentgeno- Iogico: probable coleccion de pequenos calculos. A la operacion no se encontraron calculos y se dreno la vesicula. Placas tomadas varias semanas despues no contenian ya las sombras sospechosas. Es includable que, una de dos, o Ios calculos seexpulsaron inmediatamente despues del primer examen roentgenologico o pasaron inadvertidos en el drenaje. Fig. 35. Tumor palpable en el hipocondno derecho de una vieja. Era debido a tres gruesos calculos, acompanados de vanos pequenos. Esta placa demuestra el tamano, posi- cion y compresion de la vesicula sobre el colon, segun se observa a veces. Fig. 36. Un calculo de forma bizarra y de extructura irregular. Fig. 3". Grupo de pequenos calculos pobres en calcio, no mas visibles que el con- torno de la vesicula. Para obtener su imagen es necesario usar una ampolla blanda. II \ II-: xi Fig. 34. Fig. 15. Fig. 36. Fig. 3" PLATE XII planchl xii PLANCH A XII PLATE XII Fig. 38. Three small stones. Fig. 39. One large stone. Note the irregular outline of the peripheral shadow. Fig. 40. Gall-bladder area of a woman with roentgen diagnosis of probable stones. A dense shadow, uniform in quality, was found over the edge of the vertebrae. Surgically, proved to be a pancreatic stone, the pancreas containing several stones. (See Fig. 41 for lateral view.) Fig. 41. Same case as shown in Fig. 40. Lateral view showing the position of the stone in relation to the duodenum and the posterior wall of the stomach. A, stone; B, pylorus. Stones not removed at operation. Gall-bladder removed and fcund pathological. PLANCHE XII Fig. 38. Trois petits calculs. Fig. 39. Un gros calcul; noter l'aspect irregulier de son contour. Fig. 40. Region vesiculate d'une femme suspecte de Iithiase biliaire. Une tache opaque recouvre le rebord de la vertebre. L'operation decouvrit un calcul du pancreas. (Voir aussi la figure 41.) Fig. 41. Le raeme calcul (Fig. 40), en Iaterale. On voit sa position relativement a la paroi posterieure de 1'estomac et au duodenum. A, calcul. — 5, pylore.— On laissa Ies calculs du pancreas; la vesicule etant malade, on 1'extirpa. PLANCH A XII Fig. 38. Tres calculos pequeiios. Fig. 39. Calculo voluminoso de contorno irregular. Fig. 40. Region biliar de una mujer con diagnostico roentgenologico de probable colelitiasis. Una sombra de uniforme y marcada densidad cubre el reborde de la vertebra. La operacion demostro que se trataba de un calculo del pancreas que, ademas, contenia otros. (Vease fig. 41, imagen lateral.) Fig. 41. EI mismo caso de la fig. 40. Vista lateral ensenando la posicion de la piedra en relacion con el duodeno y la pared posterior del estomago. A, calculo; B, poloro. No se extrajeron los calculos pancreaticos, pero se extirpo la vesicula enferma. PLATE XII Fig. 38. Fig. 39. Fig. 40. Fig. 41. THE VISIBLE PATHOLOGICAL GALL-BLADDER Plates XIII to XXIV are used to illustrate, so far as possible, the vari- ous types of pathological gall-bladder that one meets with in studying a series of cases, and are chosen to illustrate various sizes, shapes, and positions ol the gall-bladder. The mere study of a series of films showing a visible gall- bladder is not so important as using the complete set, including tin- barium meal. In almost every instance of a definite pathological gall-bladder, we shall observe either indirect or secondary changes. Unfortunately, it is not possible, in every instance, to add to the series of gall-bladder plates the accompanying barium meal films. The errors that arise in the stud\ of tin- visible gall-bladder occur in selecting the shadow which is produced by the gall-bladder. The commonest source of error is the visible kidney outline. For some reason not clear to the writers, the kidney becomes, m certain cases (m the female especially), vcr\ definitely visible, sometimes in an unusual position, and occasionally a portion of the kidney will show, as the upper pole or the lower pole, or one ol its borders, or a high kidney will be seen. These conditions may lead one to suspect the shadow as being due to the gall-bladder. It would seem possible, in every instance, to show the kidney, but it has not been the experience ol the writers that even in a very carefully exposed series ol films has this always been possible. Occasionally, with what is apparently the clearest and most visible gall-bladder, one may be in error, since this shadow may be the stomach full of the ordinary food meal or liquids. Again, postoperative gall- bladder cases will sometimes reveal, even alter the removal ol the gall-bladder, shadows that are similar in size, shape and position to the gall-bladder; and w c have found surgically, that in some instances this is due to omental fat which has accidentally given us a shadow. Again, extra lobes of the liver, as a caudate or RicckTs lobe, will give us a very definite shadow 87 PLATE XIII The arrows point to a visible gall-bladder overlying the upper pole of the kidney. This is the type of a pathological gall-bladder which by its size, shape and position will cause pressure either upon the first portion of the duodenum, or the antrum of the stomach, or the second portion of the duodenum. PLANCHE XIII La fleche signale une vesicule visible recouvrant Ie pole superieur du rein. Cest la le type d'une vescule pathologique pouvant, par ses dimensions sa forme et sa position, exercer une pression soit sur la premiere portion du duodenum, soit sur I'antre pylorique, soit sur la seconde portion du duodenum. PLANCH A XIII Las flechas indican la imagen de la vesicula sobrequesta a la del polo superior del rinon. Es el tipo de vesicula biliar enferma que, por su tamano, forma y posicion, corn- prime y deforma el bulbo duodenal, el antro pilorico o la segunda porcion del duodeno. GEORGE 6? LEONARD— GALL-BLADDER ''I ATF. >'HI ANNALS OF ROENTGENOLOGY, VOL. II. PUBLISHED BY PALL B. HOEBER. N. Y PATHOLOGICAL GALL-BLADDERS 89 that one might mistake for a gall-bladder. This special condition must always be kept in mind; it is in these cast's, as in all cases, that the indired or second- ary signs make the diagnosis more definite or less so. Fecal matter in the hepatic colon or proximal portion of the transverse colon may, unless the films arc carefully studied, be mistaken Tor a shadow suggestive ol the gall-bladder. &* LA VESICULE VISIBLE Les planches XIII a XXIV qui suivent ont etc choisies pour illustrer, autant epic possible, les divers types de vesicule pathologiques el les varietes de calculs qu'on pent rencontrer. La simple lecture d'une serie de plaques ou se montre la vesicule est moms utile epic ['etude de tout 1111 jeu de plaques ou figure aussi I'estomac rempli de baryum. Dans presque tons les cas ou la vesicule est visible, no pourra observer des symptomes second- aires ou mdirects. Malheureusement il n'est pas toujours possible de completer les examens de la vesicule par I'examen gastro-intestinal. En recherchant ['image de la vesicule on est expose a certaines con- tusions. L'ombre qui prete le plus aux meprises est celle du rein. Pour des raisons epic nous ignorons, le rein pent etre, surtout chez la femme, tres visible; il apparaitra dans une position msolite, parlois ties haut. Ou encore on tie vena qu'une partie de son contour, Tun ou "autre de ses poles ou son rebord. II serait facile de prendre une telle image pour la vesicule. II n'esl pas toujours possible, dans ['experience des auteurs, de montrer tout le rem, meme en multipliant les cliches. Parlois le contenu solide ou liquide de I'estomac pent donner le change. Chez un malade dont la vesicule a etc extirpee on trouvera des ombres qui semblent dues a I'organe absent. L'exploration chirurgicale nous a montre epic, dans ces cas, "ombre pro'V enah des masses graisseuses de ['epiploon. Enfin, des lobes h&patiques, lobes 90 PATHOLOGICAL GALL-BLADDERS caudes ou de Riedel, — peuvent simuler la vesicule. On devra toujours penser a ccs causes d'erreur et ne pas negliger, pour etayer Ic diagnostic, Ics indices accessoires. Bien entendu, des matieres fecales, a I'anse hepatique ou dans la premiere portion du colon, sont capables dc fournir des images semblables a cdles de la vesicule. IMAGEN ROENTGENIANA DE LA VESICULA BILIAR ENFERMA Los clises XIII y XXIV se eligieron con el proposito de ilustrar, en todo Io posible, Ios diversos tipos de vesicula biliar enferma y las situaciones dis- tmtas en que el investigador puede eueontrar la cuando estudie un grupo de casos. La mera lectura de una serie de peliculas en cjue sc muestre la vesicula no tiene tanta importancia como el estudio de un juego completo, que in- cluya la imagen del estomago Ilcno dc bario. En casi todos Ios casos de enfermedad de la vesicula biliar se observaran sintomas indirectos o secun- darios. Por desgracia, no siempre es posible completar el examen de las vias bihares con el del tubo digestive Los errores que se cometen en el estudio de la vesicula biliar dependen, en su mayor parte, de una equivocada seleccion de la sombra que ha de corresponderle en la placa. La causa mas frecuente de error es el rinon dere- cho, cuya sombra, por razones que ignoramos todavia, se muestra en cicrtos casos, pero sobre todo en las mujeres, claramente visible, apareciendo, unas veces, en posicion insolita, algunas, situado muy arriba y otras, destacando solamente la silueta dc! reborde o de uno de sus polos, bien sea el inferior o ya el superior; circunstancias todas que favorecen la confusion de estas sombras con las de la vesicula biliar, tanto mas cuanto que, segun nuestra experiencia, no es posible, ni aim multiplicando Ios clises, obtener en todos Ios casos la imagen total del rinon. A veces podria tomarse por la sombra de una vesicula bien visible Io que no es otra cosa que el estomago Ilcno de PA I HOI OGICAL GA] L-BLADDERS 91 li(|uiclo de materiales alimenticios. IVIas todavia; un operado de colecis- tectomia puede mostrar, algun tiempo despues, en la region Dinar sombras similares, porsu tamano, forma \ posicion a la de la vesicula; \ sin embargo, la experimentacion quirurgica nos ha demostrado que, en ciertos casos, dichas imagenes son producidas por masas grasosas, epiploicas. Ademas, algunos lobulos accesorios del higado, como el lobulo caudado no en la renal. Fig. 50. El mismo de la figura 49. Veanse las relaciones de las sombras sospechosas con las dos primeras porciones del duodeno, nocion que viene a reforzar el diagnostic* > probable de calculos de la vesicula y conduct us biliares. Fa vista lateral demuestra que las relaciones con el rinon son normales. La operacion descubrio 4 piedras redondas en la vesi- cula, una de ellas midiendo 2^ milfmetros cle diametro; y dos alargadas en el coledoco. La vesicula adheria a la cara inferior del higado. No habia otras adherencias. Fig. 51. Vesicula visible adherida al estomago. Solo pudo demostrarse durante el examen con desayuno opaco. PLAT! W I Fig. 49. Fig. 50. Fig. 51. PLATE \\ II PLANCIII". XVII PLANCHA XVII PLATE XVII Fig. 52. Large visible pathological gall-bladder containing calcium shadows. (It will be noted that the lines of the gown the patient wore are shown.) This case illustrates the extreme care on exposure that was necessary to bring out the outline of this gall-bladder. I echnically, the difficulty in making this examination was the over-penetration which would obscure the outline of the gall-bladder. It was only when using a very low spark gap, very high milliamperage and a very rapid exposure, with forced development, that we could get the outline of this gall-bladder. Fig. 53. Woman, aged fifty, showing a visible gall-bladder containing only dense, tarry bile. Fig. 54. Woman, aged twenty-eight, operated upon for chronic cholecystitis several years previous; drained. Complete recovery. Return of symptoms prior to this examination. Roentgen films showed visible gall-bladder with fixation ol the stomach in the area of the shadow. Operation confirmed roentgen findings Fig. 55. Visible gall-bladder. Surgically: Chronic cholecystitis, without stones. PLANCH E XVII Fig. -,"2. Crosse vesicule visible encadrant des ombres calcaires. On peut juger du soin qu'il fallut apporter a la technique par la presence des ombres vestimentaires. Un ray- onnement dur cut efface Ie profil de la vesicule. Seuls un rayonnement tres mou, avec fort courant et breve exposition purent la mettre en ex idence. Fig. 53. Femme de 50 ans; sa vesicule, visible, ne contenait cjue de la bile epaissc, poisseuse. Fig. 54. Femme de 28 ans operee plusieurs annees auparavant pour cholecystite. Guerison complete apres drainage. Reapparition des troubles. A la radio, vesicule xisible avec estomac fixe clans les limites de ['aire vesiculaire. Confirmation operatoire. Fig. ,-,". Vesicule \ isible. A ('operation: cholecystite chronique non-calculeuse. PLANCHA XVII Fig. -,"2 Voluminosa vesicula conteniendo sombras calcareas. La presencia en el clise de algunas imagenes vestimentarias da clara idea de la delicadeza de tecnica necesaria para demostrar la vesicula: empleando rayos duros no se hubiera obtenido su imagen, mientras que el exito lue posible con una breve exposition a rayos muy blandos y gran miliamperaje. Hubo necesidad tambien de forzar el desarrollo. Fig. 53. Mujer de 50 anos, mostrando una vesicula Ilena de bilis espesa y pegajosa. Fig. 54. Mujer de 28 anos, operada varios anos antes por colecistitis cronica. Drenaje de la vesicula y curacion immediata. Reaparicion de los sintomas y necesidad de un niievo examen. El roentgenograms demostro 'la vesicula xisible y el esti'nnago arrastrado. \ fijo por adherencias a la sombra vesicular. La operacion confirmo el diagnostico. Fig. si- Vesicula xisible. A la operacion, colecistitis cronica no calculosa. I'l \l I w I Fig. 52. Fig. 53. A Fig. 54. Fig. 55. PLATF, Will PLANCHK Will PLANCH A Will PLATE XVIII Fig. 56. Delinite shadow in the region of the gall-bladder. Roentgen diagnosis: Probable pathological gall-bladder which may or may not contain stones. Surgically : Moderately dilated gall-bladder full of calcium bilirubin stones. Fig. 57. Visible gall-bladder in a case apparently similar to the case shown in Fig. 56, but containing pure bilirubin lime stones in large numbers. Fig. 58. Definite outline of the lower pole of the right kidney. Over upper pole is a dense shadow which was reported as probably a pathological gall-bladder. Surgically: Chronic cholecystitis. It was with great difficulty that the differential diagnosis between the shadow over the upper pole of the right kidney and the shadow produced by the upper pole of the right kidney could be made. The diagnosis from the roentgen standpoint was doubtful. At operation, a definite pathological gall-bladder was found. PLANCH E XVIII Fig. 56. Ombre nette dans la region de la vesicule. Diagnostic radiologique: vesicule probablement malade, hthiasc douteuse. A ['operation: vesicule moyennement dilatee remplie de calculs a base de bilirubine-chaux. Fig. 5~. Vesicule visible, dans un cas analogue au precedent. Elle contient beaucoup de calculs de bilirubinate de chaux pur. Fig. 58. Le pole inferieur du rem droit, nettement profile. Recouvrant le pole supe- rieur, unc ombre intense qu'on signala comme etant probablement la vesicule. A ['opera- tion: cholecystite. On eut beaucoup de mal a differencier I'ombre du pole superieur d'avec 1'ombre sus-jaeente. Le diagnostic radiologique etait hesitant. A I'operation on trouva une vesicule evidemment malade. PLANCH A XVIII Fig. 56. Sombra precisa en la region biliar. Diagnostico roentgenologico: probable colecistitis cronica, con o sin calculos. A la operacion: vesicula medianamente dilatada Ilena de calculos de bilirubinate de cal. Fig. j~. Vesicula visible en un caso analogo al precedente, conteniendo gran numero de calculus de bilirubinate de cal puro. Fig. 58. Contorno preciso del polo inferior del rinun derecho. Sobre el polo superior se nota una sombra densa que se creyo pertenecer a una vesicula enferma. A la operacion, se confirmo la colecistitis. La diferenciacion entre la sombra del polo superior del rifton y la de la vesicula, superpuesta, fue muy dilicil. EI diagnostico roentgenologico era dudoso. La intervencion descubrio una vesicula evidentemente enferma. PLAT! Will Fig. 56. Fig. 5-. Fig. 58. PLATE XIX PLANCHE XIX PLANCHA XIX PLATE XIX Fig. 5Q. Two distinct shadows, one due to the gall-bladder (A), the other, the lower pole of kidney (B). The gall-bladder contained a large number of pure bilirubin lime stones. Fig. 60. Pathological gall-bladder, apparently without stones, and pressure on an- trum of stomach. Surgically: Chronic cholecystitis. Fig. 6i. Pathological gall-bladder containing small stones. Fig. 62. Visible gall-bladder in a woman. Surgically: Chronic cholecystitis, with one stone in the common duct, which was not visible on examination. This examination was made at the twenty-four-hour period. PLANCHE XIX Fig. 59. Deux ombres bien defmies; I'une, A, due a la vesicule; 1'autre, B, au pole inferieur du rein. La vesicule contenait de nombreux calculs de bilirubinate de chaux. Fig. 60. Meme malade. On voit ici la pression exercce par la vesicule Mir la premiere portion du duodenum. Fig. 61. Vesicule malade contenant des petits calculs. Fig. 62. Vesicule visible chez une femme. A ('operation: cholecystite chronique, avec un calcul dans le canal choledoque. II etait demeure invisible a la radiographic PLANCHA XIX Fig. ,(). Dos sombras bien definidas: una (A) es la de la vesicula y la otra (B) del polo inferior del rinon. La vesicula contenia numerosos calculos de bilirubinato de cal puro. Fig. 60. Vesicula enferma, aparentemente sin calculos, pero comprimiendo el antro pilorico. A la operacion, colecistitis cronica. Fig. 61. Vesicula enferma conteniendo calculos pequenos. Fig. 62. Vesicula visible en una mujer. A la operacion; colecistitis cronica con un calculo en el coledoco que no se revelo durante el examen. Este examen se hizo 24. horas despues de mgendo el desayuno opaco. I'l VI I \l\ Fig. ,-< Fig. 60. Fig. 61. I .... 62. PLATE XX PLANCHE XX PLANCHA PLATE XX Fig. 63. Definite pathological gall-bladder with no evidence of stones. (See Fig. 64 for surgical findings.) Fig. 64. Gall-bladder after removal, showing the gall-bladder, before opening, to contain one large stone. Note in this instance that the periphery of the stone shows no calcium deposit. Nucleus of stone faintly visible; extreme thickness of gall-bladder wall. Roentgen diagnosis: Pathological gall-bladder. Surgically: One large gall-stone was found. Fig. 65. Plate made several days after the gastro-intestinal examination lor confirma- tion of a shadow found in the previous gall-bladder plates. Original plates showed a definite, visible gall-bladder. Surgically: Chronic cholecystitis without stones. Fig. 66. Large, dense gall-bladder and several stones. It is interesting that in this case, throughout the examination, stones would appear and disappear; in some plates there were several; in others, only one. At operation a large gall-bladder full of inspissated bile and pus was found, with a number of dense calcium stones. PLANCHE XX Fig. 63. Vesicule visible, sans calcul apparent. Voir plus loin pour Ies constatation operatoires. Fig. 64. La vesicule extraitc, avant d'etre ouverte. Elle contient un gros calcul. Noter qu'il n'y a pas de calcium dans Ies couches exterieures. Le noyau est faible mentvisible. Les parois de la vesicule sont tres epaisses. Diagnostic radiologique: vesicule malade. Constatations operatoires: calculs. Fig. 65. Cliche fait plusieurs jours apres un exsmen gastro-intestinal dans le but de retrouver des ombres nettement percues sur les radiographies consacrees specialement a la vesicule. Fig. 66. Grosse vesicule tres dense, contenant plusieurs calculs. Fait curieux, 1'aspect a varie d'un cliche a ['autre. Certaines plaques montraient plusieurs calculs, d'autres un seul. A 1'opcration: grosse vesicule remplie de bile epaissie et de pus, avec plusieurs calculs a forte teneur en chaux. PLANCHA XX Fig. 63. Vesicul 1 evidentemente enferma y visible, sin calculo aparente (Vease la fig. 64 para las observaciones quirurgicas) . Fig. 64. La vesicula extirpada deja ver, antes de abrirla, un calculo grande — Notese que la periferia no contiene sales de calcio. EI nucleo es Iigeramente visible. Las paredes de la vesicula son muv gruesas. Diagnostico roentgenoiogico: Colecistitis cronica. Obscrvacion quirurgica: un calculo voluminoso. Fig. 65. Roentgenograma hecho algunos dias despues de un examen gastro-intes- tinal, para confirmar la preseneia de una sombra encontrada en anteriores examenes par- ticulares de la vesicula. Las placas originales mostraban distintamente la vesicula biliar, La operacion descubrio una colecistitis cronica no calculosa. Fig. 66. Vesicula grande y de paredes gruesas conteniendo varias piedras. Es intere- sante advertir que durante el examen de este caso Ios calculosserevelaron inconstantemente visibles; mientras que algunos clises exhiben varios, otros no muestran mas que uno. A la operacion se eucontro una vesicula grande Ilena de bilis espesa y pus, conteniendo muchos ealculos ricos en calcio. II Ml \\ Fig. 64. Fig. 63. Fig. 65. Fig. 66. PLATE XXI PLANCIII XXI PLANCHA XXI PLATE XXI Fig. 67. Large gall-bladder high up in the right quadrant, which could not be confused in the original plates with the kidney. Very dense. At operation, it was found to contain some very small bilirubin lime stones, but density in plates was due to the extreme densitj of the bile and to the partial obstruction of the cystic duct. Fig. 68. Definite, visible gall-bladder with some secondary manifestations in the gastro-intestinal examination — enough to confirm the opinion that this shadow represented the gall-bladder. Surgically: Chronic cholecystitis without stones. Fig. 69. Pathological gall-bladder with small stones. Fig. 70. Pathological gall-bladder without stones. PLANCHE XXI Fig. 67. Grosse vesicule haut situee dans I'hypochondre droit. Impossible a confondre avec le rein. A l'operation on y trouva de tres petits calculs de bilirubinate de chaux, mais I'opacite etait surtout due a la consistance epaisse de la bile et a une obstruction du canal cystique. Fig. 68. Ombre definie pouvant etre la vesicule. Confirmation suffisante par les symptomes secondaires constates au cours de 1'examen gastro-intestinal. A ['operation: cholecystite ehronique, sans calculs. Fig. 69. Vesicule visible. Elle est malade. Fig. 70. Vesicule malade, sans calculs. PLANCHA XXI Fig. 67. Vesicula grande en la region mas alta del hipocondrio derecho, imposible de confundir con el rifion. Imagen muy densa. A la operacion contenia algunos calculos peque- nos de bilirubinato de cal; la opacidad era debida a la consistencia espesa de la bilis y a una obstruccion parcial del conducto cistico. Fig. 68. Vesicula biliar bien visible. Los sintomas secundarios revelados por el exa- men gastro-intestinal corroboran esta opinion. A la operacion, colecistitis cronica no calculosa. Fig. 69. Vesicula enferma con pequenos calculus. Fig. ~o. Vesicula enferraa sin calculos. I'l Ml \\l Fig. 67. Fig. 68. Fig. 69. Fig. "ii. PLATE XXII PLANCHE XXII PLANCHA XXII PLATE XXII Fig. 71. Large pathological gall-bladder which is displacing the ascending colon and hepatic flexure, due to hydrops of the gall-bladder. Fig. 72. Shadow of a large gall-bladder. The position of the second portion of the duodenum is significant as suggesting fixation. Surgically: Hydrops of the gall-bladder. This plate was made in 191 3; it was confirmed at operation several years later. Fig. 73. Woman, aged sixty. Referred as a palpable tumor in the upper right quad- rant. Clinical diagnosis: Probable carcinoma of the stomach. X-ray examination ol the stomach, negative. This plate, made at six hours, outlined a large gall-bladder. Surgically: Hydrops of the gall-bladder. This shadow was not determined in the routine gall-bladder examination, as the fundus of the gall-bladder was below the area examined. PLANCH E XXII Fig. 71. Epanchement dans la vesicule. Elle deplace le colon ascendant et 1'anse hepatique. Fig. ~2. Image d'une grosse vesicule. La position de la seconde portion du duodenum fait penser a une fixation. Cliche fait en 1913; plusicurs annees apres, I'operation revela un epanchement dans la vesicule. Fig. -3. Femme de 60 ans. Tumeur palpable dans I'hypochondre droit. Diagnostic clinique: cancer probable de I'estomac. L'examen radiologique ne revela aucun signe de cancer. Sur le cliche ci-ioint, fait 6 heures apres ingestion de baryum, la vesicule se montre. Elle n'avait pas ete vue dans la serie pregastrique. A I'operation: epanchement dans la vesicule. PLANCH A XXII Fig. 71. Hidropesia de la vesicula. EI colon ascendente y la acodadura hepatica aparecen desplazados. Fig. ~2. Imagen de una vesicula grande. La posicion del segundo segmento del duo deno sugiere la posibilidad de adherencias y fijacion. La placa se hizo en 1913; varios afios despues la operacion revelo una hedropesia de la vesicula. Fig. "3. Mujer de 60 anos. Presenta un tumor palpable en el hipocondrio derecho Diagnostico clinico: probable carcinoma gastrico. Examen roentgenologico del estomago, negativo. Este clise fue hecho seis horas despues de la comida opaca y ofrece la imagen de una vesicula grande; imagen que no pudo observarse durante el examen particular de la vesicula, porque su fondo descendia por debajo del area examinada. A la operacion, hidro- pesia de la vesicula. PLATE XXI] Fig. 71. Fig. 72. I [G. 73. PI Ml Will PLANCHE XXIII PLANCH A XXIII PLATE XXIII Fig. -4. Large pathological gall-bladder, very easy to visualize under proper tech- nique. Unfortunatelj in this series of plates we were unable to determine the exact position of the kidney. The question whether this was the kidney or not was difficult to decide. There were no other changes, either direct or secondary, that were of help in determining this problem. Clinically, there was an easily palpable gall-bladder; surgically, the gall- bladder removed was approximately the size of the shadow. The surgeon doubted whether the shadow found in the x-ray platewas the gall-bladder. Thewriters are of the opinion that this shadow represented the gall-bladder. Fig. 75. Large shadow which might be confused with a possible displaced kidney. Clinically, a palpable tumor; under fluoroscopic examination, palpable and tender. There are some changes caused by the displacement of the colon which would indicate that it was the gall-bladder. Surgically, the tumor proved to be a moderate hydrops of the gall-bladder. PLANCH E XXIII Fig. 74. Grosse vesicule malade, facile a mettre en evidence avec une technique appropriee. Malheureusement, on ne put determiner la position du rein sur aucun des cliches de la serie. Rein ou vesicule? La reponse n'etait pas facile, aucun symptome indirect n'etayant le diagnostic. Au palper on sentait la vesicule. A I'operation, celle qui fut extraite avait a-peu-pres les dimensions de 1'ombre figuree. Bien que le chirurgien fut de 1'avis con- traire, nous croyons avoir montre la vesicule. Fig. 75. Cette ombre etendue pourrait faire croire a un rein deplace. Elle representait une masse palpable, douloureuse a la pression. On I'attribua a la vesicule, a cause d'un displacement particulicr du colon. L'operation montra un epanchement dans la vesicule. PLANCH A XXIII Fig. -4. Vesicula grande enferma, facil de demostrar con una tecnica correcta Desgraciadamente en ninguna de las placas pudimos precisar la situacion del rinon. Era dilicil decidir si se trataba del rinon o de la vesicula, pues faltaban signos indirectos o secundarios que habrian ayudado el diagnostico. Clinicamente, sin embargo, habia una vesicula lacilmente palpable. La operacion descubrio y extirpo una vesicula de tamafio aproximado al de la sombra del clise. Aunque el cirujano dudo de que dicha sombra fuera la imagen de la vesicula, nosotros creimos que si lo era. Fig. "5. Sombra extensa facil de confundir con un rinon flotante. Clinicamente era un tumor palpable; al examen fluoroscopico, masa palpable y sensible. En vista del desplaza- miento evidente del colon, se atribuyo la sombra a la vesicula biliar. La intervencion qui- rurgica probo que el tumor era la vesicula hedropica. I 'I \l I win Fig. Fig. 75. PLATE XXIV PLANCHE XXIV PLANCHA XXIV PLATE XXIV Fig. 76. Definite pathological gall-bladder, easily visible by the plate or film method. This patient had been examined by the fluoroscopic method; no evidence of a pathological gall-bladder. Confirmed at operation. Fig. 77. Visible gall-bladder, moderate in size, fixed to the hepatic flexure. Plate shows a picking up of the colon by adhesions. Surgically: Chronic cholecystitis, with adhe- sions. Fig. 78. Large bowel full of barium b\ the enema method; visible gall-bladder, which had been confirmed by a series of gall-bladder plates, and was proved pathological at operation. Fig. 79. Outline of a pathological gall-bladder overlying the shadow of the kidney. PLANCH E XXIV Fig. 76. Une vesicule bien definie, facile a radiographier sur plaques ou films. Une radioscopie n'avait rien montre de suspect. Fig. 77. Vesicule de moyenne taille, fixee a I'anse hepatique. On voit que Ie colon est tiraille par des adherences. A I'operation: cholecystite chronique, avec adherences. Fig. 78. Colon rempli de baryum par voie rectale. La vesicule biliaire est visible, corame d'ailleurs sur les plaques consacrees specialement a. sa recherche. Elle etait malade. Fig. 79. Profil d'une vesicule malade recouvrant celui du rein. PLANCHA XXIV Fig. 76. Vesicula evidentemente enferma, de facil demostracion roentgenografica. EI examen fluoroscopico, sin embargo, fue ncgativo. Confirmacion quirurgica. Fig. 77. Vesicula de tamano moderado fijada a la acodadura hepatica del colon. EI disc muestra como las adherencias agarran el colon. Comprobacion quirurgica: colecistitis cronica adhesiva. Fig. ~8. Colon Ileno con 1111 enema opaco. Vesicula visible, segun habia demostrado ya otra serie de placas. A la operacion, colecistitis cronica. Fig. 79. Imagen de la vesicula biliar enferma sobrepuesta a la sombra del rinon. I'l ATI. \.\l\ i r Fig. 76. Fig. — Fig. 78. Fig. 79. THE PATHOLOGICAL GALL-BLADDER: INDIRECT EVIDENCE 1 he changes thai take place in the first portion of the duodenumand the second portion <>l the duodenum have proved to be oi definite importance in the diagnosis oi the pathological gall-bladder, [*oo greal importance can- not be attached to pressure delects due to the gall-bladder upon tin- first portion oi the duodenum. Although perhaps it would not be wise in everj instance to consider pressure defects as the chiel point in the diagnosis, ye1 it is one oi the important signs toward making the diagnosis. Plate XW , Figures No, Si and 82 are used to show the normal stom- ach, and the first, second) and third portions ol the duodenum. Figure 80 was proved surgically to be normal. I his is the absolute normal so far as the rela- tions ol the parts ol the stomach and duodenum are concerned. Figures Si and 82 show the extreme variations ol the normal second portion ol the duo- denum. Changes found in Figure 81 may, under certain conditions, be con- sidered abnormal, orjJicse changes may be due to adhesions from the gall- bladder, yet one meets with such changes, especially in an individual who is poorly nourished and has marked ptosis of the abdominal organs. In the absence ol other direct or indirect evidence, one must be cautious in laying too much stress on changes similar to those found 111 Figure 81. Plate XXVI strikingly illustrates pressure defects due to the gall-bladder on the first portion of the duodenum, fixation and deformity, and change in the position ol the second portion ol the duodenum due to ,1 pathological condition of the biliary tract. LA INDICES INDIRECTS DES AFFECTIONS VESI- CULATES Les modifications qui peuvent survenir dans la premiere e1 la seconde portion du duodenum ne sunt pas a dedaigner pour le diagnostic des affec- 138 PATHOLOGICAL GALL-BLADDERS tions vesiculates. II est impossible d'exagerer la signification des deforma- tions que la vesicule peute imprimer. Sans doute il serait temeraire de dormer a ce signe la premiere place, mais il reste tres important. Dans la Planehe XXV, figures 80, 81 et 82, servent a montrer I'esto- mac et Ies trois portions du duodenum. La norme absolue se trouve dans la fig- ure 80. Elle a ete verifiee chirurgicalement. Les figures 81 et 82 montrent des variations considerables de la seconde portion du duodenum; elles n'ont aucune signification pathologique. Les changements figures dans la figure 81 peuvent etre attribuables a des adherences avec la vesicule. Ne pas oublier, toutefois, qu'on pent les trouver chez des individus a nutrition defectueuse et sujets aux ptoses. En I'absence de symptomes corroboratifs, on se gardera done d'v attacher trop d'importance (fig. 81). La planehe XXVI demontre clairement I'effet des compressions de la vesicule sur la premiere portion du duodenum, les tiraillements, deplace- ments et autres deformations de la seconde portion a la suite d'un etat pathologique des voies biliaires. SIGNOS INDIRECTOS (DE COLECISTITIS) Las modificaciones cjue pueden sobrevenir en Ios dos primeros segmentos del duodeno son realmente utiles para el diagnostico de las colecistitis. Aunque no debe de concederse una importancia excesiva a las deformaciones que la presion de la vesicula ocasiona a veces sobre la porcion bulbar del duodeno, es sin embargo un excelente sintoma, pero no el mas importante de todos. Las figuras 80, 81 y 82 delaplancha XXV sirven paramostrarelestomago normal y Ios tres segmentos del duodeno. La figura 80 corresponde a un caso absolutamente normal, comprobado quirurgicamente, en cuanto a las rela- ciones mutuas entre las diversas partes del estomago y del duodeno. Las figuras 81 y 82 ensenan variaciones considerables en la segunda porcion del I'l VI I \\\ Fig. 80. Fig. 8i. Fig. 82. PLATH XXVI PLANCHE XXVI PLANCIIA XXVI PLATE XXVI Lateral view shows definite pressure defect upon the first portion of the duodenum due to a pathological gall-bladder. In the original plates certain shadows suggested the possibility of gall-stones. We also found the ampulla of Vater filled throughout the series. At operation no fixation of the gall-bladder to the duodenum was found. Several gall- stones. Definite thickening of the gall-bladder walls. PLANCH E XXVI La vue Iaterale revele une deformation tres nette de la premiere portion du duodenum par la vesicule malade. Dans les cliches originaux, certaines ombres faisaient penser a des calculs. A travers toule la serie nous trouvames I' ampoule de Vater remplie de baryum. A 1' operation, la vesicule ne se montra pas adherente au duodenum. Iy y avait plusieurs calculs et un epaississement certain des parois de la vesicule. iPLANCHA XXVI j La vista lateral muestra claramente la presion de la vesicula sobre la primera porcion del duodeno. En las placar originales crertas sombras hicieronso spechar la presencia de calculos biliares. La ampolla de Vater aparecio llena da bario eu todos los clises de la serie. La operacion descubrio una vesicula de paredes espesas, conteniendo algunos calculos. No habia adherencias al duodeno. r.EORC.E if LEONARD- GAI I I'-LAPP! R PLATE XXVI ROENTGEN ILOGY, . :• M; .■ in I B HOEB1 k. s PATHOLOGICAL GALL-BLADDERS 143 duodeno c|iu' no son, sin embargo, patologicas. Las alteraciones descubiertas en la figura Si podrian, bajo ciertas circunstancias, considerarse anormales ser atribuidas a adherencias con la vesicula, pero tambien pueden encontrarse en sujetos normales pobremente nutridos \ afectos indirectos, no sera prudente conceder demasiada importancia a dichas alteraciones (fig. 80- Los clises de la plancha \\\ I (demuestran) con toda claridad el efecto iU' [as compresiones de la vesicula sobre la porcion bulbar drl duodeno e igu- almente las deformaciones, desplazamientos y fijacion anomala de la segunda porcion, consecutivas a los estados patologicos de las vias biliares. PI ATE XXV 1 1 PIAXCIIP XX\ II PLANCIIA XXVII PLATE XXVII Figs. 83 and 84 (both illustrating the same case) and Figs. 85 and 86 (illustrating a similar case). Subhepatic fixation of the stomach. This change from normal in the position of the stomach and the duodenum is, in some instances, the only indication of pathology in the biliary tract, and such changes should be regarded as a warning to make a more care- ful study of the gall-bladder region if the examination previously made has seemed negative. Errors may arise even in apparently well-fixed positions of the stomach to the right, so that upon operation no evidence of this fixation will be found. But this is only one ot the minor indirect evidences of possible pathology in the gall-bladder. PLANCHE XXVII Figs. 83 et 84. Elles illustrent Ie meme cas. Les figures 85 et 86, un cas analogue. L'estomac est fixe sous le loie. Cette anomalie, ainsi que Ie displacement du duodenum, peut- etre Ie seul indice d'un etat pathologique des voies biliaires. Cest un encouragement a reprendre les cliches "vesicule" s'ils n'ont pas ete concluants. On peut trouver, a I'operation, que l'estomac n'est pas tiraille a droite, en depit des apparences. Mais il y a d'autres signes indirects des affections biliaires. PLANCH A XXVII Figs. 83 y 84 se refieren al mismo caso; y la 85 y 86 a otro analogo. Fijacion infra- hepatica del estomago. Esta situacion anomala del estomago y duodeno es, en algunos casos, el unico indicio del estado patologico de las vias biliares; v debe deconsiderarsecomo un estimulo para repctir cuidadosamente el examen de la region vesicular, si las primeras investigaciones fueren negativas. Puede ocurrir tambien que la intervencion quirurgica, a despecho de las apariencias roentgenograficas, no encuentre el estomago desviado a la de- recha ni fiio; pero este signo es uno de Ios sintomas indirectos menos importantes de las enfermedades biliares. PLAT] XXVII Fig. 83. Fig. 84. Fig. 85. I i... 86. PLATE XXVIII PLANCHK XXVIII PLANCHA XXVIII PLATE XXVIII Fig. 87. Pressure of a moderately dilated pathological gall-bladder by fixation upon the first portion of the duodenum and the pylorus. It will be noted that the pylorus is pulled toward the gall-bladder area. This observation was constant through a series of plates made in this position. It changed only moderately in the upright position. The first portion (if the duodenum is elongated toward the liver and fixed. PLANCH E XXVIII Fig. 87. Pression exercee par une vesicule moyennement dilatee sur Ie pylore et la portion initiale du duodenum. Le pylore est ancre a la region vesiculate. Cet etat de choses, constant dans tons les cliches de la serie couchee, se modifia tres peu dans la station verticale. La premiere portion du duodenum est attiree et fixee au foie. PLANCHA XXVIII Fig. 8^. Muestra la presion eiercida por una vesicula medianamente dilatada sobre el piloro y la primera porcion del duodeno. Notese que el piloro ha sido arrastrado haciala region vesicular. El primer segmento del duodeno aparece estirado y adherido al higado. Esta observacion fue constante en todas las placas de la misma serie hechas en igual posi- cion; vario Iigeramente con el enfermo en la estacion vertical. I'l \ 1 1 \\\ III Fig. 87. PLATE XXIX PLANCH! \\l.\ PLANCHA XXIX [PLATE XXIX Fig. 88. Delect clue to pressure of gall-stones upon the first portion of the duodenum and fixation of the beginning of the second portion ol the duodenum. Fig. 89. Deformity of the first portion of the duodenum with a pseudodiverticulum due to adhesions from the gall-bladder. Fig. 90. Artist's drawing of the same case as is shown in Fig. 89, illustrating changes found at operation. PLANCHE XXIX Fig. 88. Deformation de la premiere portion du duodenum et fixation du commence- ment de la seconde par une vesicule calculeuse. Fig. 89. Deformation de la premiere portion du duodenum et pseudodiverticule cause par des adherences a la vesicule. Fig. 90. Dessin montrant ce qu'on trouva a I'operation du malade de la figure 89. PLANCHA XXIX Fig. 88. Deformacion del primer segmento del duodeno y fijeza de la porcion inicial del segundo producidas por una vesicula calculosa. Fig. 89. Deformacion del primer segmento del duodeno y pseudo-diverticulo, oca- sionados por adherencias a la vesicula. Fig. 90. Dibujo mostrando Io que se encontro en la operacion del caso de la fig. 89. PLAT] XXIX Fig. 88. Fig. 89. Omentum PijIoruS i<> Fig. on. PLATE XXX PLANCIII XXX PLANCH A XXX PLATE XXX Fig. 91. A constant filling delect of the first portion of the duodenum. Clinically: No evidences of ulcer. Plates are not characteristic of ulcer. Roentgen diagnosis: Pathological gall-bladder with probable gall-stones. Surgically: Pathological gall-bladder with stones. Fig. 92. Defect of the first portion of duodenum. Opinion passed from this roentgen examination: Chronic ulcer of the duodenum, with gall-stones. At operation, the deformity was found to be due to fixation of the gall-bladder. No evidence of ulcer. Gall-stones. PLANCHE XXX Fig. 91. Radiographic d'un individu corpulent montrant un defaut persistant de la premiere portion du duodenum Pas de symptomes cliniques de I'ulcere. Les cliches non plus n'etant passuggestifs de I'ulcere, on diagnostiqua: vesicule malade, probablement calculeuse. Confirmc. Fig. 92. Defaut clans la premiere portion du duodenum. Diagnostic radiologique: ulcere chronique du duodenum avec calculs bihaires. A I'operation: calculs, adherences peri-vesiculaires, pas d'ulcere. PLANCH A XXX Fig. 91. Laguna persistente de la primera porcion del duodeno. No hay signos clinicos de ulcera. Los discs tampoco son caractiristecos de ulcera. Diagnostico roent- genologico: enfermedad de la vesicula, probable colelitiasis. Confirmacion operatoria. Fig. 92. Laguna en el primer segmento del duodeno. Diagnostico roentgenologico: ulcera cronica del duodeno con calculos biliares. La operacion descubrio calculos y adhe- encias peri-yesiculares; pero no Iesiones uicerativas. P] \M \W It,. 91. : Fig. 92. IM Ml W\l PLANCHE XXXI PLANCH A XXXI PLATE XXXI Figs. 93, 94, 95 (illustrating the same case). Pressure defect upon the first portion of the duodenum, due to gall-stones. In this instance, the gall-stones were not found in the original plates until after the operation although they were plainly visible. Roentgen diagno- sis: Probable gall-bladder disease by pressure delect in the first portion of the duodenum. PLANCHE XXXI Figs. 93, 94 et 95. Meme malade. Les calculs deforment la premiere portion du duode- num, lis ne furent apercus qu'apres ['operation, bien qu'iis fussent evidents. PLANCH A XXXI Figs. 93, 94 y 95. (Se refieren al mismo caso.) Defecto por compresion de la vesicula calculosa sobre la primera porcion del duodeno. Aunque Ios calculos eran netamente visibles en Ios clises, pasaron sin embargo desapercibidos en su primera Iectura; fue despues del acto operatorio que una revision cuidadosa permitio descubrirlos. EI diagnostic© roentgenologico habia sido: probable enfermedad de la vesicula, supuesta por la compresion y deformacion del duodeno. I'l \ 1 1 \\\l Fig. 93. Fig. 94. I IG. 95. pi.au. xxxii PLANCHE XXXII PLANCH A XXXII PLATE XXXII Figs. 96 and 97 (illustrating the same ease). Visible gall-stones defect, being charac- teristic of an obstructive chronic ulcer of the duodenum. In the writers' opinion this filling defect of the duodenum was due to chronic ulcer. At operation, gall-stones were found with perforation of the gall-bladder into the duodenum. Fig. 98. Pressure defect upon the first portion of the duodenum, due to a gall-stone, which was not visible in our examination. Fig. 99. Lateral view oi same case as shown in Fig. 98, showing the same pressure defect. PLAXCHE XXXII Figs. 96 et 97. Deformation produite par des calculs, mais simulant un ulcerechronique du duodenum. On opta pour I'ulcere, mais I'operation revela des calculs, avec fistule vesiculo- duodenale. Fig. 98. Deformation par pression sur la premiere portion du duodenum, due a un calcul qui ne fut pas decele par la radiographic. Fig. 99. Meme cas, vue laterale (tig. 98). Autre aspect de la deformation. PLANCH A XXXII Figs. 96 y 97. (Se refieren al mismo caso.) Deformacion producida por calculos biliares, simulando el aspecto caracteristico de una ulcera cronica y obstructiva del duodeno. En opinion de Ios autores la laguna del duodeno se debia a una ulcera. Laoperaciondescubrio calculos biliares con perforacion de la vesicula dentro del duodeno. Fig. 98. Deformacion del primer segmento del duodeno por un calculo biliar invisible durante el examen. Fie. 99. Vista lateral del mismo caso de la fig. 98, mostrando eldefectoporcompresion. 'I A I I \ \ \ I Fig. 96. Fig. 97. In.. 98. Fig. 99. H VII X.Will PI.ANCIH. XXXIII H.ANCIIA WXIII PLATE XXXIII Fig. ioo. Illustrates pressure of the gall-bladder, containing stones, with adhesions to the first portion of the duodenum. Confirmed at operation. Fig. ioi. Pressure of a gall-bladder against the first portion of the duodenum. This plate is republished here to illustrate the type of pressure that the writers feel is important as at least suggestive of the pathological gall-bladder, which might or might not contain gall-stones. Fig. 102. Lateral view of a stomach showing pressure of the gall-bladder upon the first portion of the duodenum, and a visible, single large gall-stone. This stone was not visible in the routine gall-bladder examination. Fig. 103. Extreme pressure of a large gall-bladder with fixation of the stomach to the gall-bladder. No stones found. PLAXCHE XXXIII Fig. ioo. Pression exercee par une vesicule calculeuse adherente a la premiere portion du duodenum. Confirmation operatoire. Fig. ioi. Vesicule deformant la premiere portion du duodenum. Nous pensons qu'une telle deformation est pour Ie moins tres suggestive d'un etat pathologique de la vesicule, avec ou sans calculs. Fig. 102. Gros calcul decouvert au cours de I'examen gastrique et demeure invisible dans la serie pregastrique. On voit la pression exercee sur la premiere portion du duodenum. Fig. 103. Deformation considerable et fixation de I'estomac a la vesicule. Pas de calculs. PLANCHA XXXIII Fig. ioo. Compresion de una vesicula calculosa adherida a la primera porcion del duodeno; conlirmada quirurgicamente. Fig. ioi. Compresion de la vesicula sobre el primer segmento del duodeno. Este clise se reproduce con el fin de mostrar el tipo de deformacion que los autores consideran sugestivo de estados patologicos de la vesicula, acompaflados o no de calculos. Fig. 102. Vista lateral del estomago mostrando la presion de la vesicula sobre el primer segmento del duodeno. Vese tambien un calculo solitario grande. Esta piedra paso inadvertida en el examen regular de las vias biliares. Fig. 103. Deformacion considerable y fijacion del estomago a una vesicula volumi nosa. Ausencia de calculos. I'l \l I XXXII] Fig. too. Fig. mi . Fig. 102. Fig. 103. PLATE \\\l\ PLANCHEX\\I\ PLANCII\ XXXIV PLATE XXXIV Fig. 104. Fixation of first portion of the duodenum to a pathological gall-bladder. Fig. 105. Illustrates the direct, the indirect, and the secondary manifestations of pathology in the biliary tract. It is to be noted that the jejunum is transferred from its normal position on the left to the upper right quadrant. There is a marked deformity of the first portion of the duodenum, suggestive of ulcer, found to be due to adhesions, for the most part. The pathological gall-bladder is found in the original plates. Fig. 106. Gall-bladder of case illustrated in Fig. 10^ after removal, before being opened. Full of stones of such character that they will not in themselves cast a shadow. It is to be noted that the contained bile is denser in character than the gall-stones themselves. PLANCHE XXXIV Fig. 104. La portion initiale du duodenum est ancree a un ve.sie.ule malade. Fig. 105. Illustrant Ies signes directs, indirects et secondaires des etats pathologiques de la vesicule. Noter que Ie jejunum, au lieu d'etre a gauche comme d'habitude, est dans I'hypochondre droit. Deformation considerable de la premiere portion du duodenum sug- gerant un ulcere, mais due en majeure partie a des adherences. Sur Ie cliche original on voit la vesicule malade. Fig. 106. La vesicule du cas precedent (fig. 105), extirpee, mais pas encore ouverte. A cause de leur composition, les calculs qui s'y trouvent ne portent pas d'ombre appreciable. Noter que la bile est plus opaque que Ies calculs. PLANCHA XXXIV Fig. 104. Primera porcion del duodeno adherida y lija a la vesicula enferma. Fig. 105. Demuestra los signos directos, indirectos y secundarios de Ios procesos patologicos biliares. Notese que el yeyuno ha sido traspuesto al hipocondrio derecho. Hay notable deformacion del primer segmento del duodeno, como en las ulceras, pero en este caso producida mayormente por adherencias. Sobre Ios clises originales se nota la vesicula enferma. Fig. 106. Vesicula del caso anterior despues de extirpada, pero sin abrir. Llena de calculos de composicion quimica tal que no pueden proyectar sombra apreciable. La bilis es mas opaca que Ios calculos. >LA1 I XXXIV Fig. 104 Fig. 105. Fig. Hid. PLATE XXX\ PLANCIII WW PLANCUA XXXV PLATE XXXV Fig. 107. Adhesions due to the pathological gall-bladder and chronic ulcer of the duodenum. Fig. 108. Artist's drawing of case shown in Fig. 107, illustrating the changes found in this type of case. PLANCHE XXXV Fig. 107. Adherene.es eonsecutives a une affection biliaire; ulcere chronique du duo- denum. Fig. 108. Dessin figurant ee qu'on trouve dans des cas comme celui de la fig. 107. PLANCHA XXXV Fig. 107. Adherencias consecutivas a una afeccion biliar y ulceracronicadelduodeno. Fig. 108. Dibujo figurando lo'que se encontro en el caso de ia fig. 107. Ml WW t I lc. 107. V Ulcer. .V- b f' * A*V I i < ; . 10S. H All WW I PLANCIII WW I PLANCIIA WW I PLATE XXXVI Plates XXXVI and XXXVII illustrate a very important sign which, when present, is indicative oi the pressure of a moderately dilated or distended and thickened gall-bladder, or a gall-bladder full of stones that rests against the antrum of the stomach. This change is so characteristic, when found, that to the writers it becomes one of the most important indirect signs. Fig. 109. Pressure defect of the pathological gall-bladder upon the antrum of the stomach. Confirmed at operation. Fig. 1 10. Pressure defect upon the antrum of the stomach. In the original plates it was thought possible to see small shadows within this area which indicated small stones. At operation, the pathological gall-bladder and several very small stones were found. PLANCH E XXXVI Les plauches xxxvi et xxxvii illustrent un signe tres precieux qui origine de la pression d'une vesicule moderement dilatee ou epaissie 011 calculeuse sur I'antre pylonque en contact avec elle. Ce signe a une importance que nous estimons capitale. Fig. 109. Pression exercee par une vesicule malade sur I'antre pylonque. Verifie a l'operation. Fig. 1 10. Deformation du pylore par pression exteneure. On crut apercevoir, dans Ie voisinage, deux petites ombres suspectes. A l'operation: vesicule malade contenant plusieurs tres petits calculs. PLANCHA XXXVI Los roentgenogramas de las planchas xxx\ 1 y xxxvii ilustran un signo muy importante, efecto de la presion de una vesicula moderadamente dilatada o de paredes gruesas y dis- tendida orepleta de calculos, apoyandose contra el antro pilorico. Es una alteracion pato- Iogica tan caracteristica que los autores la considcran como uno de Ios signos indirectos mas importantes. Fig. 109. Laguna del antro pilorico causada por presion de la vesicula enferma. Con- firmacion opcratoria. Fig. iio. Deformacion del antro pilorico por presion de la vesicula. Se creyo poder distinguir en Ios primeros clises pequeiias sombras de origen calculoso dentro de la zona lacunar. La operacion descubrio una vesicula enferma conteniendo varios calculos muy pequenos. I'l \l I \V\VI Fig. i PLATE XXXVII PLANCIII". XXXVII PI ANCHA XXXVI] PLATE XXXVII Fig. hi. Fixation by adhesions of the first portion of the duodenum and antrum of the stomach to the gall-bladder area. Pressure delect upon the antrum of the stomach due to the gall-bladder. Stones visible. Fig. 112. Pressure defect upon the antrum of the stomach, due to the pathological gall-bladder without stones. PLANCH E XXXVII Fig. iii. Tiraillement de I'antre pylorique et du duodenum vers la region vesiculate. Encoche de compression a I'antre. Calculs visibles. Fig. 112. Deformation de I'antre pylorique par une vesicule malade non-calculeuse. PLANCH A XXXVII Fig. iii. EI antro pilorico y la primera porcion del duodeno aparecen fijos por ad- herencias a la region vesicular. La presion de la vesicula causa una Iaguna del antro pilorico. Calculos visibles. Fig. 112. Deformacion del antro pilorico por vesicula enferma no calculosa. PI Ml WW II 'IG. III. Fig. 112. PLATE WW III PLWCIII WW III PLANCHA WW III PLATE XXXVIII Fig. 113. Pressure of the pathological gall-bladder against the antrum of the stomach, also displacement of the first portion of the duodenum. Fig. 114. Pathological gall-bladder causing pressure against and displacement of the first portion of the duodenum and a part of the antrum of the stomach. Fig. 115. Pathological gall-bladder. (Plate made in six hours.) No visible gall-stones found during gall-bladder examination. Stomach fixed to the subhepatic region without any other indirect or secondary manifestations. During six-hour examination, plates showed this fixation with a group of gall-stones. Plate used, in this instance, to illustrate the pressure of the gall-bladder against the antrum of the stomach. PLANCH E XXXVIII Fig. 113. Compression exercee par une vesicule malade sur 1'antre pylorique et emplacement de la premiere portion du duodenum. Fig. 114. Cas analogue au precedent. Fig. 1 15. Vesicule malade. On n'avait pas trouve de calculs sur Ies cliches consacres a Ieur recherche; on en trouva sur la plaque des 6 heures. L'estomac est ancre sous le foie et son pylore est deforme. PLANCHA XXXVIII Fig. 113. Presion de la vesicula enferma sobre el antro pilorico y desplazamiento de la primera porcion del duodeno. Fig. 114. Vejiga biliar patologica comprimiendo y desplazando la primera porcion del duddeno y parte del antro pilorico. Fig. 115. Vesicula enferma (placa de seis horas). El examen roentgenologico especial de las vias biliares no demostro calculos. Estomagofijadoalaregioninfra-hepatica. Ausencia de otros signos indirectos. Ademas de la fijaeion, la placa de seis horas muestra un grupode calculos. Notese la presion de la vesicula sobre el antro pilorico. I'l Ml WW III I' !(,. II Fig. 114. Fig. 1 1 5. PLA1 I KXXIX PLANCHE XXXIX PLANCIIA XXXIX PLATE XXXIX Fig. i 1 6. Definite fixation of the second portion of the duodenum to the gall-bladder. In the gall-bladder plates particles of calcium were found within the gall-bladder area. In this plate, we see faintly the calcium shadow within the area of the gall-bladder. Fig. i 17. Artist's drawing of the case shown in Fig. 1 16, made at the time of opera- tion. Positive fixation of the second portion of the duodenum to the gall-bladder; the calcium shadows found in the original plates were due to gall-stones. Fig. 118. Fixation of the second portion of the duodenum to the gall-bladder. At operation, a small number of very small bilirubin lime stones were found. A, shows faint outline of the gall-bladder. PLANCHE XXXIX Fig. 1 16. Fixation evidente de la deuxieme portion du duodenum a la vesicule. Dans Ies cliches de la serie "vesicule" on trouva des taches calcaires correspondant a son emplace- ment. On voit ici une ombre assez faible situee clans Ies limites du profil de la vesicule. Fig. ii~. Dessin fait au cours de I'operation du cas precedent (fig. 1 16). Les consta- tations de la radiologic sont confirmees. Fig. 118. Fixation de la deuxieme portion du duodenum a la vesicule. En A on voit la vesicule faiblement dessinee. A I'operation: quelques petits calculs de bilirubinate de calcium. PLANCH A XXXIX Fig. 116. Fijacion evidente de la segunda porcion del duodeno a la vesicula. Tanto en los clises de la serie especial de la vesicula como en este se ven sombras calcareas en la zona vesicular. Fig. ii". Dibujo del mismo caso hecho durante la operacion. Confirma la fijacion del duodeno y la presencia de calculos. Fig. 118. Fijacion a la vesicula de la segunda porcion del duodeno. La operacion descubre un pequeno numero de diminutos calculos de bilirubinate de cal. (A) sehala el delicado contorno vesicular. IM \l I XXXIX Lii/cr Duo Vom Fig. i [6. Fig. ti" PLATE XL PLANCHE \l PLANCHA XL PLATE XL Fig. 119. Pressure defect by the gall-bladder upon the second portion of the duo- denum in a woman, aged eighteen. Gall-bladder contained a large number of very small calcium bilirubin stones. Fig. 120. Deformity of the second portion ol the duodenum due to adhesions. Origin of the adhesions was not fully determined at operation. PLANCH E XL Fig. 119. Pression exercee par la vesicule sur la deuxieme portion du duodenum chez une femme de 18 ans. On trouva un grand nombre de tres petits calculs de bilirubinate de chaux. Fig. 120. Defaut dans la deuxieme portion du duodenum, du a des adherences dont on ne put determiner la cause a 1'operation. PLANCHA XL Fig. 119. Compresion de la vesicula sobre el segundo segmento del duodeno en una joven de 18 aiios. La vesicula contenia gran numero de diminutos calculos de bilirubinate decal. Fig. 120. Deformacion del segundo segmento del duodeno, causadaporadherencias — La operacion no preciso el origen de dichas adherencias. I'l Ml XL Fig. i 21 PLATE Ml PLANCHE XL! PI.WCIIA \l I PLATE XLI Figures 121, 122, 123 and 124 illustrate the filling of the ampulla of Vater during the barium meal. It has been found, in the writers' experience, that with all other signs absent, when the ampulla of Vater is found lull of barium during the meal, it is signifi- cant of pathological changes in the biliary tract or within the pancreas. This sign should not be considered a positive indication of disease either of the biliary tract or of the pancreas, but more as a warning that something has been overlooked in the previous gall-bladder examination. One should persist in these cases in looking for direct or indirect evidence of pathology either of the biliary tract or of the pancreas. The errors that may arise in this connection are in occasional cases where a small diverticulum of the second portion of the duodenum or an ulcer with perforation may simulate a barium-filled ampulla. Fig. 123. Collection of gall-stones and the ampulla of Vater filled with barium. Fig. 124. Barium-filled ampulla in the right lateral diameter (A); pressure of a moderately dilated gall-bladder upon the second portion of the duodenum (B). These two observations together make a reasonably positive diagnosis. PLANCHE XLI Les figures 121, 122, 123 et 124 illustrent la penetration du repas baryte dans I' ampoule de Vater. Dans I'experience des auteurs, quand tous les autres signes manqueraient, la presence du baryum dans ['ampoule denote un etat pathologique de la vesicule 011 du pancreas. II n'y faudrait pas voir un signe patho gnomonique, mais un avertissement d'avoir a scruter plus attentivement les radiographics deja prises de la vesicule. Rechercher avec persistance les signes de morbidile dans les voies bihaires 011 Ie pancreas. II est bon de se rappeler qu'un petit diverticule dans la seconde portion du duodenum ou un ulcere perforant pourraient dormer le change et simuler une ampoule remplie de baryum. Fig. 123. Amas de calculs. Ampoule de Vater remplie de baryum. FiG. 124. A, I'ampoule vue en position laterale droite. B, pression par une vesicule movennement dilatee sur la seconde portion du duodenum. On peut etre assez affirmatif quand on a les deux signes. PLANCHA XLI Los siguientes roentgenogram as (figs. 121, 122, 123 y 124) ilustran la penetracion de la comida opaca en la ampolla de Vater. Es la creencia de Ios autores que, en la ausencia de otros sintomas, esta penetracion es signo probable de un estado morboso de las vias biliares o del pancreas. No es un sintoma de certeza, sino mas bien una sefial de alerta de que algo paso desapercibido durante los examenes previos y de que es necesario persistir en la in- vestigacion de Ios signos directos o indirectos de las afecciones biliares o pancreaticas. No se olvide, sin embargo, que un pequeno diverticulo de la segunda porcion del duodeno o una ulcera perforante pueden simular la ampolla de Vater Ilena de bario. Fig. 123. Coleccion de calculos y ampolla de Vater Ilena de bario. Fig. 124. (A) la ampolla de Vater, Ilena de bario, vista en pocicion lateral derecha. (B) Segunda porcion del duodeno comprimida por una vesicula moderadamente dilatada. Con estos dos signos puede aventurarse un diagnostico positivo. I'l \ II \l Fig. i2i. Fig. 122. Fig. 123. Fig. i 2 1. PLATE XI M PLANCH I XI M PLANCHA XI II PLATE XLII Fig. 125. Jejunum transferred from the left to the right upper quadrant. This change is significant of one of two things: it is due either to adhesions in the upper right quadrant or to changes which are the result of tubercular peritonitis in early life. Occasionally, tumors in the upper left quadrant, such as hypernephroma of the kidney or a markedly enlarged spleen, will displace the jejunum to the right. This can be determined by pressure on the stomach, which will be produced by a hypernephroma or an enlarged spleen. Fig. 126. Postoperative effect upon the stomach causing marked deformity — the re- sult of cholecystotomy. The original plates showed 2 remaining gall-stones. These are not visible m the reproduction. Fig. i2~. Secondary manifestations of probable gall-bladder disease upon the hepatic flexure and the proximal portion of the transverse colon. These changes were confirmed at operation. Similar changes occur commonly in very large and well-nourished individuals, when gall-bladder disease is present; uncommonly in those very poorly nourished. PLANCHE XLII Fig. 125. De gauche, le jejunum a passe dans 1'hypochondre droit. Cela peut etre du a des adherences dans cette region ou a des modifications produites au cours du jeune age par une peritonite tuberculeuse. Parfois, des tumeurs dans 1'hypochondre gauche, com- me l'h\ pernephrome ou I'hypertrophie de la rate, peuvent produire le meme effet. Mais alors, on a des deformations considerables de I'estomac. Fig. 126. Deformation considerable de I'estomac consecutive a une cholecystotomie. Les cliches originaux montrent deux calculs oublies. On ne peut les voir ici. Fig. i2~. Contrecoup d'une affection probable de la vesicule sur la coudure hepatique et la portion initiale du transverse. Verifie a 1'operation. Cet etat de choses est frequent chez les malades corpulents, rare chez les amaigris. PLANCHA XLII Fig. 125. Yeyuno trasportado desde la izquierda al hipocondrio derecho. Esta modi- ficacion patologica puede ser ocasionada, ora por adherencias en la region biliar o bien por lesiones consecutivas a una peritonitis tuberculosa de la infancia. A veces Ios tumores del hipocondrio izquierdo, como el hipernefroma o las esplenomegahas, desplazan el yeyuno hacia la derecha, pero entonces coexisten deformaciones considerables del estomago. Fig. 126. Notable deformacion del estomago consecutiva a una colecistotomia. Los discs originales muestran dos calculos olvidados por el cirujano. No se ven en esta copia. Fig. 12-. 1 fecto secundario de una afeccion probable de la vesicula biliar sobre la acodadura hepatica del colon y la porcion inicial del transverso, confirmado por la operacion. Alteraciones analogas son Irecuentes en los enfermos corpulentos y robustos; raras en los flacos. I'l VI I \1 II III,. 12*' Fig. 127. PLA1 I \l Ml I'l WCIII- XI. Ill PLANCH A XLIII PLATE XLIII Fig. 128. The more common type of deformity of the hepatic flexure and proximal portion of the transverse colon due to adhesions in the upper right quadrant, both from the gall-bladder and from veils and adhesions of this portion of the bowel. These changes become more important when there is distinct, direct evidence of pathology in the biliary tract. Fig. 129. Type of spasm which has been found frequently associated with gall-bladder disease. This spasm involves the antrum of the stomach, producing a tubular appearance in the distal end of the stomach for a distance of several inches. It is interesting to note when found with evidence of gall-stones or other pathology of the biliary tract, though in itself it is not an important diagnostic sign. PLANCHE XLIII Fig. 128. Aspect habitue! des deformations de 1'anse hepatique et de la portion initi- ale du colon transverse par suite d'adherences dans i'hypoehondre droit. Elles peuvent avoir une origine vesiculate ou intestinale. Quand on aura, par ailleurs, des signes d'affection biliaire, ces deformations sont tres significatives. Fig. 129. Type de spasme gastrique irequemment associe a l'existence des affections de la vesicule. II etreint tout I'antre pylorique et peut le reduire a I'etat d'un simple tube sur une longueur de plusieurs centimetres. Isolement, ce signe n'a pas grande importance. PLANCHA XLIII Fig. 128. Variedad la mas comun de las deformaciones de la acodadura hepatica del colon y porcion inicial del transverso, producidas por adherencias en el hipocondrio derecho, ya provengan de la vesicula o se deban a franjas membranosas o adherencias intestinales. Cuando coexisten con signos directos de enfermedad biliar, estas deformaciones son muy significativas. Fig. 129. Variedad de espasmo gastrico frecuentemente asociado a Ios procesos vesiculares; comprime el antro pilorico y Io transforma en un tubo sobre una extension de varios centimetros. Importante cuando coincide con otros signos de enfermedad biliar, no tiene por si solo gran valor diagnostico. I'l VII Mil Fig. 129. PLATE XI IV PLANCHE XLIV PLANCHA XLIV PLATE XLIV Figs. 130, 131, 132 (the same case). Clinically diagnosed as gall-stones. The roent- gen examination revealed a group ot gall-stones as seen in Fig. 1 30. Stones the size of gall- stones, and with most of their usual characteristics, were found as clearly defined on the kidney examination as on the gall-bladder examination. The lateral view (Fig. 131) showed the stones in the anatomical region of the kidney. The writers felt that unless there was some very unusual anatomical rearrangement of the gall-bladder, kidney, and stomach, these shadows, for the most part at least, must be within the kidney. For various reasons it was impossible to cystoscope this case and iniect the kidneys. In spite of the tacts obtained by this examination and the probability that these were, in the most part, stones within the kidney, the case w-as operated upon as a case of gall-stones. No evidence whatsoever of pathology was found within the gall-bladder. The kidney was explored and removed. Fig. 132 shows the kidney with these stones within the kidney substance. This case and the series of plates illustrate the value of the right lateral view in determining whether or not a suspected stone or stones are located in the normal position for the gall-bladder or kidney. In a large percentage of cases, the lateral view will determine whether the shadows are of the gall-bladder or its contents, or whether they are ol the kidney. PLANCHE XLIV Figs. 130, 131, 132. Meme cas. Diagnostic chnique: lithiasc biliaire. La radio- graphic (Fig. 130), montra des calculs. La radiographic du rem en montra d'analogues. Un cliche en position Iaterale (fig. 131), fit voir qu'ils siegeaient dans la Ioge renale. On dut conclure qu'a moins d'anomalie anatomique, ces ombres, pour la plupart, devaient etre dans Ie rein. Pour diverses raisons on ne put faire une pyelographie. En depit des constata- tions, on decida d'explorer la vesicule. Elle eta it absolumcnt normale. On enleva le rein; la figure 132 Ie montre avec sun contenu. Tout ceci prouve I'utilite de la vue en Iaterale droite quand il s'agit de rapporter des calculs au rem droit ou a la vesicule biliaire. PLANCHA XLIV Figs. 130, 131 y 132. Se refieren al mismo caso. Diagnostico clinico; colelitiasis. Los roentgenogramas de la vesicula (fig. 130) revelaron un grupo de calculos de tamafio y cstructura semejantes a Ios biliares. Los roentgenogramas del riii6n tambien revelaron cal- culos similares. La radiografia lateral, sin embargo (fig. 131), mostraba Ios calculos en la region renal. Se opino que, salvo alguna anomalia anatomica, las sombras, cuando menos en su mayor parte, eran de origen renal. Por circunstancias especiales no se hizo una pielografia. A pesar de Ios signos en contrario, se decidio explorar las vias biliares, que resultaron com- pletamente normales. Entonces se practico la nefrectomea derecha. La ligura 132 muestra la imagen de dicho rinon conteniendo Ios calculos denunciados por Ios anteriores roentgeno- gramas. Hechos semejantes prueban la capital importancia de la radiogralia en posicion lateral derecha para diferenciar Ios calculos biliares de Ios renales. En una gran proporcion de casos ella decidira si las sombras son de la vesicula o si contenido, osi proceden del rinon. I'l \ I I \l !\ Fig. 130. Fig. 131. Fig. 13: Date Due PRINTED IN O.S.A CAT NO 24 161 D 000 225 511 5 WI 750 G3U?p 1922 George, Arial W The pathological gall-bladder Jeorge, Arial W The pathological gall-bladder WI 75C G3^7d 1922 MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664