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ft, ■
I
I
ROENTGEN INTERPRETATION
J
A MANUAL
FOR STUDENTS AND PRACTITIONERS
BY
GEORGE W. HOLMES, M.D.
ROENTGENOLOGIST TO THE MASSACHUSETTS GENERAL HOSPITAL AND INSTRUCTOR
IN ROENTGENOLOGY, HARVARD MEDICAL SCHOOL
AND
HOWARD E. RUGGLES, M.D.
ROENTGENOLOGIST TO THE UNIVERSITY OF CALIFORNIA HOSPITAL AND CLINICAL
PROFESSOR OF ROENTGENOLOGY, UNIVERSITY OF CALIFORNIA MEDICAL SCHOOL
ILLUSTRATED WITH 181 ENGRAVINGS
LEA & FEBIGEE
PHILADELPHIA AND NEW YORK
1919
BOSTON MEDICAL LIBRARY
IN THE
FRANCIS A. COUNTWAY
LIBRARY OF MEDICINE
COPYKIGHT
LEA & FEBIGER
1919
DEDICATED TO
WALTER J. DODD, M.D.
PIONEER IN ROENTGENOLOGY
AND
MARTYR TO HUMANITY
PEEFACE.
It is hoped that this book will prove of practical aid to those
in search of a working knowledge of roentgen interpretation. The
intention has been to present the essentials in a comprehensive
form. More detailed information may be secured through the
references to the recent literature, which will be found at the end
of the chapters.'
The illustrations have been chosen as types of lesions, or as
momentary phases of constantly changing and extremely variable
processes. The beginner should not attempt to make diagnoses
from them by comparison with his own plates.
The necessity of a medical training as a prerequisite in this field
is, of course, recognized, but the particular importance of thorough
grounding in pathology is not always sufficiently plain. In attempt-
ing to study gross changes by means of shadows, a knowledge of
pathology is as essential to the roentgenologist as anatomy to the
surgeon. G. W. H.
H. E. R.
Boston, 1919.
r
CONTENTS.
Introduction 17
CHAPTER I.
Confusing Shadows and Artefacts 19
CHAPTER II.
Anatomical Variations and Development 26
CHAPTER III.
Fractures and Dislocations 33
CHAPTER IV.
Bone Pathology 50
CHAPTER V.
Skull 83
CHAPTER VI.
Joints, Tendons and Burs-e 97
CHAPTER VII.
The Chest Ill
CHAPTER VIII.
Gastro-intestinal Tract 151
CHAPTER IX.
Genito-urinary Tract 191
EOENTGEN INTEEPRETATION.
INTRODUCTION.
It cannot be too strongly emphasized in the beginning that
roentgen images are shadowgraphs; that they are the record of the
varying opacities through which a bundle of rays has passed;
and that they are subject to the possibility of erroneous deductions
consequent upon the fact that they are shadows. Objects are visible
when they differ in density from their surroundings. The outline
of the heart is distinct against the air-filled lung about it while the
uterus of similar density is lost in the shadow of the pelvis.
Furthermore, the roentgenogram is a projection on a flat surface
of everything in every plane between the plate and the tube's target.
It must not be forgotten that in addition to the patient this includes
opaque objects upon the filters, the clothing of the patient a#i the
envelope of the plate. The shadow of a rounded bone with ridges
on opposite sides will appear on the plate as a flat image with the
ridges lying side by side. It is therefore essential for the roentgen-
ologist to have a thorough knowledge of the projected appearance of
anatomical structures, so that he may be able to visualize from a
flat plate the relative depth of objects seen upon it. The study of
stereoscopic plates is of great value in this connection.
Another source of possible error lies in the fact that we commonly
employ divergent rays. Parallel rays are seldom made use of in
roentgenology except in determinations of the size of the heart.
Ordinarily plates are produced by a tube which is relatively close
to the plate; therefore we are using divergent rays, and the images
of objects in their path will be distorted according to their position
with reference to the plate. Objects in contact with the plate give
an image of actual size and are sharply outlined. As they recede
from it their outline becomes more hazy and their size increases.
When a wide field of illimaination is employed the central rays are
practically parallel, but at the margins of the field they strike
2
18 INTRODUCTION
obliquely, giving a markedly distorted image. It is customary,
therefore, to limit the rays as much as possible to the central bundle
by the use of diaphragms and to place the area under observation
as closely as possible to the plate. There is an additional advantage
to be gained in the employment of small diaphragms because the
plates are brighter. Anything in the path of the rays gives off
secondary radiation and scatters the primary beam just as light is
scattered by fog. This secondary and scattered radiation tends to
obscure the image cast by the primary rays, therefore the area of
tissue exposed to the rays should be as limited as possible.
One view is an isolated observation and is perhaps less to be
relied upon than a single observation in any field of medicine. As
far as possible, plates should always be secured in planes at right
angles to each other, and often additional plates at various angles
will establish a diagnosis which would otherwise be impossible.
This is particulariy important in studies of the skull, spine and
the neighborhood of joints.
In conclusion, there are several axioms which form the basis for
successful roentgen interpretation:
1. Do not attempt to include everything on one plate; several
small ones are always preferable.
2. Tjo not make a diagnosis before everything possible has been
done; thoroughness is essential.
• 3. Be familiar with the projected appearance of normal structures.
4. Use routine positions for all examinations as far as possible.
5. Do not give opinions on poor plates.
In order to avoid confusion in the use of the terms ^'increased" and
'"diminished" density, it should be understood that when they occur
in this text they apply to the tissues of the patient. These expres-
sions may be employed to designate the thickness of the silver
deposit on the roentgenogram — the actual density in the image of
the emulsion — ^which necessarily is reciprocal to the density of the
patient. So, in this book, '"increased density" means the loss of trans-
parency to the rays and light areas on the roentgenogram. Dimin-
ished density means increased radiability and darkening of the
plate. Most of the illustrations are positives of the original roentgen
negatives and therefore their values are the opposites of those in
the plates.
CHAPTER I.
CONFUSING SHADOWS AND ARTEFACTS.
There are many shadows in nonnal plates which may cause
errors in interpretation. Their significance is obvious when they
have once been recognized, but the beginner is prone to attach
undue importance to them, particularly when they occur in regions
to which his attention has been directed by the clinical picture.
In case of doubt it is always wise to take plates of the corresponding
parts or to compare them with other plates of the same region in
other individuals.
lines Mistaken for Fractures. — ^The most common error here occurs
with the epiphyseal lines, which appear as a definite break in the
continuity of the bones. It is therefore essential for the roentgen-
ologist to have a complete knowledge of the time of appearance of
the various centers of ossification, the location of epiphyseal lines
and the approximate age at which they disappear.
When one bone overlaps another or the edge of a muscle bundle
crosses a bone there may be a thin, sharply drawn black line which
at times resembles a fracture. This appearance is often noticed in
the transverse process of the lumbar vertebrae where the inner
margin of the psoas muscle crosses them.
A third possibility of error is furnished by the markings due to
bloodvessels which are particularly evident in the skull where the
course of the middle meningeal artery appears as a tortuous groove
behind the coronal suture and is more or less sharply outlined.
The venous channels in the diploe of the skull provide another set
of dark lines, irregular in their course and indefinite in outline.
In the long bones there is ordinarily a definite groove where the
nutrient artery enters the shaft, which may be mistaken for a
fracture when seen in profile, as, for example, in the phalanges of
the hands and feet. It is well, therefore, to be familiar with the
anatomy of these vessels.
An accurate knowledge of the location and appearance of the
sutures of the skull will prevent their misinterpretation, a common
20 CONFUSING SHADOWS AND ARTEFACTS
error particularly with the parietomastoid, which is often called a
fracture of the base.
The characteristics of a fracture line which are usually sufficient
to identify it are that it is a dense black with sharply cut margins;
its course is usually irregular and, particularly in the skull, at vari-
ance with that of the bloodvessel markings.
Rougbening of the Margixis of Bones Mistaken for Periostitis. —
Frequently there is a thin plate of bone extending out on the inter-
muscular septum, as, for example, between the tibia and fibula,
or radius and ulna, which seen in profile is quite suggestive of peri-
osteal proliferation, and one must be careful to differentiate this
condition from a true periostitis.
A similar process is liable to occur at the attachment of tendons,
such as the tendo Achillis, the triceps, along the margin of the iliac
crests, along the linea aspera of the femur and about the external
occipital protuberances of the skull. There is very commonly a
roughening and slight proliferation along the margins of the pha-
langes of the hands, which is without significance. The flange behind
the intercostal groove on the inferior margin of the ribs posteriorly
is often exaggerated and suggests a periostitis. The tibial tubercle
may be somewhat widened and its lateral margin projected outside
the outer border of the tibia a short distance below the head; it
is frequently mistaken for a localized proliferation of periosteum.
There is normally a variable amount of roughening on the inferior
margin of the pubes and ischial tuberosities.
A true periostitis consists of more or less extensive deposit of new
bone upon a normal appearing cortex. This deposit may be laid
down in multiple thin lamellae, giving it a delicately stratified struc-
ture, which is a form frequently seen in lues; or it may be a low
irregular fringe, as seen in some forms of osteomyelitis.
Calcifications. — Calcium salts cast a dense shadow wherever they
occur. They have an extensive distribution in the body outside of
the bony structures. Cartilage is perhaps the tissue in which cal-
ciimi salts are most prone to be deposited. This is seen in the costal
cartilages, where the deposit usually occurs upon the surface of the
cartilage in the form of irregular plaques appearing in the chest,
spine, gall-bladder and kidney plates. These shadows are without
significance and their nature is, as a rule, easily determined.
Calcification also occurs in the same manner in the cartilages of
the larynx and is easily recognizable in lateral views of the neck.
In anteroposterior views of this region, however, they are projected
CALCIFICATIONS 21
in the region of the lateral masses of the cervical vertebras and have
been mistaken for hypertrophic changes in the spine or calcified
vertebral arteries.
Another common seat of calcification is old tuberculous foci,
examples of which are the irregular masses in bronchial glands, the
characteristic agglomerations of small masses which produce the
irregular mulberry-like shadows typical of tuberculous glands, which
Tio 1. — Calcified retroperitoneal uland sungesticg gall-atooeB.
are frequently found in the neck and throughout the mesenterj- in
the abdomen. They are usually multiple. Small, -rounded, dense
masses sometunes occur scattered throughout the spleen and may
occur anywhere beneath the peritoneum as the end-result of localized
tuberculous processes. An extensive calcification Is sometimes
encountered ui tuberculous kidneys. Extensive sheets of calcifica-
tion are sometimes seen in the pleura and very rarely in the peri-
cardium following tuberculous infection.
22 CONFUSING SHADOWS AND ARTEFACTS
The calcification which occurs in arterial walls as a result of
arteriosclerosis is a familiar picture. It may be found in the course
of any of the arteries, and is sometimes extensive and striking.
The age of the patient must always be taken into consideration
in estimating its proper significance. When it occurs in a young
patient it is most commonly the result of lues. These changes in
the internal iliac arteries may be mistaken for stone in the ureter.
Calcification appears in veins most frequently in the form of
small, rounded, dense masses, so-called phleboliths, seen in the
pelvis and in the region of the ischial spines; they represent small
calcified thrombi on the distal side of the valves, and must not be
mistaken for ureteral stones. Rarely, calcification similar to that
seen in arteriosclerosis may be evident in old varicose veins.
Extensive calcification may occur in hematomata; this is most
commonly seen about the elbow and in the quadriceps extensor.
It may develop rather suddenly several weeks after an injury and
present an appearance on the plate which resembles periosteal sarcoma.
Definite irregular deposits of calcium salts may be found about
foreign bodies, such as silk sutures, and the cysts of parasites.
Coming under this head may be mentioned calcified pineal glands
which are fairly common and the rare cases of calcification within
a dead fetus.
Calcification is fairly common in tumor masses whose blood supply
has been obliterated, of which an ordinary example is that seen in
uterine fibroids. It is encountered also in other slow-growing and
benign tumors of the connective-tissue group, such as fibromata
and lipomata. It occurs in certain slowly growing scirrhous carci-
nomata and has been noted in some timiors in the pancreas and
gall-bladder as well as in glandular metastases. Angiomata may
contain round cyst-like masses of varying size, representing calci-
fied thrombi, and endotheliomata frequently contain irregular dense
areas, as, for example, in psammomata in the skull.
Ovaries are sometimes the site of calcification, in which case they
appear as flat oval masses resembling glands in the lateral portions
of the pelvis.
Mention must also be made of the fact that mfarcts of any of the
viscera may subsequently calcify. Another rare condition is the
so-called calcareous metastasis in which in extreme resorption of
bone from extensive caries, malignant disease, etc., a widespread
deposit of calcium salts may occur in the cartilages, mucous mem-
branes of the mouth, stomach and arteries.
AREAS OF INCREASED DENSITY IN SPONGY BONE 23
Areas of lacreased Density in Spongy Bone.^Sinall round areas
of condensation are sometimes seen in cancellous bone. There is
no disturbance in the normal structure of the bone about them,
and their significance has been a matter of considerable speculation.
They may represent old healed areas of infection or some localized
Fig. 2.^FQreign body io soft tissues. (MetnlUc injection.)
disturbance in the growth of the bone. At any rate, they have no
pathological importance. They may occur near the ends of long
bones m the carpus, tarsus or within any of the flat bones. The
transverse dense lines, oftenmultiple, which occur alongthe medullary
canal toward the end of the long bones, are the result of disturbances
of growth which occurred at the time when the epiphyseal line was
24 CONFUSING SHADOWS AND ARTEFACTS
at that point; they may be likened to the growth of rings in the
trunk of a tree.
Warts and Fibromata on the Sltin. — Any area of skin which presses
heavily on the plate will be recorded as a spot of increased density,
common examples of which are outlines of the buttocks of a thin
individual in a plate of the entire pelvis, the breasts of women in
anteroposterior plates of the chest or the ears in lateral skull plates.
Fia. 3. — Gas ganEreoe.
In the same way warts and fibromata appear as rounded areas of
increased density, which when they occur in the kidney and gall-
bladder regions may strongly suggest calculi. A characteristic
which may help to identify them is that they have extremely sharp
margins because of the fact that they are in contact with the plate.
The presence of fibromata should always be noted in the patient's
record.
DEFECTIVE PLATES 25
Metallic Salts. — ^Dense shadows of the metallic salts may be seen
where there are bismuth or barium residues in the sinus which has
been injected or in portions of the gastro-intestinal tract; where
zinc or mercurial ointments are present on the skin, or iodin which
in any form casts a shadow of particular density. The presence
of iodin upon the skin or within the soft tissues as a result of intra-
muscular injection is quite striking (Fig. 3). Air or gas in the soft
tissues also gives a characteristic picture. •
Gas in the Intestinal Tract. — Accumulations of gas, particularly
in the colon where it overlies the spine, the wings of the ilia or
sacrum, arc sometimes mistaken for areas of rarefaction in the bone.
Careful inspection will reveal the presence of normal bone structure
in the doubtful area or the patient may be reexamined.
Defective Plates. — Plates may show irregular light or dark areas
as a result of defects of manufacture, or fogging by light or x-rays.
One particularly troublesome defect is the occurrence of localized
thin spots in the emulsion which give shadows light in color resem-
bling those of stones. Irregular patterns of increased or diminished
density occasionally result from uneven immersion of the plate in
the developer; these are very sharply marked and have long curved
outlines. Finger marks appear on plates as light or dark spots,
depending upon the substance present on the finger at the time of
impression; their presence is always an indication of faulty dark-
room technic.
BIBLIOGRAPHY.
Wells, H. Gideon: Metastatic oaleification, Arch. Int. Med., 1915, xv, p. 574.
Hetherington, J. P.: Causes of apparent and leal mistakes in x-ray diagnosis,
Railway Surg. Jour., 1915-16, xxii. p. 223.
Pirie, A. H.: Interpretation of x-ray negatives, British Med. Jour., 1910, part 2,
p. 584.
Jones, R., and Morgan, D.: On osseous formations in muscles due to injury. Arch.
Roent. Ray, 1904-5, ix, p. 245, and 1905-6, x, pp. 10, 46, 72, 100, 199, 249, 275, 304.
Outerbridge, G. W.: Non-teratomatous bone formation in the human ovary.
Am. Jour. Med. Sc, 1916, cli, 868.
Klotz, Oskar: Obsolete miliary tu]:>ercles of the spleen. Am. Jour. Med. Sc, 1917,
clxxx, p. 786.
CHAPTER II.
ANATOMICAL VARIATIONS AND DEVELOPMENT.
Anatomical variations in bone structure may occur anywhere
in the skeleton and are of considerable importance aside from their
interest as curiosities, for they are commonly points of lowered
resistance. A strain or injury which would be without effect on a
normally constructed individual may give rise to severe and stub-
born symptoms when such anomalies are present. This is particu-
larly true of variations in the spine.
Skull. — ^The skull may show partial absence of bones or variation
in the width of sutures, of which extreme examples are acephalic
monsters. Thin areas appearing as holes are occasionally seen in
the frontal and parietal regions and along the sagittal suture.
The sinuses and mastoids are subject to wide variation, from com-
plete absence to enormous size. Cases have been observed in which
the mastoids communicated with the sphenoid sinus anteriorly and
with each other posteriorly.
Vertebrae. — ^A most common anomaly in the spinal column is the
presence of extra bodies, e, g.y six lumbar or thirteen thoracic seg-
ments, or of extra portions of bodies which take the form of a
triangular wedge which may bear an extra rib when it occurs in
the thoracic region.
Another frequent finding is the failure of union of the posterior
ring. All degrees of this condition are seen from bifid spinous
processes to complete spina bifida.
There may be increase of length or size of the transverse processes,
particularly in the last cervical and last lumbar vertebrae. There
are all gradations found up to partial or complete fusion of the pro-
cess with the sacrum, or so-called sacralization. These enlarged
processes give rise to symptoms whenever, on account of size or
position, they cause pressure on nerve trunks or impinge on neigh-
boring bones. On the other hand, the processes of the first lumbar
are often short and have accessory ribs attached; these may be
mistaken for fractures.
— Congenitnl abnormality. Wedee-shnpcd vortebra.
Fio. 5. — Enlarged sacraliied traDS^-eree process on fifth lumbar vertebra.
28 ANATOMICAL VARIATIONS AND DEVELOPMENT
While spinous processes are ordinarily arranged in a straight
line, slight lateral deviations of individual processes may occur
without pathological significance. Unusually long or thick spinous
processes may impinge on one another, especially in the lumbar
spine in cases of exaggerated lumbar curve.
There is a considerable variation in the plane of the articular
facets at the lumbosacral junction. Normally these articular sur-
faces are approximately transverse, but one or .both may be rotated
so that the plane of the articulation between them is anteroposterior.
These are a potential source of symptoms in the lower back because
they permit of various degrees of forward dislocation of the fifth
lumbar vertebra upon the sacrum.
Fin. C. — Double cervical riba.
Ribs. — One anomaly has already been mentione<i; that is, the
occurrence of extra ribs which may appear in the lower cervical or
upper lumbar regions or attached to extra bodies. These cervical
ribs may be of sufficient length to articulate with the sternum or
be attached to the first rib. They are usually longer than they
appear on the plate, due to foreshortening of their shadow. On the
VARIATIONS OF THE TARSUS 29
other hand, one or more ribs may be absent, or partially so, or
adjacent ribs may be fused, A mild form of this latter condition
is frequently seen near the sternal end, where a rib may flare con-
siderably before its attachment to the costal cartilage, and this
enlargement may or may not be perforated.
Scapnlse.— These bones vary considerably in thickness and holes
may occur in the thin regions, especially in old people; in the same
way unusually prominent grooves may simulate fractures. There is
a condition known as congenital elevation of the scapula (Sprengel's
deformity), in which a partially developed scapula is found high up
toward the neck. In cases of obstetrical paralysis there may be an
imperfect development of the lower half of the scapula.
Fig. 7. — Congenital abnormality of the acapulte.
Variatloiis of the Caipu^'^t'erhaps the most important anomaly
here is the divi<led scaphoid, which is to be differentiated from a
fracture of the scaphoid. The margins of the halves are more
rounded and smooth an<l the space separating them is not quite so
black as in the case of fracture. The semilunar and the radial
sesamoid of the thumb may be similarly divided. Small extra
bones may be found, of which the most common is the styloid; this
develops from an extra center of ossification bing between the
trapezoid, the magnum and the third metacarpal.
Variations ol the Tarsus. — The astragalus bears a ba<?kward pro-
longation of variable length which often exists as a separate bone,
the trigonum; when present it must be differentiated from a frac-
ture of a long process. The next in order of importance is the tibiale
externum, a small detached bone which sometimes occurs at the
30 ANATOMICAL VARIATIONS AND DEVELOPMENT
posterior end of the scaphoid on the inner side of the foot. The
peroneum in the tendon of the peroneus longus overlying the
cuboid may be subdivided.
The small separate center of ossification on the outer side of the
posterior end of the fifth metatarsal may persist into adult life as a
small bone called the vesalianum.
Divided sesamoids in the tendons of the flexor hallucis brevis
beneath the head of the first metatarsal are fairly common. They
must be carefully differentiated from fracture of single sesamoids,
which are extremely rare.
The subject of variations in the hands and feet is exhaustively
treated by Dwight.
Other Bony Variations. — In every roentgenological practice one
may encounter cases of partial or complete absence of long bones,
particularly the fibula, radius and phalanges. On the other hand,
supernumerary bones, usually extra fingers or toes, may also be
seen. Fusion of bones may be looked for occasionally; this is most
frequently found between the radius and the ulna. Adjacent carpal
and tarsal bones may be united, and there is an hereditary anomaly
in which the first and second phalanges of one or more digits may
coalesce with obliteration of the interphalangeal joint. Atavistic
variations may occur, as, for example, the hooked supracondylar
process occasionally found on the inner margin of the humerus above
the elbow.
Ossification. — Variability is also evident in the time of appearance
of centers of ossification. The following table taken from Rotch
and Morris's Anatomy gives figures which can be relied upon as
a working average.
Age of Age of
appearance, fusion.
Ribs: Epiphyses for head and tubercle 15 23
Clavicle: Small epiphysis of the sternal end ....... 18 25
Humerus: Head 8 mos. 20
Greater tuberosity 3 20
Ijesser tuberosity 4 20
(All fuse at six years and join the shaft at twenty years).
Capitellum 1 17
Internal epicondyle 5 18
Trochlea 10 17
External epicondyle 12 17
(The capitellum, trochlea and external epicondyle join
as a mass at seventeen and the internal epicondyle at
eighteen years.)
Radius: Head 5 17
Lower epiphysis 2 20
Ulna: Olecranon 10 17
JiOyrer epiphyses ......,, 4 18
OSSIFICATION 31
Age of Age of
appearance, fusion.
Carpus: (In the order of appearance.)
Magnum 1
Uneiform 1 to 1 J
Cuneiform 2to3
Semilunar 4 to 5
Trapezium 5
Scaphoid 5 to 6
Trapezoid 6 to 8
Pisiform 12
Metacarpals: Epiphyses 3 20
Phalanges: Epiphyses 3 18
Pelvis: (Pubis and ischium unite at eight years; the acetabulum
closes at sixteen years.)
Epiphyses for
Crest of ilium,
Ischial tuberosity, [15 20
Anterior inferior iliac spine,
Tubercle of pubes.
Femur: Head 1 19
Greater trochanter 4 18
Lesser trochanter 13 17
Lower epiphysis 8 mos. 20
Patella: 3 24
Fibula: Upper epiphysis 4 24
Lower epiphysis 2 20
Tibia: Upper epiphysis 9 mos. 22
Lower epiphysis 2 18
Tarsus: (In order of appearance.)
Calcis 6 mos.
Epiphysis of calcis 10
Astragalus 7 mos.
Cuboid 9 mos.
External cuneiform 1
Internal cuneiform 3
Middle cuneiform 3
Scaphoid 4
Metatarsals: Epiphyses 3 to 8 20
Phalanges: Epiphyses 4 to 7 18
Sesamoids of flexor hallucis bre\'is: 5
Vertebrae: Ossification is from three primary centers, one for the body and one for
each lateral mass. The nucleus for the body is often bilobed, with a par-
tial plane of cleavage in the vertical or horizontal diameter. The
laminse unite during the first year. Five secondary centers described
in the anatomies — namely, thin plates on the upper and lower surfaces
of the body and the tips of the mammillary tubercle, transverse and
spinous processes — appear at the age of fifteen to twenty years and
unite at twenty-five. The fifth lumbar vertebra is an exception in that
it ossifies from five centers, one for the body, one on each side from
which is developed the superior articular process, pedicle and trans-
verse process, and one on each side which subsequently form the
inferior articular process, lamina and spinous process.
It is well to bear in mind that epiphyses which appear last are
the first to unite and that the nutrient foramen is directed toward
them; that ossification begins earliest in the epiphyses bearing the
largest relative proportion to the shaft (except the fibula); that
when an epiphysis ossifies from several centers, they fuse together
before uniting with the shaft,
32 ANATOMICAL VARIATIONS AND DEVELOPMENT
Thomas Morgan Rotch has called attention to the fact that the
time of appearance of the carpal centers is the best index we have
of the actual development of an individual.
Delayed Union or Failure of Union. — Variations in the normal
process of the union of epiphyses are of great importance as a factor
in the production of deformities. For example, failure of develop-
ment of a center in the lateral masses of the fifth lumbar may result
in scoliosis. Abnormal fusing of the lower epiphysis of the radius
produces the malformation known as Madelung's deformity, in
which the plane of the radiocarpal articulation is rotated inward
and backward.
Delayed union may be an evidence of retarded mental or physical
development, of which a common example is cretinism; of infections,
prominent among which is lues; or of injury.
BIBLIOGRAPHY.
Milne, James A.: Congenital absence of the radii, British Med. Jour., 1915, ii, p.
821.
Piersol, George A.: Congenital perforations of the parietal bones, Univ. Penna.
Med. Bull., 1902, xv, p. 203.
Skillern, P. G.: Congenital perforations of the parietal bones, Ann. Surg., 1914,
ix, p. 807.
Adams: Relation of anomalies of lumbar and sacral spine to lordosis. Am. Jour.
Orthop. Surg., 1915, xii, p. 45.
Hodgson, F. G.: Congenital deformities of the vertebrae and ribs. Am. Jour. Orthop.
Surg., 1916. xiv, p. 34.
Case, J. T. : Anacephaly successfully diagnosed before birth, Surg.. Gynec. and Obst.,
1917, xxiv, p. 312.
Boorstein, S. W.: Symmetrical congen'tal malformation of extremities, Ann. Surg.,
1916, Ixiii, p.'l92.
Rugh: Sprengel's deformity, Tr. Philadelphia Acad. Surg., 1915, xvii, p. 62.
Albers-Schonberg: A skeletal anomaly, the supracondylar process. Am. Jour. Roent.,
1916, iii, p. 182.
Geist, E. S.: Supernumerary bones of the foot. Am. Jour. Orthop. Surg., 1914-15,
xii, p. 403.
Ruh, H. O.: Acrocephalosyndactylism, Am. Jour. Dis. Children, 1916, xi, p. 281.
Schueller, A. : Peculiar cranial defects in young individuals. Am. Jour. Roent., 1916,
iii, p. 497.
Ashhurst, A. P. C: Congenital absence of the fibula, Ann. Surg., 1916.
Peckham, F. E.: Congenital elevation of the scapula, British Med. Surg. Jour.,
1916, clxxiv, p. 315.
Dwight, T.: Closure of cranial sutures as a sign of age, British Med. Surg. Jour.,
1890, cxxii, p. 389.
Hartung, A.: Congenital anomalies and variations of the bony skeleton, Am.
Jour. Roent., 1916, iii, p. 430.
Dunlop: Adolescent tibial tubercle, Am. Jour. Orthop. Surg., 1912-13, ix, p. 313.
Goldwaite, J., and Painter, C. F.: Congenital elevation of shoulder, Tr. Am. Orthop.
Assn., xix, p. 302.
Barnes, N. P.: The sesamoids of the flexor brevis hallucis. New York Med. Jour.,
1915, cii, p. 940. Tr. Am. Therap. Soc, 1915, p. 59.
Clark, D. A.: Sacralization of lumbar vertebra, Canadian Med. Assn., Jour. 1916,
vi, p. 914.
Pryor, J. W. : Ossifications of the bones of the hand, Bull. Univ. Kentucky, viii, No.
11, November, 1916. Reviewed in Am. Jour. Roent., 1916, iii, p. 416.
Sever, J. W.: Obstetrical paralysis, Am, Jour, Orthop. Surg., 1916, xvi, p. 456.
CHAPTER III.
FRACTURES AND DISLOCATIONS.
FRACTURES.
It is most important for a roentgenologist to have a thorough
knowledge of roentgen anatomy and of the surgical pathology of
wound and fracture repair. Gross fractures are, of course, obvious,
but in a doubtful case the diagnosis may depend entirely upon the
breadth of his anatomical and surgical experience. He should at
least know that the more accurately a fracture is reduced the
sooner will function be restored and the smaller the callus which
results; that calcification begins in callus in from two to four weeks
and is usually complete in six; that at first callus may show very
little evidence of lime deposit when there is no displacement of
fragments; and that an extensive comminution or a malposition
of fragments should be accompanied by a large, thoroughly calcified
callus.
The prognosis of fractures involving joints should always be
guarded because of the fact that there is no means of estimating
from the roentgen examination how much damage has occurred to
the soft tissues or what effect their repair will have on function.
The possibility of organization and calcification in extensive hema-
tomata which may follow injuries to the supporting structures
should always be remembered.
The question of union is often a difficult matter to decide from
roentgen evidence alone. One cannot determine from a plate show-
ing a fracture without evidence of bony union whether there are
soft tissues between the fragments which will interfere with repair,
whether an uncalcified callus is present or whether or not there is
firm fibrous union. It must not be forgotten that non-union is
prone to occur when the site of fracture involves a nutrient artery
or when the patient is syphilitic or asthenic.
In the reduction of fractures normal weight-bearing lines should
be restored as far as possible and every attempt should be made to
replace articular surfaces in their normal planes with reference to
3
34 FRACTURES AND DISLOCATIONS
the shaft. In doubtful cases comparison plates of a sjTnmetrical
part may help to decide whether a reduction is satisfactory.
Fracture lines will usually become obliterated in from three to
six months, and if reposition of the fragments has been accurate all
evidence of the injury may have disappeared in that time. The
shadow of linear fractures in the skull, however, may persist for a
longer period, but ordinarily are not visible beyond one year after
the injury. In any fracture, when reduction has been poor or the
callus formation extensive, evidence of the deformity may persist
for life.
The roentgenogram will often furnish evidence of value to the
surgeon aside from the position of the fragments, such as indica-
tions of a pathological process in the bone or of the presence
of foreign bodies within the wound, and occasionally the early
appearance of gas in the soft tissues as a result of infection with
Welch's bacillus.
FRACTURES 36
Skull. — From its structure the'skull is subject to linear fractures
which appear on the plate as thin black lines with sharp ragged
edges. They may run in any direction. They are to be differen-
tiated from suture lines, diploic vessels and arterial grooves, all of
which have fairly definite courses, smooth margins and are lighter in
color. Fracture lines may open up sutures or follow bloodvessel
markings, but they can usually be traced beyond the course of these
normal lines.
Comminuted and stellate fractures are usually obvious. A
depressed fracture often appears as a white line because of overlap-
ping of the margins of the break; whenever possible profile views
of them should be obtained.
Fractures of either the inner or the outer table appear as areas
of slight irregularity in the density and structure of the bone.
Fractures limited to the base are frequently overlooked; a vertical
projection of the base in addition to an anteroposterior, postero-
36 FRACTURES AND DISWCATIONS
anterior and both lateral views should be a routine in searching for
skull fractures.
Cranial aerocele may develop Following fracture through the
sinuses, especially the frontal sinus. They are produced by the
increased air pressure within the nasal cavity when the patient
sneezes or blows the nose. At this time air and bacteria may be
forced through the fracture into the cranial cavity. The pocket
containing the air will appear on the plate as an area of markedly
diminished density, usually in the frontal region. Plates should be
taken from both sides, as it may be absent in one.
Via. 10. — ^Fracture of the spine (lateral view).
VertebiEB. — Fracture lines are rarely seen in the bodies of verte-
brse. What is seen is abnormality in outline or in relations to
neighboring vertebrae. Crushing fractures of the bodies occur most
FRACTURES 37
commonly in the thoracic and lumbar regions as the result of severe
injury. They may be overlooked in an anteroposterior view, and a
lateral view should always be obtained as a check. These fractures
run a long clinical course and give no evidence of callus formation,
even after months or years. Localized hypertrophic spurs or
bridges to adjoining bodies often develop after these injuries.
Fia. 1 1.- — Fracture along the tran
]i
Fractures of the body of the fifth lumbar may occur but it is not
common. This vertebra, owing to its tilted position, is so distorted
in the average picture that its outlines are recognized with difficulty.
A diagnosis of fracture of this body should not be made without a
good stereoscopic inspection of its direct anteroposterior diameter
in addition to a lateral view if possible.
Transverse processes may be fractured by severe lumbar injuries,
usually several vertebree being affected. There may or may not
be considerable separation of the fragments.
Fracture of the posterior ring and transverse processes is seldom
38 FRACTURES AND DISLOCATIONS
directly shown. They may be diagnosed by the change in the rela-
tions of the vertebrte at the site of the lesion, usually a slight rota-
tion or angulation so that the spinous processes of the vertebrEe
above the lesion are out of line with those of the one below. This
condition is to be differentiated from the slight lateral deviations
which frequently occur in individual spinous processes without
significance.
Fin. 12.— Typical Colles's fracture. The lateral view shows the amount of deformitj-.
Fractures of spinous processes may be suspected from deformities
of their outlines in anteroposterior views. A lateral view, however,
will usually confirm the diagnosis.
Pelvis. — Pelvic fractures are usually due to violent injuries such
as falls and crushes and the resulting deformity is easily recognized.
The regions about the sacro-iHac and the symphysis are most fre-
quently involved. A typical injury consists of fracture of the pubis
FRACTURES 39
with more or less wide separation of the sacro-iliac, or fracture
through the sacrum or ilium close to the synchondrosis. The femoral
head may be driven into the pelvis, carrying the inner wall of the
acetabulum^before it.
Ribs. — Fractures of the ribs are usually obvious but may be over-
looked in the overlapping axillary shadows. Slight rotation of the
patient will bring the suspected area into clear view. Fracture of
the costal cartilage may occur which, of course, is not evident on the
roentgenogram unless the cartilage is extensively calcified.
Carpus. — The bones involved in the order of frequency are the
scaphoid, cuneiform and magnum. These fractures are often asso-
ciated with those of the radius and ulna and should not be over-
looked by exclusive attention to the latter. In case of doubt it is
advisable to secure plates of both wrists in symmetrical position
for comparison.
CoUes's Fracture. — ^This is probably the most common of all frac-
tures. The usual deformity is a compression of the posterior margin
of the radius which results in a backward tilting of the articular
FRACTURES AND DISLOCATIONS
FRACTURES 41
surface as seen in the lateral position. After reduction, the former
relation of the styloid processes of radius and ulna should be restored
and the plane of the articular surface should be tilted toward the
palmar surface forming a normal angle with the axis of the shaft. A
special type of this injur;- results from backfiring of automobiles and
consists of an oblique fracture through the styloid of the radius.
Tia. 1«,— SnhperioBti
Elbow. — Fractures here in the order of frequency are supra-
condylar fractures of the humerus, fractures of olecranon, head of
radius and coronoid process. The two latter injuries may occur
without a great deal of displacement and may be overlooked unless
they are carefully searched for.
Shoulder. — Fractures of the anatomical and surgical neck are
usually the result of falls and they may or may not be impacted.
Stereoscopic observation of this region or a lateral view is always
recommended for the recognition of the true relation of the frag-
ments.
42 PHACTVnES AND DlfiLOCATIONS
Fractures of the scapula are often overlooked on flat plates.
Stereoscopic examination will minimize this error,
Tarsua.— Fractures of the os calcis are the most frequent. They
produce more or less disturbance in the normal structure consequent
upon crushing of the spongy bone and deformity of outline. The
« of the patellie. The fracture
line of fracture is seldom seen. The resulting disability i-'! usually
severe. More rarely fractures of the astragalus and cuboid may
occur.
Pott's Fracture. — In any fracture of the tibia it is essential that
the fibula be explored throughout its extent in order to avoid missing
breaks which occur at a different level from that of the tibial injury.
The essentials in reduction of a Pott's fracture are that the weight-
Fin. 18. — Old fracture ot the femur, with extenaive cbHhs and deformity.
Fin. 19. — Pathnlogioal fracturp of the upper end of the tibia
Fia. 20.— Green-stick
Fio. 21.— Fracture of the Deck of the femur, with marked abfwrption of the n
DISLOCATIONS 45
line be restored accurately and tbat the foot be slightly
inverted.
Knee. — Fractures of the condyles of femur and tibia have the
characteristics of fracture involving any joint. The spine of the
tibia may be evulsed; the patella may sustain a transverse break
with wide separation of the fragments or it may suffer a stellate
fracture or shelving fractures of the upper or lower margins as a
result of division of the attachment of the patellar tendon.
Hip. — These fractures occur anywhere in the neck of the femur
between the head and intertrochanteric line. When there is any dis-
placement of the fragments, there will be a disturbance of Shenton's
line, which is a smooth, regular curve formed by the upper margin
of the obturator foramen, the inferior border of the neck of the
femur and the inner margin of the shaft.
In the prognosis of hip fractures the possibility of failure of union
and of absorption of the head of the femur must always be kept in
mind.
Fjo. 22, — Double congenital dislocation of the hip.
DISLOCATIONS.
Dislocations of the spine are usually accompanied by fracture.
They are most common in the cervical region. The first cervical
vertebra may be displaced backward on the second with fracture
of the odontoid or, more rarely, rotated upon the second without
fracture of the odontoid. The most frequent injury is a forward
displacement of the upper cervical vertebne upon the ones below
in the region of the third to the seventh.
FRACTURES AND DISLOCATIONS
Fia. 23.— Dislocation ot the shoulder.
Flo. 34. — DiBplacement of the epiphyna of tbe humerus.
DISLOCATIONS 47
The saero-iliac joint may be disarticulated as a result of severe
trauma. The so-called sacro-iliac slip is not demonstrated on plates.
Subcoraeoid dislocations of the shoulder usually have an asso-
ciated fracture of the greater tuberosity, which is reduced when the
head of the humerus is replaced.
Fio. 25,— Dislocation of the sirth on the seventh cervical vsrtebr*.
In the carpus the semilunar is occasionally dislocated forward
and may be overlooked in an anteroposterior view although it is
obvious in a lateral one.
Epiphyseal separations usually involve a fragment of the adjoin-
ing shaft. When unaccompanied by a fracture of the shaft they
can only be diagnosed by the abnormal relations of the e
48 FRACTURES AND DISLOCATIONS
which do not often occur. Plates of symmetrical parts should always
be taken to check up these findings. When these separations are
promptly and accurately replaced there is rarely any interference
with the growth of the bone.
Fio. 26. — Fracture of the fifth cervical vcrtehne,
Delaj'ed union of the ossification center of the tibial tubercle is
fairly common, particularly in the presence of a chronic infection
such as lues. Separation of the tibial tubercle (Osgood-Schlatter
disease) occurs usually as a result of indirect violence. The tubercle
is elevated from the diaphysis and the margins of the epiphyseal
line beneath it are thickened and ragged. A similar injurj- may
occur to the epiphysis of the os calcis.
Congenital dislocations of the hip may be single or double. They
are characterized by displacement of the head of the femur upward
on the ilium, flattening and deformity of the head, and shallowness
of the acetabulum.
BIBLIOGRAPHY 49
Dislocations may occur at any joint. They are usually obvious
and require no particular description. In any dislocation careful
search should be made after reduction, as well as before, for fractures
which may have been overlooked.
BIBLIOGRAPHY.
Cotton, F. J.: Fractures of the transverse processes of the vertebrae, Interstate
Med. Jour., Supplement on Roentgenology, October, 1916, p. 138.
Sever, J. W.: Fracture of a lumbar vertebra, Surg., Gynec. and Obst., 1916,
xxii, p. 338.
Young, J. K.: Ununited fractures of lumbar vertebrae, Ann. Surg., 1916, Ixiii,
p. 374.
Boardman, W. W.: Pseudofracture of the sesamoid bones of the big toe, Surg.,
Gynec. and Obst., 1915, xxi, p. 394.
Crook, J. L.: Fractures of the astragalus. Rail. Surg. Jour., 1916, p. 17.
Cotton, F. J.: Os calcis fracture, Ann. Surg., Ixiv, p. 480.
Codman, E. A., and Chase, H. M.: Fracture of the carpal scaphoid and disloca-
tion of the semilunar bone, Ann. Surg., May, 1905.
Solomon, E. P.: Unusual surgical conditions following trauma, Internat. Jour.
Surg., 1916, xxix, p. 248.
Skillern, P. G.: Fractures of sesamoid bones of the thumb, Ann. Siu-g., 1915, Ixii,
p. 297.
Scudder, C. L.: Treatment of fractures, with notes upon a few common disloca-
tions, Ed. 8, rev. Philadelphia, 1915.
Pancoast, Henry K.: Roentgen examination of the spine; surgery of the spine
and spinal cord, Franzier-Appleton, New York.
CHAPTER IV.
BONE PATHOLOGY.
Normal bones are smooth and regular in outline, the cortex is
homogeneous and the cancellous tissue of uniform consistency. The
thickness of the cortex and the texture of the spongy bone vary
considerably with the individual. The cortex is thickest along the
center of the shaft of the long bone, diminishing toward the ends
to a thin line which continues beneath the articular cartilage. The
student should have a general idea of the normal thickness of the
cortex of each individual bone.
Bone disease is manifested by changes in size, in outline and in
density. Various forms and combinations of these changes result
from the action of pathological agents, so that it is often difficult
from the roentgen findings alone to identify positively the causative
factor. For this reason the clinical history should always be com-
bined with the roentgen findings in making a diagnosis.
Bones are increased in size in osteomyelitis, tumors, Paget 's
disease, syphilis and cystic disease. They are diminished in size
in paralysis, chronic disease of neighboring joints or in -develop-
mental anomalies. Changes in outline result from periostitis, which
may be traumatic or infectious, from callus formation and from
tumors of the bone.
Changes in density may be either local or diffuse. Diminished
density (increased radiability) occurs as a result of disuse, infection
or of actual destruction from involvement by tumor, cyst or surgical
intervention. The form of rarefaction due to disuse is commonly
referred to as bone atrophy although this term is not strictly correct.
There are two types: spotted and diffuse. In the spotted form small
local areas of rarefaction appear scattered through the spongy bone
and may be noticed as early as one week after complete fixation
of the parts. This condition may be mistaken for metastatic malig-
nancy but the history will usually differentiate them. The diffuse
form occurs in more chronic processes as a result of prolonged fixa-
tion, chronic infections in neighboring joints or atrophy of the soft
parts, or as a result of senile changes. As the name implies, it is a
OSTEOMYELITIS 51
more extensive process and consists in a uniform decrease in density
with thinning of the cortex and trabeculae. Increased density occurs
as a diffuse process in old osteomyelitis, in syphilis and in Paget's
disease. It is found locally about certain low-grade infections and
carcinomatous metastases of slow development.
In the presence of a pathological process in bone, the following
points should Be determined: (1) Is there involvement of the med-
ulla; (2) is there evidence of involvement of the cortex; (3) b there
Fia. 27. — The bono atrophy of diaoae.
any associated pathology in the soft parts; (4) is the lesion multiple;
(5) is it confined to the shaft or does it invade the epiphysis and
joint; (0) are neighboring bones affected; (7) is it destructive or
proliferative or both?
Osteomyelitis. — ^The characteristics of this process are a variable
amount of destruction of medulla and cortex; extensive reaction
of the periosteum whenever involved; sequestration and irregular
sclerosis. It may attack any bone at any age and rarely extends
beyond the epiphyseal line.
52 BONE PATHOLOGY
The process may exist one or two weeks without producing any
changes whatever in the shadow of the affected bone. Then areas
of diminished density appear at the site of involvement. Prolifera-
tion of the periosteum occurs as a result of irritation beneath it and
may become extensive, as more of the bone is involved leading ulti-
mately to the formation of a shell of new bone, the involucrum.
Fia. 2S. — Osteomyelitis of the upper cud of the titaa in a child.
about the necrotic mass of the old shaft which then becomes a
sequestrum. The process may involve only a portion of the shaft,
in which case a variable amount of irregular sclerosis appears about
the affected area and small sequestrum may form.
Two atypical forms are the virulent or fulminating type and the
non-virulent bone abscess. The former may give very little positive
TOUERCl'LOSIS 53
roentgen evidence or show extensive irregular rarefaction through-
out the bone with elevation and thickening of the periosteum, but
no sclerosis, or new bone formation. The avirulent type shows a
circumscribed area of rarefaction in the medulla usually with a wall
of increased density about it and little or no proliferation of the
overlying periosteum.
Fio. 29. — Osteomyelitis of the second metacarpal.
Tuberculosis. — This disease appears in the bones as a slowly
progressive, local, destructive process without attempt at regenera-
tion. It most commonly attacks the joints or epiphyses In young
individuals and is rarely found in the shaft. The early stages may
show merely effusion in the aiTected joint, but rarefaction of the
neighboring bones soon occurs resulting in the characteristic blurred,
hazy picture with loss of detail and perhaps local areas of destruc-
tion in the affected epiphyses. In the carpus and tarsus this bone
BONE I'ATHOWGY
Fig. 31. — Osteomyelitis of the ilium in b child.
TUBERCULOSIS 55
atrophy may be severe so that the bones appear of the density of
soft parts with finely penciled outlines. Enlargement and squaring
of the epiphyses is the rule. As the process continues there is more
or less destruction of the joint surfaces eventually resulting in anky-
losis as the process heals. Periostitis may develop in the neighbor-
hood of tuberculous lesions, but only as a result of secondary
infection.
Fig. 32.— Tuberculoua spine (anteroposterior view).
The rare cases of tuberculosis of the shaft appear as an irregular
destruction in the medulla resembling that seen in a syphilitic osteo-
myelitis but without involvement of cortex or periosteum.
In the spine tubereulosis usually begins in the neighborhood of
the intervertebral disks and destroys the adjacent body or bodies,
which collapse, producing a kyphos. This portion of the spine Is
56 BONE PATHOLOGY
often surrounded by the fusiform shadow of a prevertebral abscess.
Calcification may occur later in such an abscess.
Caries sicca is a slow destructive process which is most common
in the shoulders. It causes irregiular erosion of the joint surfaces and
Fig, 33. — Tuberculous spine (lateral view),
the epiphyseal end of the humerus. There is no bone atrophy; on
the contrary, there may be slight increase in density in the affected
area.
Dactylitis (spina ventosa) is characterized by considerable
increase in the diameter of the diseased phalanx, which shows
extensive areas of destruction in the medulla. The cortex may be
SYPHILIS 57
somewhat thin or slightly increased in thickness. This condition
is differentiated from syphilitic dactylitis by the fact that the
enlargement in tlie latter is due to periosteal proliferation with the
formation of a collar of new bone outside of the old cortex; there is
very little involvement of the medulla and from giant-celled
sarcoma by the absence of trabeculation.
Fig. 34.— Cranial tabes.
Syphilis. — Syphilis is a destructive and proliferative process,
assuming varied forms which may simulate other conditions. It
attacks any bone at any age. Its commonest manifestations are
periostitis and irregular areas of destruction.
Periostitis is usually limited to the shaft, and the picture which
results from it vaiies according to the age and activity of the
process. When acute the appearance is that of multiple distinct,
thin laminse laid down upon the old cortex, and the outline of the
free margin is usually irregular. As the condition becomes more
chronic these laminse become thicker and more compact, so that
58 BONE PATHOLOGY
ultimately the area involve<l becomes as dense as the normal cortex.
At the same time the surface loses its fringj' character and becomes
smooth, although it may be more or less irregular. This increase in
thickness of the cortex will often give an appearance of bowing, as is
seen in the so-called sabered tibia, for example. It should be noted
that this thickening of the cortex usually occurs on the convex
side of the curve as compared with rickets, where it appears on the
Flo. .15. — TonRcnital syphilis (periosteal type).
concave side. There is often an accompanying endosteal prolifera-
tion with narrowing of the medullarj' canal.
Periostitis may also occur as small local elevations of the perios-
teum (bone blisters) at times near the ends of the long bones
and assumes the form of multiple confluent small blisters. There is
another type of lesion, a sort of lacework pattern, which consists of
strands of calcified material which run out at right angles to the
cortex and arch together at their terminations. Running through
sypHius 59
this pattern, parallel to the shaft and midway between the cortex
and the periphery, there is a definite thin sheet of calcification.
At the margins of the process where it blends into the normal bone
is the usual tj'pe of laminated periosteal thickening. In the con-
genital form in infants the periosteum may be floated awaj' from the
shaft for a considerable distance, gi\ing a clear space between it
and the cortex.
Fig. 36. — Types of specific periostitis of the tibiEC,
Irregular areas of destruction may occur in any I)one, usually as
a result of gummatous changes. In the skull the picture is striking
and represents punched-out areas involving boih the outer and inner
table. In the long bones they are usually associated with periosteal
changes, although at times a bone may be riddled with these areas of
rarefaction and show only slight periosteal change. This is partic-
ularly commoninthemoreacutecases. Inchildren a common picture
BONE PATHOLOGY
is the so-called juxta-epiphyseal lesion, which occurs in the diaphysis
near the epiphyseal line. They are characterized at first by an
irregular loss of substance close to the epiphyseal line and perhaps
a slight periostitis. The affected area later becomes sclerosed, lead-
Fio. 37. — Spedfic perCoatitis (congenital type).
ing to the formation of a white line, which resembles somewhat
that seen In scorbutus.
Joint lesions may be unilateral or symmetrical. Ordinarily little
is seen beyond an increase in density in the soft parts, due to
TYPHOID 61
effusion and synovial thickening. Later on, low rounded hyper-
trophic growths may appear about the margins of these joints.
Extensive destructive processes may sometimes occur in the epiphy-
seal ends of bones, causing considerable deformity. Localized areas
of destruction suggesting tuberculosis may sometimes be found in
the epiphyses of children.
Fia. 38.— Specific dactilitie.
In the spine, lues causes the destruction of one or more bodies,
usually preserving the intervertebral disks. The affected area is
often surrounded by calcified masses of detritus. Extensive hyper-
trophic changes are seen on the neighboring vertebrae.
Typhoid. — Typhoid in the bone is a localized destructive and pro-
liferative process of long duration, usually occurring in early adult
life. It is characterized by circumscribed areas of destruction in the
ribs, the margins of vertebral bodies and occasionally the cortex and
long bones. It may cause a local periostitis and at times extensive
irregular periostitis indistinguishable from that of sv'philis. In the
spine the first roentgen evidence usually appears at an interval of
weeks or months after the onset of symptoms, when a small area of
destruction may appear in the corner of a vertebra close to the disk.
62 BONE PATHOLOGY
Subsequently coarse hypertrophic bridges may appear about this
area or the intervertebral disk may be destroyed with a resulting
fusion with the adjacent vertebrae.
Actinomycosis. — ^Actinomycosis causes a chronic osteomyelitis.
It usually occurs in the jaw, and is characterized by its slow course
and by the pronounced proliferation of bone with the resulting
general increase in density.
Oidiomycosis. — Oidiomycosis may attack the bone in severe cases.
The roentgenogram will show extreme bone atrophy in involved
areas, with more or less irregular destruction which suggests tuber-
culosis when it occurs in the region of a joint. Local areas of destruc-
tion may occur in the cortex with loose fuzzy strands of proliferating
periosteum overlying them.
Leprosy. — Leprosy is characterized in its early stages by bone
atrophy of the terminal phalanges and a variable amount of peri-
ostitis. As the disease progresses these phalanges disappear and
there is progressive involvement of the other phalanges.
Phosphorous Poisoning. — Phosphorous poisoning causes a chronic
osteomyelitis of the jaw, indistinguishable roentgenologically from
the ordinary pyogenic form.
BONE TUMORS.
In the study of hone neoplasms' it is particularly important to
determine whether or not they are chiefly medullary or cortical and
as far as possible whether or not there is involvement of the soft
tissues. The most important question which one is called upon to
decide is whether the lesion is benign or malignant. This may be
a matter of considerable difficulty.
Benign Lesions. — Osteomata. — Osteomata are merely irregular
extensions of normal bone into the surrounding tissues. They are
characterized by their very slow development, by the fact that their
structure is that of normal bone and that they blend into the bone
at their site of origin. They are most commonly found near the ends
of the long bones in adults. They may consist of hook-shaped pro-
cesses called exostoses or broad, rounded masses — true osteomata.
Enchondromata. — Enchondromata cause irregular eccentric enlarge-
ments of the bones. They are usually multiple and are most common
in the hands, feet and long bones. There is considerable distortion
in the outline as a result of tumor growth with or without thinning
of the cortex, and the trabeculse of the medulla may be replaced by
BONE TUMORS 63
a homogeneous, putty-like shadow or by multiple small rounded
areas of rarefaction. In extensive tmnors the thinning of the cortex
may be so extreme that it is reduced to small, thin flakes of bone on
the periphery of the growth, which in the flat plate are projected
upon the tumor and must be differentiated from calcification within
the growth.
Fio. 39.- — Osteoraota of the femur.
Multiple CartUagmous Exostoses. — Multiple cartilaginous exostoses
are an hereditary anomaly of development, in which large cartilagi-
nous outgrowths of diminished density and iriegular outline appear
in the region of the epiphyseal lines. These growths are multiple,
usually involving most of the epiphysis, and cause considerable
deformity and interference with the normal development of the bone
involvement.
G4 BONE PATHOLOGY
Bone Cysts. — Bone cysts occur in the long bones and in the jaw.
They are characterized by sharply defined, rounded or oval areas
of rarefaction containing few or no trabeculse. The process is
entirely within the shaft, and spreads longitudinally in the medulla
without involving the cortex which, however, may be considerably
thinned from pressure. There is no deformity in outline unless a
Fig. 40. — Multiple cartilagiooua
fracture has occurred. Spontaneous fractures are often the first
indication of the presence of a lesion and they are usually followed
by extensive callous formation.
Osteitis Fibrosa. — Allied to cystic disease is a rare condition which
may involve one or all of the bones. It consists in the replacement
of the normal structure by irregular strands of trabecule enclosing
BONE TUMORS 65
multiple cysts which vary in size and shape. There is considerable
expansion in the bone, and spontaneous fractures are common as
a result of the thinning of the cortex. There is no periosteal pro-
liferation. When cysts occur in the neighborhood of epiphyseal
lines there may be interference with growtJi.
F[G. 41. — Bone cyat'in upper end of humerus. Fig. 42, — Bone oyat and fracture.
Osteitis Deformans (Paget's Disease).— Osteitis deformans is a
slowly prt^ressive process which usually involves most of the
bones, but in rare forms may be limited to one, particularly
one end of the tibia. It shows extensive thickening of the cortex
on both sides, with enlargement and bowing of the bone and re-
arrangement of the trabecule into strands or bundles running lon-
gitudinally. The medulla shows mottled areas of rarefaction which
usually extend into the epiphysis. This involvement of the epiphysis
is important in the differentiation from lues, which very rarely
affects the epiphysis in the same manner. In the skull this condition
causes an increase in the size of the head as a result of expansion
of the cranial bones, which show great thickening of both tables
and coarse mottling throughout the diploe.
BONE PATHOLOGY
Malignant Lesions. — Sarcoma.— Giant-celled sarcoma is probably
not a true malignancy and should be classed with the benign lesions,
although one case in our experience became malignant following
Fio. 43. — Paget's diseBBe.
intensive roentgenization. This tumor, which is of slow growth,
occurs as an isolated lesion, usually near the end of a long bone or
in the jaw. The growth is eccentric, that is, it causes asymmetrical
enlargement of the bone and tends to balloon out the cortex rather
BONE TUMORS 67
than to spread along the medullary canal. Ordinarily it does not
break through the cortex. The mass of the tumor consists of
irregular areas of rarefaction containing coarse trabeculfe, sometimes
suggesting a mass of soap-bubbles,
Osteosarcomaia are slowly growing masses which usually originate
in the medulla of long bones or in the flat bones. Their charac-
teristic is an early, extensive, irregular deposition of lime salts
throughout the growth. They are not particularly malignant.
They may be mistaken for an old osteomyelitis but the historj- will
usually differentiate them.
Hound or spindle-celled {medvUary) mnontaia are of very rapid
development and metastasii^e early. They involve the shaft, often
the greater part of it. Their appearance is that of extensive rare-
faction with destruction of trabeculee, early invasion of the overly-
ing cortex and extension into the soft parts. Often there is a com-
plete loss of bone substance in the area occupied by the tumor, the
outline of which can be traced into the soft tissue. At times the
68 BONE PATHOLOGY
picture resembles that of a virulent osteomyelitis which should be
differentiated by the history and clinical course.
Periosteal sarcomata are rapidly pawing tumors which are
extremely malignant and which originate from the periosteum,
most commonly along the shaft of the long bones. In the earliest
stages they may appear as a slight erosion of the cortex or a blister
i'la. 46. — Medullary sarcoma of the lower end of the fibula.
beneath the periosteum which is elevated by the growth. As the
growth increases, the shadow of its outline in the soft tissues becomes
evident. A most characteristic finding is the presence of fine strands
of calcified material radiating into the substance of the tumor and
terminating freely. There may be slight erosion of the cortex which
ends abruptly at the limits of the growth. In the early stages careful
BONE TUMORS 69
examination of the entire periphery of the bone may be necessary
to demonstrate the lesion.
Caicinoma-^Carcinoma is practically always metastatic and may
involve any one or all of the bones. It may be identified by a
moth-eaten appearance due to the irregular destruction of bone
FiQ. 46. — PerioBteal sarcoma of the femur in a child.
substance and its replacement by tumor mass. The cortex may be
involved, but ordinarily only in the later stages. There is no perios-
teal reaction and no change in outline unless spontaneous fracture
occurs. In the skull it appears as irregular areas of bone destruction
which typically are limited to the diploe and do not involve either
table. When the spine is involved there is more or less extensive
70 BONE PATHOLOGY
destruction of several bodies but ordinarily they do not collapse
owing to the fact that the dense tumor tissue affords considerable
support. This is of importance in the differentiation from tubercu-
losis and lues, in which collapse of the affected bodies is the rule.
There is a second form of metastatic carcinoma usually secondary
to a tumor of the prostate or breast, which is of extremely slow
development — cases having been seen ten years after the recognition
FiQ. 47. — Metnstatic rarKinoma of the fomiir.
of the primary disease. It is characterized by the extensive produc-
tion of new bone in the vicinity of the growths. Its usual site is in
the spine and pelvic bones, which become greatly increased in density
and coarsely mottled from the intermingled areas of rarefaction and
condensation. The bones are sometimes enlarged and may be
mistaken for osteitis deformans. The long history may also be
stive of this condition. More careful inspection will show
BONE TUMORS 71
that the picture is produced by adjacent areas of bone destruction
and proliferation, with the latter predominating, and that there is
no evidence of the rearrangement of trabeculse into bundles, which
is typical of Paget's disease. Furthermore, the distribution of the
lesions is quite dissimilar. Osteitis deformans more commonly
attacks the long bones and skull and rarely involves the spine, while
this form of carcinoma shows a preference for spongy bone. The
demonstration of a primary growth particularly in the prostate
should be conclusive.
Fio. 48. — MetsBtatic sarcoma of the slaill in a child.
Barer Bone Tumors. — Any type of tumor may be encountered
in the bones and the roentgen appearance of different pathological
entities is naturally very similar, as they are manifested only by
irregular areas of bone destruction which are not characteristic of
any particular neoplasm. They are commonly diagnosed as carci-
noma roentgenologically. Under this heading come hypernephroma,
myeloma, myxoma, fibroma, etc. The age of the patient and
the distribution of lesions may help.
72 BONE PATHOLOGY
HTpemephioma. — Hypernephroma occurs as multiple small areas
of rarefaction with loss of trabeculse and no attempt at new bone
formation. It may be distributed throughout the skeleton and is
particularly common throughout the skull, sternum, ribs and bodies
of vertebrae .
Fig. 50.— Pulmonary OHteoarthropatby.
Myeloma. — Myeloma is a low-grade malignancy of slow evolu-
tion which typically causes small multiple areas of rarefaction,
BONE TUMORR 73
usually limited to the flat bones, although extensive single lesioDs
have been obseived in long bones. Owing to its slow growth, defor-
mities in outline occur as a result of thinning and expansion of the
cortex overlying the growth. For the same reason spontaneous
fracture is fairly common. Its appearance often resembles that of
carcinoma, although the areas are usually smaller, more rounded
and more sharply defined. It is accompanied hy the presence of
Bence-Jones bodies in the urine. Some cases have responded well
to roentgen therapy.
Myxoma. — M>-xoma is a slowly growing tumor which usually
involves a single long bone. It causes irregular enlargement of the
whole shaft, irregular rarefaction of the medulla and thinning of
the cortex. It may also invade tlie soft tissues and show small
spicules of periosteal bone in the soft tissue mass, suggesting sar-
coma. Pathological examination may be necessary in a differential
diagnosis.
BONE PATHOLOGY
DISEASES OF NUTRITION.
Pulmonarr OBteoarthrop&thy. — The first stage in this process is
enlargement of the soft tissues of the ends of the fingers, so-called
Fio. 52. — Bowing of the tlhia in the adult, due to rachitis.
club fingers. Later proliferation of the periosteum, which is difficult
to distinguish from that of lues, appears along the metacarpals and
phalanges and frequently about all the long bones. As a result,
DISEASES OF NUTRITION 75
these bones have a thickened cortex and in the later stages are
increased in width.
Acromegaly. ^Acromegaly, in addition to the characteristic changes
in the skull, gives rise to a general enlai^ment of the skeleton.
A typical finding is the change which occurs in the cancellous bone,
the texture of which becomes verj- coarse and heavy. There is also
clubbing of terminal phalanges.
Fio. 53.— Active rnchitis.
—This is a disease usually occurring during the first
dentition. It shows in the roentgenogram a flaring and widening
of the diaphysis above the epiphyseal line; the bone between shaft
and epiphysis is increased in thickness, with ragged, fringy margins.
The shaft side of the epiphyseal line may appear as a broad white
7C BONE PATHOLOGY
line, as a result of the deposit of lime salt. The shaft may be bowed
and the cortex considerably thickened on the concave side of the
curve. Mild periosteal proliferation sometimes occurs. There may
be areas of decreased density in the cranial bones along with promi-
nence of the frontal and parietal bosses. In the form which comes
on later during adolescence there is irregular rarefaction and enlarge-
ment of the long bones, resulting in disturbance of the weight-bearing
lines, as, for example, coxa vara and genu varum.
Scorbutus. — This condition is commonly seen during the first
years of life and may or may not have an associated rickets. The
earliest evidence of its presence is a white line in the shaft mai^in
of the epiphyseal zone. This line is thinner, more dense and more
sharply defined than the one seen in rickets. Later in the clinical
course subperiosteal hemorrhages appear as more or less extensive
irregular elevations of the periosteum over the entire length of the
DISEASES OF NUTRITION 77
shafts of the long bones. In severe cases the hemorrhage may be
sufficient to produce separation of the epiphysis. The final process
consists of organization of the clot which produces a shadow of
considerable density about the shaft.
Fio. 55. — Oataogcnesis imperfecta.
Differential diagnosis is from lues and osteomyelitis. Lues is
more apt to be a generalized process, the periosteum is less elevated
and epiphyseal dislocation does not appear. In osteomyelitis there
is destruction of the shaft which is miaffected in scorbutus, and the
clinical picture is, of course, quite characteristic.
78 BONE PATHOLOGY
Achondroplasia (Chondrodystrophy Fetalis). — The bones in this
condition are shortened, compact and at times bowed. The epiphy-
seal line is very thin and sharply defined and closes considerably
earlier than the normal. This results in an adult whose long bones
are verj- much shortened, with corresponding loss of weight. This
process is said to involve only those bones in which ossification has
begun before the sixth month.
Fi(i. 56. — Osteoniaiacia in a child.
Osteogenesis Imperfecta (Fragilitas Ossium, Periosteal Dysplasia
or Osteopsathyrosis). — In the infantile form of this disease the bones
show great diminution in lime salts and thinning of the cortex
without changes in size. This results in a wealiening of the structure
of the bones and multiple spontaneous fractures occur, usually
followed by a fair amount of callous formation.
DISEASES OF NUTRITION
In the adult form the bones are nearly normal in size and calcium
content but usually present considerable deformity as a result of
the multiple spontaneous fractures which the patient has suffered.
Fig. 57. — Oatcomiilacia, with pat lioloeical fracture in adult female.
Osteomalacia. — This is a condition of extreme and irregular
diminution in the density of all the bones. There is usually consider-
able deformity due to bending and spontaneous fractures with poor
callous formation. This condition may result from any one of several
causes and is therefore not properlj' to be regarded as an entity.
80
BONE PATHOLOGY
A TABULATION OF THE FINDINGS IN THE MORE COMMON BONE
LESIONS FOR USE IN DIFFERENTIAL DIAGNOSIS.
Osteomyelitis.
1 . Usually a single lesion.
2. Both destructive and proliferative.
3. A disease of the shaft, involving the
epiphysis — rarely the joint.
4. Produces bone atrophy.
5.
6.
7.
1.
2.
3.
4.
5.
Usually starts in the medullary por-
tion and involves the cortex, peri-
osteum, and soft tissue.
Occurs at any age.
Enlargement and deformity of the
bone.
Syphilis.
Usually a multiple process.
Usually proliferative. The gumma-
tous form, which is rare, is both
proliferative and destructive.
Usually a disease of the shaft, but
rarely it involves the joint and
epiphysis.
Usually confined to the periosteum,
but may involve the cortex. Does
not cau^e bone atrophy.
May appear at any age.
6. There may be enlargement and con-
siderable deformity of the bones.
Periosteal Sarcoma.
1. Always single.
2. Proliferative.
3. Involves the shaft only, as a rule —
rarely invades the epiphysis. Never
enters a joint.
4. Invades the soft tissues in the im-
mediate neighborhood, presenting
characteristic ray-like formation.
Bone atrophy is absent.
5. Common in young adults.
Carcinoma.
1. Multiple lesion.
2. Usually purely destructive; rarely
there is bone proliferation about
the invaded area.
3. Attacks the medulla and cortex of the
long and flat bones. The perios-
teum and joints are not involved.
4. A disease of adults.
5. In the proliferative type, the bones
may be enlarged and deformed.
Tuberculosis.
1. Usually a single lesion.
2. A destructive process.
3. A disease of the joints and epiphyses.
4. Rarely invades the shaft and soft
tissues ; the neighboring bones show
marked atrophy. The periosteum
is not involved.
5. More common in children.
5.
3.
4.
5.
Facet's Disease.
1 . A multiple lesion.
2. Proliferative.
3. Involves the shaft and epiphysis-
the joints are not affected.
4. Late adult life.
Overgrowth of the bony structures
and abnormal trabeculation. The
soft tissues are not invaded.
Giant-cell Sarcoma.
1. Single lesion.
2. Destructive type.
3. Involves the medullary portion of the
shaft; the cortex may be thin but
is not invaded. The joints and soft
tissues are unaffected.
4. Childhood and young adults.
5. The bone is not deformed.
Bone Cyst.
1. Single lesion.
2. Purely destructive.
Located in the medullary portion of
shaft. Does not invade the cortex,
joint, or soft tissue.
Children and young adults.
The bone is not deformed.
BIBLIOGRAPHY 81
Medullary Sarcoma. Osteoma
•
1. Single lesion. 1. Usually a single lesion.
2. Purely destructive in the bone. 2. Purely proliferative.
3. Involves the shaft, rarely the epiphy- 3. Arises from the cortex. Never invades
sis; never the joint. the bone.
4. The cortex of the bone is destroyed 4. Common in children and young
and the soft tissues invaded. adults.
5. Usually in young adults. 5. There may be some deformity of
bone from pressure. Structure of
the growth resembles normal bone.
BIBLIOGRAPHY.
Kuth, J. R.: Early congenital bone lues, Arch. Ped., 1915, xxxii, p. 244.
Risley, E. H.: Skeletal cancer, British Med. Surg. Jour., 1915, clxxii, p. 584.
Boorsteif), S. W.: Syphilis of bones and joints, Surg., Gynec, and Obst., 1914,
xviii, p. 46.
Fitz Simmons, H. J.: Multiple bone tuberculosis, British Med. Stirg. Jour., 1914,
clxx, p. 547.
Locke, E. A.: Secondary hypertrophic osteoarthropathy. Arch. Int. Med., 1915,
XV, p. 659.
Kessel, L.: Relation of hypertrophic osteoarthropathy to pulmonary tuberculosis,
Arch. Int. Med., 1917, xix, p. 239.
Cotton and McCleary: Myxoma of femur. Am. Jour. Roent., 1918, v, p. 95.
Fassett, F. J.: Kohler's disease. Jour. Am. Med. Assn., 1914, Ixii, p. 1155.
Hetzel: Kohler's disease, Am. Jour. Orthop. Surg., 1917, xv, p. 214.
Lock, N. F.: Note on tunnels and large cavities in bone, British Jour. Surg., July,
1916, p. 145.
Murphy, J. B.: Bone and joint diseases in relation to typhoid fever, Surg., Gynec.
and Obst., 1916, xxiii, p. 119.
Wile, Udo. J., and Senear, F. E.: A study of the involvement of the bones and
joints in early syphilis. Am. Jour. Med. Sc, 1916, clii, p. 689.
Wilde: Acute bone atrophy after an accident. Am. Jour. Roent., 1916, cxi, p. 54.
Perussia, F.: Phosphorus necrosis of the maxillse. Am. Jou*. Roent., 1916, cxi, p.
177.
Gouldesbrough, C: Pulmonary osteoarthropathy. Arch. Roent. Ray, 1913, xviii,
p. 208.
Ehrenfried, Albert: Multiple cartilaginous exostoses. Jour. Am. Med. Assn., 1915,
Ixiv, p. 1642.
Murphy, John B.: Typhoid spine, Surg., Gynec. and Obst., 1916, xxiii, p. 119.
Gaenslen, F. J.: Osteitis deformans. Am. Jour. Orthop. Surg., 1915, xiii, p. 96.
Bythell, W. S. J. : Bone tumors: in proceedings of Royal Society of Medicine,
Electrotherapeutical Section, March 20, 1914, Arch. Roent. Ray, 1914, xix, p. 185.
Royce, C. E.: Sarcoma of the scapula, Surg., Gynec. and Obst., 1916, xxiii, p. 74.
Weber: Multiple cartilaginous exostoses, Am. Jour. Roent., 1916.
Hirsch: Bone tumors. Am. Jour. Electro, and Radiol., January, 1917.
Boggs, R. H.: X-ray in bone disease. New York Med. Jour., 1917, cv, p. 112.
Symmers, D., and Vance, M.: Hemangio-endothelioma, Am. Jour. Med. Sc,
1916, cbcxix, p. 28.
Connell: Giant-celled tumor of bone, Surg., Gynec. and Obst., 1915, xxii, p. 427.
Barrie, G.: Cancellous bone lesions, Ann. Surg., 1915, Ixi, p. 129.
Coon, C. A.: Bone and joint syphilis, Am. Jour. Surg., 1915, xxix, p. 211.
Mclntyre, Milne: Diffuse myxochondroma of a long bone. Lancet, December,
1916, p. 1013.
Cotton, F. J. : Diagnosis of p>eriosteal sarcoma with the x-ray, British Med. Surg.
Jour., 1916, p. 946.
Rugh, J. T.: Typhoid spine, with autopsy findings. Am. Jour. Orthop. Surg., 1915,
xiii, p. 289.
Henderson, M. S.: Osteochondromatosis, Am. Jour. Orthop. Surg., 1917, xv, p.351,
6
82 BONE PATHOLOGY
Kohler, A.: Kohler's disease, Mtinchen. med. Wchnschr., 1908, Iv, p. 1923.
Pfahler: Kohler's disease, Surg., Gynec. and Obst., 1913, xvii, p. 625.
Neve, A.: A case of leprosy diagnosed by x-rays, British Med. Jour., December 4,
1915, p. 814.
Connell, F. G.: Giant-celled tumor of bone, Tr. Western Surg. Assn., 1915, xxiv,
p. 221.
Denit, G. B.: Giant-celled sarcoma of pelvis, Ann. Surg., 1915, Ixii, p. 636.
Landon, L. H.: Ostitis fibrosa cystica, Tr. Philadelphia Acad. Surg., 1915, xvii,
p. 90.
Van Zwaluwenburg: Ostitis fibrosa, Jour. Michigan Med. Soc, 1915, xiv, p. 46.
For complete bibliography of ostitis fibrosa cystica and of bone cysts, see Blood-
good: Ann. Surg., lii, No. 2, p. 145. Muller: Univ. Pennsylvania Med. Bull., Septem-
ber, 1906, p. 173. Strumpf: Deutsch. Ztschr. f. Chir., 1912, pp. 114, 417. Silver:
Am. Jour. Orthop. Surg., 1911-12, ix, 563.
Vance: Multiple myeloma. Am. Jour. Med. Sc, November, 1916, p. 691.
Haussling, F. R., and Martland, H. S.: Bone tumors, Ann. Surg., 1916, Ixiii, p. 454.
McCrae, T.: Typhoid and paratyphoid spondylitis, with bony changes in the
vertebrae, Am. Jour. Med. Sc, 1906, clix, p. 878.
Lord, F. T.: Analysis of twenty-six cases of typhoid spine, Boston Med. Surg.
Jour., 1902, cxlvi, p. 689.
Koch, J. C.: Laws of bone architecture. Am. Jour. Anat., 1917, xxi, p. 177.
Walker, C. A., and Cummins, W. T.: Echinococcic bone disease. Jour. Am. Med.
Assn., 1917, Ixviii, p. 839.
Fisher, A. L.: Syphilitic bone and joint lesions simulating tuberculosis. Jour.
Am. Med. Assn., 1917, Ixviii, p. 366.
Grey and Carr: Bone atrophy, Johns Hopkins Med. Bull., 1915, xxvi, p. 381.
Elaine, E.: Idiopathic infantile osteopsathyrosis. Am. Jour. Roent., 1916, iii,
p. 438.
Hurwitz, S. H.: Monoosteitic form of Paget's disease, Am. Jour. Roent., 1915,
ii, p. 755.
Langnecker, Harry L. : Lesions of the lumbosacroiliac region, Jour. Am. Med. Assn.,
1915, Ixv, p. 1866.
Jacobsohn: The causes of rickets, New York Med. Jour., 1916, ciii, p. 68.
Hirsch, 1. S.: Bone tumors. Am. Jour. Electro, and Radiol., 1917, xxxv, pp. 1, 72,
113, 116.
Bythell and Scott: Bone tumors, Proc. Roy. Soc. Med., London, 1913-14, Electro-
therapeutic Section, pp. 63-78.
Lovett: Rickets, Jour. Am. Med. Assn., 1915, Ixv, p. 2062.
Crawford, H. de L. : Congenital syphilis of hands and feet, Tr. Roy. Acad. Med.,
Ireland, 1915, xxxiii, p. 224.
Retard and Alamartine: Bone disease simulating bone tumors. Rev. de Chir.,
1914-15, p. 137.
Cameron, H. C: Osteogenesis imperfecta, Proc. Roy. Soc. Med., 1915-16, Section
on Diseases of Children, ix, part 1, p. 43.
Hess, J. H.: Osteogenesis imperfecta. Arch. Int. Med., 1917, xix, p. 163.
Ehrenfried, A.: Hereditary deforming chondroplasia, "multiple exostoses," British
Med. Surg. Jour., 1916, clxxiv, p. 327.
Montgomery: Congenital exostoses, Internat. Clin., 1916, xxvi, 111, p. 140.
Carman, R. D., and Fisher, A. C: Multiple congenital csteochondromata, Ann.
Surg., 1915, Ixi, p. 142.
MacCoUum, W. G.: Chondrodystrophia fetalis, Johns Hopkins Hosp. Bull.,
1915, xxvi, p. 182.
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Honeij, James A,: Bone changes in leprosy. Am. Jour. Roent., New York, October,
1917,
CHAPTER V.
SKULL.
Roentgenology of the skull, its contents, sinuses, mastoids and
teeth has become a field of its own. There is naturally a close asso-
ciation between the teeth and sinuses, and the two should always be
studied togetlier. The bones of the skull are subject to fractures
and diseases affecting the skeleton generally, which have already
been considered.
HTdrocei^alus. — Hydroce])haIus is perhaps the commonest brain
condition with which the roentgenologist has to deal in children.
The picture is one of chronic intracranial pressure — enlaixement and
great thinning of the vault of the skull, with exaggeration of the
convolutional depressions and often separation of the sutures.
84 SKULL
Oxycephalus. — A condition in which there is early union of the
cranial sutures followed by increased intercranial pressure. On the
Roentgen plate the skull appears small and thin with absence of
the suture line. Areas of diminished density due to pressure of the
convolution are unusually prominent.
Brain Tumor. — Brain tumor rarely gives direct evidence of its
presence. Localized erosion of the ealvarium over the lesion or
increased density due to new bone formation by the dura overlying
it or, very rarely, calcification in the mass itself may help to localize
the process. In 90 per cent, of tlie cases all that appears on the plate
is the evidence of intracranial pressure and the common findings
are compression or destruction of the posterior clinoid processes,
enlargement of the bloodvessel channels distributed to the affected
SELLA 85
area and, at times, increased impressions of the cerebral convolu-
tions. In severe cases separation of one or more suture lines may
be present.
Subdural Hemorrhages. — Subdural hemorrhages cannot be diag-
nosed on the roentgenogram. Thin areas in the temporal region or
areas of increased density in the panetals are often erroneously
ix)inted out as hemorrhages.
FiO. 60, — Pituitary tumor. The sella is enlarged and its Boor destroyed.
Sella. — True lateral views, preferably stereoscopic, are essential
for the proper observation of the sella. It is subject to considerable
variation both in size and shape, of which the latter is the more
important. As already noted, deformity of the posterior clinoids
may occur as a result of tumor in any portion of the brain. Hypo-
physeal tumors cause a ballooning of the sella with thinning of the
floor and usually of both anterior and posterior cHnoid processes.
Associated with these changes may be seen more or less enlargement
of the sinuses, elongation of the mandible and general enlargement
86 SKULL
of the bones, particularly those of the hands and feet. The clinoids
occasionally meet, bridging in the roof of the sella. Attention has
been called to the fact that this is a common occurrence in epilepsy
and sterility. (Faulty technic in securing views of the sella which
are not true laterals may cause an appearance of rooting which a
true lateral will correct.)
Fig. 61. — Very large sinuses.
Calcified Pineal Glands. — Calcified pineal glands are frequently
seen in individuals over thirty. They appear as dense white spots
a millimeter or two in diameter located in the mesial plane several
centimeters above the mastoids. They are without significance.
Sinnses. — For a proper study of the sinuses anteroposterior,
lateral, anil vertical projections are necessary. The anteroposterior
plate, in addition to the outline of the sinuses themselves, affords
filNUSES 87
some evidence of the shape of the septum, size of the turbinates and
relative depth of the fJoor of the nose and the floor of the antra.
The lateral plate is particularly useful in checking up the antero-
posterior of the frontals to determine their depth and the thicknessof
their walls. Teeth or foreign bodies in the antra may be well
projected in this view which often gives a clue to the condition of
the sphenoidal sinus, but is of little value in the study of the ethmoids.
The vertical projection outlines the sphenoidal sinus very well.
The normal sinus, because of its air content and thin walls,
appears as a more or less darkened area with sharply defined edges.
Any change in the amount of air contained within it or in the thick-
ness of its walls will be recorded as a change in density on the plate,
and both these factors must be considered in making a diagnosis.
This is particularly true in the case of the frontals, where a degree of
density which Is normal for one individual may be quite pathological
in the case of another whose air space is larger and walls thinner
and whose sinuses should therefore appear darker. For the recog-
nition of pathologj', it is essential to compare the two sides and to
have a fairly definite mental picture of the api>earance of the normal
sinus. In the study of the frontals both anteroposterior and lateral
views must be combined.
88 SKULL
A general haziness with a slight increase in density in one or more
sinuses usually means thickening of the lining membrane. This may
be corroborated in the case of the frontals by the additional evidence
of thickening of the septal markings which become hazy and are
surrounded by an indefinite zone of slightly increased density, as
contrasted with the sharply outlined normal septa. This general
thickening may involve only one sinus, all of the sinuses on one side.
or those of both sides. In the last condition, some difficulty may arise
from the fact that comparison of opposite sides is impossible and the
roentgenologist must fall back upon his empirical knowledge of
what the normal should be.
Granulations, pus or tumors produce a shadow of greater density,
which usually obliterates the sinus completely. Their shadows are
identical in every respect, so that it is usually impossible to tell
POLYPI 89
which one we are dealing with from the roentgen plate alone. When
there is a fluid exudate in a sinus it is often possible to make out a
fluid level in the suspected ca:vity upon a plate taken with the patient
upright. However, the absence of a fluid level does not rule out pus.
Tumors of the sinuses will ordinarily give some evidence of their
nature by erosion or invasion of the walls or adjacent bones. Very
rarely a sinus or portion of the orbit will be occupied by a dense
osteoma. Absence of frontal sinuses is fairly common and must be
difTerentiated from thickening which has obscu-^d the mai^ins and
obliterated the outline of a well-developed sinus. A lateral view
will show no evidence of a sinus and no room for it at the base of
the frontal. Careful inspection of the anteroposterior view should
show the presence of bone structure in the suspected area.
FiQ. 64. — Sclerosed and normal mastoid.
It must not be forgotten that a sinus may be found filled with
mucoid material at operation and yet cast no abnormal shadow on
the plate. In fact, mucoceles by erosion of the bone overlying them
often appear as areas of diminished densitj'.
Polypi. — Polypi can sometimes be visualized in the frontals and
antra as rounded areas of slightly increased density. The entire
sinus will usually appear somewhat hazy as a result of the thickened
membrane.
Burnham has called attention to the occurrence of a dense
fusiform shadow overlapping the septum in a case of gumma of
the septum.
90
SKULL
The patency and course of nasal ducts may be determined from
roentgenograms made with opaque probes in situ.
Mastoids. — Plates of both sides should always be taken as a
routine for purposes of comparison. Normally the cells are bright
and clear with sharply outlined walls. The broad grooves of the
lateral sinus can usually be traced down across the mastoid as a
streak of diminished density. In an acute mastoiditis there is
general haziness of the aflFected cells and blurring of their margins,
followed later by destruction of the cells and loss of their outlines,
which are replaced by an indefinite area of increased density. In
chronic cases there is more or less absence of cells and a variable
degree of sclerosis.
Teeth. — ^The roentgenologist should have a general knowledge of
the development, anatomy and pathology of the teeth, for he will
surely be called upon to do a certain amount of dental roentgenology.
An understanding of the course of dentition is helpful not only in
the interpretation of dental conditions in children and adults but
also in the determination of the ages of children. The following
table from Thoma can be relied upon as a working basis. :
Tooth,
Calcifieation
Calcification
temporary.
begins.
complete.
Eruption.
Shed.
Central incisor . .
u
years
6 to 8 months
7 years
Lateral incisor. .
u
<(
Ito 9
8 "
Cuspid
2
ti
17 to 18
12 *•
First molar
20 months
14 to 15
10 "
Second molar. . .
20
((
18 to 24
11 "
Central incisor . . .
1 year
10 years
7 to 8 years
Lateral incisor. . .
1 '*
10
7 to 8 "
Cuspid
3 years
4 "
12
12 '*
First bicuspid . . .
12
10 "
Second bicuspid.
5 "
12
11 "
First molar
Before birth
9 to 16
6 **
Second molar . . .
5 years
17 to 18
13 "
Third molar ....
. ' 9 "
18 to 20
18 "
The importance of good technic in dental roentgenology must be
insisted upon. This includes adequate exposures with the least
possible amount of distortion, preferably from several angles and
the use of both plates and films.
Anomalies of development, irregularity of eruption, misplaced
and unerupted teeth are perhaps the most frequent examples and
the diagnosis is obvious. Impaction, which is particularly common
in the molars, is a common finding. The presence of retained
temporary teeth is readily recognized.
In adult teeth the roentgen examination is often of value in demon-
ALVEOLAR ABSCESS 91
strating fracture of tlie teeth below the gum level, the extent of
carious processes, and in determining the extent and position of
root canal fillings and the results of operative procedures. Pulp
stones are often revealed In the pulp cavities. They are small,
round, dense masses frequently multiple, which form in the pulp
cimmber of one or more teeth. They have been accused of being
the cause of severe neuralgias. Inasmuch as they are frequently
seen without symptoms, their significance is questionable.
The most important pathological conditions with which the
mtgenologist has to deal are, of course, pyorrhea and alveolar
Fio. 65. — Multiple pus pockels involving the roots of the molars and bicuspids.
Pyorrhea. — Pyorrhea in its early stages gives little roentgen
evidence aside from a slight increase In the width of the dark line
about the tooth, which represents the peridental membrane. As the
infection continues and the alveolar process becomes Involved, the
bone retracts from the neck and finally the roots of the teeth, which
are then kept in place only by the fibrous tissue of the gums. As
a general rule, when the retraction of the alveolar process Involves
over half of the root the tooth is doomed.
Alreolar Abscess. — Alveolar abscess in the acute stage, like osteo-
myelitis, gives no roentgen evidence of its presence. ^ ery shortly,
however, rarefaction appears about the root involved and at first
Fig. 66. — 1, pyorrhea pocket about the nicsiobuccal root of the left upper first
molar; 2, advanced Rigg's disease, with absoiption and receasion of the alveolus,
but without definite pyorrhea pockets; S. chronic abacesses at apicea of palatal and
mesiobuecBl roots of the left upper first molar; i. osteomyelitis arising from the roota
of the left lower first molar; 5, proliferative infiammatory Rranuloma. with central
softening at the apex of the right upper second bicuapid; 6. devitaJiied left lower
molar showing caries, root canal fillings and small apical granuloma; 7, impacted right
lower third molar, with pus pocket: 8, small pyorrhea pocketa about both upper
central incisors; transverse fracture of the left upper incisor.
CYSTS 93
the resulting dark area merges into the structure of the surrounding
cancellous bone. As the process becomes more chronic, a limiting
wall appears about it and the picture then becomes one of a definite
dark sac attached usually about the apex of the root. This is the
familiar form of alveolar abscess. Pathologically most of them are
found to be a mass of granulation tissue containing a certain number
of bacteria, less frequently a definite abscess cavity with a lining
membrane. Erosion of the tip of the root extending into this cavity
is often seen and in long-standing cases deposits of new bone laid
down about the apex of the root produce bulbous enlargements and
may wholly or in part fill the old abscess cavity. The treatment
of such an abscess is one to be decided by all the other evidence,
medical and dental, which can be acquired. Not every tooth which
shows an alveolar abscess should be extracted. Each case should be
Fio. ST.— Impacted uppei canine tooth.
treated upon its individual merits. Abscesses must not be confused
with extensions of the antra downward or pockets in the antra in
the region of the upper bicuspids and molars nor with the sub-
mental foramen which frequently overlies the apex of a lower
bicuspid. Films of the upper incisors occasionally show the shadow
of the nostril overlying a root which simulates an abscess.
Cysts. — Cysts are fairly common in the jaw. There are two forms:
root cyst and dentigerous cyst. The former arises perhaps most
frequently from an old alveolar abscess. It appears as a large
rounded area of rarefaction in the jaw, usually attached to or
partially enclosing one or more tooth roots and showing little or no
evidence of trabeculation. They may be multiple. Dentigerous
cysts have a similar appearance except that they develop from a
buried tooth bud and generally contain teeth or portions of them.
The bony structure of the jaws may be subject to any of the diseases
which affect the rest of the skeleton. Osteomyelitis is fairly common
and shows the same irregular destruction and proliferation seen
Fio. CS.— Simple eyst of the jaw
Fjc. 60. — Dontigcrous cyst.
CYSTS 95
elsewhere. A particular sort of osteomyelitis occurs with phos-
phorous poisoning; the bone becomes increased in density and
thickness as a result of new bone production which is followed later
by suppuration and necrosis represented by irregular rarefaction.
Syphilis occurs occasionally in the form of an irregular mottling
of the bone due to extensive spotted rarefaction.
Tumorsof all sorts may be encountered — giant-cell sarcomaand the
more malignant forms of sarcoma, carcinoma and hypernephroma,
for example. Their appearance is identical with that of similar
growths in other flat bones. In addition, the jaw is the seat of a
Fig. 70.— Cystoma of the jaw.
tumor peculiar to it, the odontoma, which is a dense mass made up of
various tooth tissues and may be attached to a tooth or be composed
of several teeth fused together. Sometimes they take the form of
undefined masses of considerable density, which continue to grow
and develop into large deforming tumors. Salivary calculi must be
mentioned in any consideration of the teeth. They cast dense round
or oval shadows seen in the position of the salivary glands or ducts.
When projected upon the mandible in oblique views they must
not be mistaken for areas of density in the bone. The shadows of
calcified glands often appear in tooth plates. They are spotted
96 SKULL
mulberry-like shadows, characteristic of calcified glands anywhere.
The tip of an unusually long styloid process may be projected upon
the upper molar region and be mistaken for an extra tooth root or
supernumerary tooth.
BIBLIOGRAPHY.
Heuer, G. J., and Dandy, W. E.: Roentgenography in the localization of brain
tumors, Johns Hopkins Hosp. Bull., 1916, xxvii, p. 311.
Veasey, C. A.: Osteoma of sinuses, Ann. Ophth., 1916, xxv, p. 699.
Probert, C. C: Osteoma of sinuses, Jour. Michigan Med. Soc, 1916, xv, p. 304.
Boas, E. P., and Scholz: Calcification of the pineal gland, Arch. Int. Med., 1918,
xxi, p. 66.
Stewart, W. H., and Luckett, W. H.: Roentgen diagnosis of fracture of the skull.
Arch. Radiol., 1915-16, xx, p. 150.
Gould and Le Wald: Chloroma, Med. Rec, 1916, p. 757.
Sharpe, W.: Oxycephaly, Am. Jour. Med. Sc, 1916, cli, p. 840.
Osgood: Lesions of tibial tubercle, British Med. Surg. Jour., January 29, 1903.
Mauclaire, P.: Absence d'ossification du cartilage de conjugaison des deux tuber-
osities tibiales anterieures chez un adulte, Bull, et M^m. Soc. de chir. de Paris, 1915,
xli, p. 2457.
Gushing, Harvey P.: Pituitary body and its disorders, Philadelphia, 1912.
Thoma, Kurt. H. : Oral abscesses, Boston, 1916.
i
CHAPTER VI.
JOINTS, TENDONS AND BURSiE.
There is as yet no really satisfactory classification of the
joint diseases because of the lack of accurate pathological knowl-
edge. Probably the best one so far proposed is that of Barker,
upon which the following outline is based. It must be insisted
that no hard-and-fast adherence to the general types described
below is possible. Atypical joints and those which fall under more
than one heading are often observed. In the study of a pathological
joint, the following features should be carefully noted: (1) Peri-
articular swelling in the soft parts, (2) effusion in the joint, (3)
erosion of cartilage as evidenced by diminution of the joint
space, (4) changes in density of the bone, (5) outgrowths of new bone
formation and (6) the joints involved. Probably the commonest
form of arthritis is the hypertrophic, which occurs in individuals
over forty, more often men. Its characteristic feature is the pres-
ence of spurs or lipping on the margins of articular surfaces, which
include vertebral bodies. These outgrowths are dense with sharp
edges and in some cases cause fixation of a joint by interlocking
or fusion. There is no fluid in the joint imless it has been recently
injured. There is no loss of articular cartilage and no decalcification
of adjacent bone. It may attack any joint, usually the larger, and
is very common in the spine. These joints may exist ?or a consider-
able length of time without giving many symptoms but they are
apparently points of lowered resistance, for after injury they may
be the seat of acute painful reactions which are entirely out of pro-
portion to the injury and would not have occurred in a normal
joint. This condition is continually being encountered in industrial
accident work.
Gout. — Gout is less common but, like the first type, occurs after
forty, more frequently in men than in women. In a typical case it
presents peri-articular swelling and very characteristic punched-out
areas in the bones at the margins of the articular surfaces. These
holes are sharply cut and vary from one to several millimeters in
diameter, in severe cases causing complete destruction of an articular
7
98 JOINTS, TENDONS AND BURS^
end of the bone. There is little effusion in the joint, erosion of the
cartilages occurs only in the late severe cases and there is no decal-
cification. Usually some slight hypertrophic spurs are present. It
ordinarily occurs in the phalangeal joints of the hands and feet,
but may affect the carpus or tarsus and in rare cases a large jomt,
such as the knee, simulating here an early Charcot joint from the
Fig, 71.— Gout.
amount of destruction and new bone formation which takes place.
In the early stages before the punched-out areas become evident
it may be mistaken for a hypertrophic arthritis. It is, of course,
accompanied by other clinical evidence of the disease,
Charcot Joints. — A striking picture which occurs in patients with
tabes or syringomyelia is seen usually in middle age. There is tre-
mendous swelling of the soft parts, destruction of articular surfaces,
ATROPHIC ARTHRITIS 99
amounting to complete disorganization, and lai^ irregular masses
of calcified material scattered throughout the joint. There is no
decalcification of bone. Its commonest sites are the knee, hip,
ankle and spine. Conditions which may be confused with it are
(1) gout, which is rare in large joints and always involves the smaller
ones in addition; (2) loose bodies in joints, in which case the cal-
cified masses are small, dense and few in number, and the joint
Fig. 72.— Charcot joint.
surfaces are not disturbed except that the point of origin of the
fragment may be evident in a chipped-off area on the inner condyle
of the femur; or (3) calcified hematomata, in which the calcification
is much more extensive. The joint surfaces are intact.
Atrophic Arthritia. — Atrophic arthritis is more common in women
and it is seen between the ages of twenty-five and forty-five. It
begins with periarticular swelling followed by gradual loss of
articular cartilage, shown by narrowing of the joint space and by
100 JOINTS, TENDONS AND BURS^
severe atrophy of the soft parts, and decalcification of bone. There
is no tendency to new bone or spur formation. The process extends
over a period of years, ending typically in complete ankylosis.
Lifections Arthritis. — Infectious arthritis attacks any joint at any
age. Its forms are extremely varied owing to the number of causa-
tive agents. The most common types are pyogenic, gonorrheal,
tuberculous and syphilitic.
Fio. 73. — Infectious arthritis o( the knee-joint. An early case.
PyoKenic Arthritis. — Pjogenic arthritis is usually due to staphylo-
coccus, streptococcus or pneumocoecus. llie acute forms attack one
or many joints which show soft tissue swelling and effusion in the
synovial cavity. The process may then subside with disappearance
of these signs. If it persists for several weeks, decalcification of the
articular ends of the bones will occur and there may be erosion of
cartilage with narrowing of the joint space. I>ater, as repair begins,
hypertrophic changes may make their appearance at the margins
TUBERCUWmS 101
of the articular surfaces or the cartilage ma;' be entirely destroyed
and ankylosis result when healing is complete.
Gonorrheal Artbritis. — Gonorrheal arthritis is usually monarticular
but it ma>' be indistinguishable roentgenologically from other
pj'ogenic joints. However, there are two findings in addition to
those of pyogenic infection which are very suggestive of Neisserian
origin. One is a localized destruction of the cartilage on the under
surface of the patella which sinks in towards the condyles of the
femur. Subsequently hj-pertrophie changes appear on its margins
Fig. 74.-=-Hypertrophic arthritis of the knee-joint.
and on the adjacent areas of the femur. The second is the occur-
rence of small localized areas of rarefaction In the bone at the junc-
tion of articular surfaces and cortex. Another result of this infec-
tion is the development of spurs upon the os calcis which tend to
grow out along the plantar fascia. These spurs maj' be the result
of the activity of streptococcus but the great majority are gonorrheal.
Tuberculosis. — Tuberculosis is more common in children. It
causes slight enlargement of the soft parts, effusion in the capsule,
and general haziness and muddiness of the entire joint area. There
is extreme decalcification so that the outlines of the bones may be
JOINTS, TENDONS AND BURSM
FiG. 75. — TubecovUoaia of the knae-joint.
FlQ, 7G. — Tuberculosis of the hip.
TUBERCULOSIS
Fig. 77.— The a
Fio. 78.— The a
104 JOINTS, TENDONS AND BURSAC
reduced to a thin pencilled white line. Enlar^ment and squaring
of the epiphyses are seen and later more or less destruction of joint
surfaces, and interference with the growth of the bone. There is
no new bone formation. The occurrence of periosteal reaction and
bony ankylosis in these joints is the result of secondary infection.
During the process of repair there is increase in density due to
deposit of lime salts. Caries sicca is seen most commonly in the
shoulders in adults. It shows a chronic ragged erosion of the
articular surfaces, no soft tissue swelling, no effusion and no
decalcification.
Fio. 79, — Gumma of the spine.
Syphilis. — Syphilis may be seen at any age and it is manifested
by increased density m the soft tissue and the occurrence of a
slight periostitis at the junction of the periosteum and synovial mem-
brane; occasionally by destruction of articular surfaces, particularly
those of the small bones, such as carpus and tarsus, and by local
lesions in the epiphyses suggesting tuberculous foci. In some cases,
as the result of chronic low-grade inflammation in the synovial
membrane, low, rounded hypertrophic ridges will appear at the
margins of the articular surfaces.
Villous Arthritis. — Villous arthritis consists of a thickening in the
soft parts due to overgrowth of synovial fringes. It may be
Fio, 80.— Syphilis ot the knee-joint.
Fia. SI. — Mulliple calcified bodies in the knee-joint.
106 JOINTS, TENDONS AND BVRSM
seen in lateral \'iews of the knee, where the posterior portion
of the capsule is occupied by a mass of slightly greater density than
normal, and where a stringj', fan-shaped shadow can be made out
radiating anteriorly between the condyles of the femur and tibia.
Hemophilia. — When the joints are involved in this disease the
signs are those of chronic joint irritation suggesting tuberculosis.
There is bone atrophy amounting even to pencilling of the outlines,
effusion into the joint and moderate enlargement and squaring of the
epiphyses. At times erosion of the articular ends of the bones may
occur, or calcification of the blood-clot within the joint.
Fm. 82. — Hemophilia with oreoniiing blood-clot in the capsule r>( the elbow-joint.
Osteochondritis Deaiccans.— Osteochondritis desiccans is charac-
terized by the pre.senee of a mass of cartilage loose in the joint
whose site of detachment ma,\' usually be made out upon the articu-
lar surface of the inner condyle of the femur. If these loose pieces
do not calcify they are invisible, but fortunately most of them
do in the course of time.
Osteochondritis Deformans (Perthe's disease). — Osteochondritis
deformans is revealed by a flattening and mushrooming of the head
of the femur, suggesting tuberculosis but without typical clinical
signs. The joint is not involved. There is little bone atrophy and
interference with growth is not marked. It is possibly due to
OSTEOCHONDRITIS DEFORMANS
— Ostco chondritis deaiceana.
JOINTS, TENDONS AND BURSM
Fio. 85.— Perthe'a diw
Fio- 88- — Perthe'a diaeaae. Same caai
enomi nation. The head ot the femur is :
TENDONS AND BURSJi
interference with the blood supply of the epiphysis. The end result
of such a process as seen in adults is a flattening of the head, which
is sometimes displaced downward slightly on the neck.
TEHDOHS AHD BURSA.
Effusion or hemorrhage in or about these tissues is shown by an
area of slightly mcreased density with indefinite mai^ins. Syno-
vitis of the Achilles, quadriceps or extensor longus pollicis tendons
may occasionally be suspected from thickening of the shadow and
blurring of its ordinarily sharp outlines. Areas of increased density
seen in the region of the subdeltoid bursa may be true calcifications
Fia. 87. — Subdeltoid bursitis.
in the bursa, which are rare ; accumulations of an opaque gelatinous
substance in the bursa; or, what is more common, calcification
about the tendon of the supraspinatus beneath it. Calcification
may occur in any bursa which has been the seat of trauma or
infection.
no JOINTS, TENDONS AND BURS^
BIBLIOGRAPHY.
Gushing, H.: Hereditary ankylosis of the proximal phalangeal joints (sympha-
langism), Jour. Nerv. and Ment. Dis., 1916, xliii, p. 445.
Goldthwait, J. E.: Lumbosacral articulation, British Med. Surg. Jour., 1911,
cbdv, p. 365.
Ogilvy: Subluxations of atlas upon the axis. Am. Jour. Orthop. Surg., 1914-15,
xii, p. 314.
O'Reilly, A.: Joint syphilis. Am. Jour. Orthop. Surg., 1913-14, xii, p. 431.
Brickner, W. M.: Subacromial bursitis, Am. Jour. Surg,. 1916, xxx, p. 108.
Dunlop: Deposit simulating subacromial bursitis. Am. Jour. Orthop. Surg., 1916,
xiv, p. 102.
Brickner, W. M.: Subacromial bursitis, Jour. Am. Med. Assn., 1916, Ixvi, p. 912.
Stein: Syphilitic arthritis, Med. Rec, 1915, p. 472.
Skillem: Joint lues, Internat. Clin., 1914, xxiv, p. 192.
Whitelocke: Loose joint bodies, British Jour. Surg., 1914, p. 650.
Legg, A. T.: An obscure affection of the hip-joint, British Med. Surg. Jour.,
1910, clxii, p. 202.
Berry, John McW. : Roentgenological shadows associated with subdeltoid bursitis.
Am. Jour. Orthop. Surg., 1916, xiv, p. 476.
Scott, S. G.: Myositis ossificans, Charcot's joint associated with. Arch. Radiol.,
1917, xxi, p. 239.
Barker, L. F.: Differentiation of diseases included under chronic arthritis. Am.
Jour. Med. Sc, 1914, cxlvii, p. 1.
Legg, A. T.: Osteochondral trophopathy of the hip-joint, Surg., Gynec. and Obst.,
1916, xxii, p. 307.
Freiberg, A. H.: Hemophilia affecting the knee. Lancet, Clin., 1916, cxv, p. 588.
Brickner, W. M.: Cause of Roentgen shadow in cases of subacromial bursitis.
Am. Atlas Stereoroent., 1916, i, p. 34.
Henderson, M. S.: Loose bodies in the knee-joint. Am. Jour. Orthop. Surg., 1916,
xiv, p. 265.
Brickner: Prevalent fallacies concerning subacromial bursitis. Am. Jour. Med. Sc,
1915, p. 540.
Carnett, J. B.: Typhoid spine, with a report of cases, Am. Surg., Philadelphia,
1915, Ixi, pp. 456-471.
Perthes, G.: Ueber osteochondritis deformans juvenalis. Arch. f. klin. Chir., 1913,
ci, p. 779.
Bracket, E. G., and Hall: Osteochondritis desiccans, Am. Jour. Orthop. Surg., 1917,
XV, p. 79.
CHAPTER VIU
THE CHEST.
The shadow of the chest may be divided into (1) that of the
thoracic wall, (2) a central shadow consisting of supraposed ster-
num, heart, great vessels, mediastinimi and spine, (3) the diaphragm
and (4) the lung fields.
Pathological processes in the thoracic wall may consist of injuries
to the ribs, of infections and of timiors. They are similar to the same
processes elsewhere. Occasionally there is an emphysema of the
soft tissues usually associated with fracture of the ribs or surgical
interference. The plate is very striking and shows the presence of
dark areas representing air scattered through the muscles and sub-
cutaneous tissue.
The central shadow is concerned with the outlines of the thymus
and thyroid, of mediastinal masses and with the shape, size and
position of the shadows of the great vessels and pericardium. Nor-
mally the thyroid and thymus are not visible in a chest plate. A
substernal thyroid or enlarged thymus appears as a dilatation of
the upper end of the central shadow with sharp margins which
extend upward beyond the clavicles. In children, an enlarged thymus
gives a particularly characteristic shadow. It is roughly quad-
rangular with rounded lower corners and sharp margins which extend
straight down from above the clavicles and overlap the shadow of
the heart and vessels. It is less dense than other tumors and is
easily overlooked. In our experience, lateral and oblique views are
of little value in its recognition.
Thsrroid. — ^The thyroid, when intrathoracic, shows as a dense,
sharply defined shadow extending down and overlapping the great
vessels. It may be differentiated from thymus and other medias-
tinal tumors by the fact that it moves with deglutition.
Mediastinal masses may be due to enlargements of the medias-
tinal glands, growths, aneurysms, vertebral abscesses and dilatations
of the esophagus.
Enlargement of the glands is usually due to tuberculosis,
Hodgkin's disease or malignancy. Their outline is sharp and irregu-
lar or lobulated and the process is usually bilateral. They seldom
show pulsation although large masses may transmit the impulse
112 THE CHERT
of heart or aorta. By careful fluoroscopic examination it is some-
times possible to separate their shadow from that of the aorta or
to demonstrate a norma! aorta.
The most common tumors are lymphosarcoma, Hodgkin's disease,
and carcinoma, primary or metastatic. They produce dense
shadows with sharply defined borders and may displace or com-
press the surrounding oi^ans, often showing transmitted pul-
sation. They may be mistaken for aneurysm, but careful study
with the fluoroseope and plates at different angles will usually
Fio. 88.— Malignant tumor of the mediastinum, resembling aneurysm.
differentiate them. In lymphosarcomaandHodgkin'sdisease, glands
elsewhere in the body are usually involved and the masses tempo-
rarily disappear with great rapidity under roentgen radniatio.
Primary malignancy is rare. It usually occurs as a unilateral,
irregular enlargement of the hilus shadow which shows a tendency
to grow in the direction of the affected bronchi. Metastatic malig-
nancy, in addition to the enlargement of the hilus shadows, may
show the characteristic, annular, sharply defined patches through the
lung fields. Teratomata may invade the mediastinum in rare cases,
decretmc in the si
Fig. 80. — The same case as Fijt. 88, one year after the first examination.
114 THE CHEST
causing an increase in the width of the central shadow without
distinguishing characteristics. Dermoid cysts may occur and
should be recognized by their cystic wall and the fact that they
arise from the mediastinum. Lipomata may also develop in this
region.
THE HEART ANB GREAT VESSELS.
In an examination of the heart we should obtain the following
data: Size, shape, its movements with respiration, pulsation of the
Fig. 91. — Teleradioemm of the normal heart and great vcssela:
No. I on the right is the ascending aorta.
No. II on the right is the right auride.
No. 1 on the left is the aortic arch.
No, 2 on the left is the pulmonary artery.
No. 3 on the left is the left auride.
No, 4 on the left is the left ventride.
various chambers, and any change of shape which may occur with
change in position of the patient. We should also note the size
THE HEART AND GREAT VESSELS
115
Fig. 92. — Tracing showing the shape of the normal heart and great vessels and
the points from which measurements are taken. (From Groedel.)
Fig. 93. — A tracing showing the normal respiratory excursion of the heart and
diaphragm during quiet and forced breathing. Patient is standing.
IIG THE CHEST
and shape of tlie aorta in both its anteroposterior and lateral
diameters.
This data may be obtained by means of orthodiagraphy or by
combination of tele-roentgenologj' and fluon>scopic examination.
Fig. 94.— The drop heart of the plotip.
The advantages of orthodiagraphy are its accuracy' in the hands
of experts and ability to outline the apex. Its disadvantages are:
the time required to perfect a technic, and constant chance for error
due to the personal limitations of the operator.
Fio. 95.— The enlargement of the left ventricle and aortic regurgitation.
s feet. Note the
US THE CHEST
Tele-roentgenology has the advantage of eliminating the personal
equation and of producing a permanent record. Its disadvantages
are; the slightly higher cost and the difficulty of demonstrating
the apex and the junction of the left auricle with the left ventricle.
These points are of importance, as without them all the measure-
ments cannot be obtained.
Fia. 97.— The dilated heart.
By fluoroscopy it is possible to obtain a fairly accurate outline
of the shape and position of the heart shadow and of its movements
with respiration; also of any change of shape which may occur with
change of position. By combining this data with the data obtained
from a plate taken at a seven-foot target film distance, all the
required findings are present.
This method of combined fluoroscopy and tele-roentgenography
has been in use at the Massachusetts General Hospital for the past
five years and has proved quite satisfactory. The fluoroscopic
observation is made first. The patient is placed in the upright posi-
THE HEART AND GREAT VESSELS 119
tion behind a fixed screen. The focal spot of the tube is at a distance
of 24 inches from the screen. From 2 to 3 ma. at 60,000 volts gives
a good image.
A thin plate of glass in front of the fluoroscopic screen serves as
a receptacle for the tracing which is made of the outline of the heart
and great vessels during normal breathing, forced inspiration and
forced expiration.
Fio, 98, — Mitral disease.
The patient is then rotated to the left so that his right chest is
in contact with the screen, and the posterior mediastinal space with
the arch of the aorta are studied. By changing the position of the
patient slightly, the size of the shadow of the aorta will be seen to
grow larger or smaller. The smallest possible shadow which can be
obtainetl represents the true diameter of the aorta plus the amount
of magnification due to its distance from the screen,
A tracing is made of the aorta in this position for comparison
120 THE CHEST
with the tracing made in the anteroposterior view. From the two
tracings an estimate can be made of the amount of overlapping of
the ascending and descending aorta. The glass with its tracing is
removed and the pulsation of the various chambers of the heart
is studied and compared. If there is anything in the findings
which suggests a pericardial effusion, the patient is examined in the
prone position.
Fia. 99,— The w
After the fluoroscoptcobservations are completed, a mark is placed
on the patient's chest opposite the center of the heart shadow to
serve as a point upon which to focus the tube for the plate which is
taken with the patient standing. The focal spot of the tube should
be at a distance of at least six feet from the plate.
Special care must be taken so to place the patient that the central
rays from the tube pass through the chest at right angles to its
THE HEART AND GREAT VESSELS 121
transverse diameter. At this distance a small amount of displace-
ment of the tube to the right or the left from the median line does
not appreciably distort the heart shadow, but a slight rotation of
the patient does produce definite distortion.
In stout patients it is better to have the plate in contact with the
chest wall and the patient standing erect. If the plate is placed at
Fio, 100. — The same caae aa FiR. 99, hut taken with the patient prone. Note
the change in the aliape of the heart shadow, due to the ahifting of the fluid within
the pericardium,
right angles to the central ray from the tube, its upper portion
may be some distance from the chest wall; and as we are not
dealing with absolutely parallel rays, a slight amount of magnifica-
tion of the aorta will result.
On the other hand, if the patient is allowed to lean forward to
bring the chest entirely in contact with the plate, there will be a
certain amount of apparent sagging of the content* of the chest.
The time of exposure should be sufficiently long to covef one full
122 THE CHEST
heart cycle, so that the shadow obtained will be the shadow of the
heart in diastole. Where very rapid exposures are made the result-
ing picture may represent the heart either in systole or diastole or
at some phase between. The period of diastole is the one from which
estimates of the heart size are made.
Therefore, it is evident that a relatively long exposure is desirable.
The patient should be instructed to keep still, but it is not desirable
for him to take a deep breath nor is it necessary to hold the breath.
The amount of movement of the heart shadow in normal respiration
is very slight. With deep inspiration there is a definite change both
in the shape and size. The amount of current passed through the
tube may vary according to the type of apparatus available. About
the same degree of penetration should be used as in frontal sinus
work. Intensifying screens are desirable.
After the plates are developed and dried the measurements are
THE HEART AND GREAT VESSELS 123
made from them according to the plan adopted by Groedel. This
plan includes six points from which measurements are taken: three
on the right and three on the left side of the heart shadow. The
upper point on the right is at the junction of the heart shadow with
that of the great vessels. The second point on the right is at the
furthest point of the heart shadow to the right, and the lowest point
is at the junction of the heart shadow with the diaphragm. On the
left, the highest point is at the junction of the left auricle with the
left ventricle. The second point is at the greatest distance to the
left, and the third point is at the heart apex. A line is then drawn
along the center of the spinal column. This may be used as the
midline.
The greatest distance to the right and the greatest distance to
the left from this line are easily obtained. Their sum represents the
greatest transverse diameter of the heart shadow. A line drawn
from the highest point on the right to the heart apex represents the
total length of the heart; and lines drawn at right angles to it,
one to the highest point on the left and one to the lowest point on
the right, give us the diameter of the base.
By comparing these figures and the shape of the heart and aorta
with the respiratory movements and pulsations as recorded on the
tracing, the conclusions are made.
To interpret the findings one must have a thorough knowledge
of the anatomy of the heart and great vessels, and of the normal
radiographic shadow.
Normally, the central shadow approximates the outline in Fig. 91.
At the top, on the left side, the edge of the arch of the aorta appears
with the descending aorta extending downward from it; below it
the slight prominence of the pulmonary artery and the small left
auricular appendage in the angle between it and the ventricle. The
rounded mass of the ventricle makes up the largest part of the
shadow and disappears below the diaphragm line. The location of
the apex is a matter of considerable uncertainty, as it varies with
the size, shape and position of the heart and of the patient, and the
position and shape of the diaphragm.
The right border begins at the top with the poorly defined shadow
of the superior vena cava above and overlapping the ascending
aorta, which is sometimes indented by the right bronchus in its
lower portion. The line then curves outward over the right auricle
to join the right diaphragm at an acute angle at the apex of which
the inferior vena cava is sometimes apparent.
124 THE CHEST
Diseases of the Heart Valves. — Diseases of the heart valves are
accompanied by an enlargement of the corresponding chamber or
chambers. For instance, in mitral regurgitation, the enlargement of
the shadow is to the right and across the base because of the changes
in the left auricle and the right ventricle (see Fig. 98).
Aortic Disease, — ^The enlargement is almost entirely to the left.
A knowledge of the physiology and pathology of the heart will
enable one to accurately interpret these lesions from the changes
in the shape of the heart shadow.
Auricular Fibrillation. — ^Auricular fibrillation may be demonstrated
by the tremendous enlargement of the shadow of the auricles and
absence of visible pulsation in them. In certain of these cases the
heart shadow seems to rock.
Heart Block. — In this condition, if the pulsation is not too rapid,
it is possible to compare the beats of the auricle with those of the
ventricle and determine their respective rates.
Dilatation. — Dilatation is seen as a general enlargement of the
heart shadow with weak pulsation and an absence of the rounding
of the apex seen in hypertrophy.
Congenital Abnormalities. — Congenital abnormalities give rise to
changes in shape and abnormal areas of pulsation. Here again the
knowledge of the anatomical and pathological variations of the heart
and great vessels will enable one to arrive at a diagnosis from their
appearance on the plate or screen.
Pericardial Effusion. — ^With fluid in the pericardimn the heart
shadow tends to become more triangular in shape. When the
patient is prone there is an increase in the width at the apex of the
triangle, and when upright an increase at the base, or it may assume
a water-bottle shape. The cardio-hepatic angle is seldom obliterated,
although it may be so to percussion. Pulsation is considerably
diminished. In obtaining the shape of the heart in different posi-
tions for comparison, it is not wise to depend on screen observa-
tions alone. Either a careful tracing or plates taken at a distance
of seven feet should be made and the outlines thus obtained
superimposed.
Adhesive Pericardium. — It has been noted in a small group of
cases that the respiratory excursion of the heart is limited. There
is also apt to be some haziness in outline of the heart shadow and
apparent obliteration of the angle between it and the diaphragm.
Dilatation of the Arch. — ^The dilatation of the aorta as seen radio-
graphically occurs most frequently as the result of specific disease.
THE HEART AND GREAT VESSELS 125
There may be a slight amount of dilatation present in arterio-
sclerosis and cases with high blood-pressm*e.
Very large hearts seem to have a relative enlargement of the
aortic shadow. With a high position of the diaphragm the aortic
shadow is slightly wider than in cases with a low diaphragm.
Probably part of these variations are due to the difference in the
shape of the aortic arch. In a wide arch there is less overlapping
of the ascending and descending aorta and consequently an increased
diameter of the shadow.
Specific aortitis tends to appear first just above the aortic valves
and as the wall of the aorta becomes weakened, a bulging of this
area takes place. On. the plate or fluoroscopic screen the position
of this bulge is seen just above the shadow of the right auricle.
A marked prominence of the aortic shadow to the right is almost
always due to specific aortitis. In arteriosclerosis the calcified
plaques in the aorta are not visible unless extensive. The tortuous
aorta, however, does give a definite, fairly characteristic change in
the appearance of the aortic shadow. There is a distinct, sharp
increase in the upper part of the shadow to the left.
Diffuse dilatation of the aorta also occurs and is seen as a general
enlargement of its shadow. There is much more difficulty in inter-
preting this type from roentgen evidence, as the findings may be
the result of the changes in the aortic curve already mentioned.
Aneurysm. — ^The size, position and location of aneurysms of the
aorta are seen on the plate or fluoroscopic screen in sharp contrast
to the surrounding limg structure. Should the lesion occur in the
subclavian or vessels of the neck, which are not in contact with the
lung structure, the aneurysm is invisible.
Aneurysms of the ascending aorta are seen to the right, while
aneurysms of the arch usually show to the left of the spine high up.
Aneurysms of the descending aorta are seen in the lower portion of
the aortic shadow to the left and they may be partially hidden by
the shadow of the heart. Large diffuse aneurysms may appear as
a general increase in the shadow of the great vessels.
The pulsations of aneurysms are not always seen on the fluoroscopic
screen. It is extremely difficult to differentiate between expansile
and transmitted pulsations, so that the presence or absence of pul-
sation, as observed fluoroscopically, is not of conclusive value in
the diagnosis. The position of the sac is of more importance. Its
outline should be sharply defined and the shadow of the normal
aorta should not be seen through it. Mediastinal tiunors other than
126
THE CHEST
aneurysms are usually less sharply defined. They may be nearer
the front or back of the chest than the position of the great vessels,
or they may occupy a position higher or lower than is usually occu-
pied by aneurysms; and occasionally the shadow of a normal aorta
may be seen through them. They are more likely to displace the
heart and aorta than are aneurysms.
The following table worked out by Claytor and Merrill^ gives a
fairly good guide as to the measurements of the normal heart.
Males (37 cases).
Weight, pounds.
Cases.
Mr.
Ml.
T. D.
L. D.
3
7.0
10.7
11.8
Minimum
120-129
3
3.7
7.2
10.9
12.6
Average
4.3
7.5
11.3
13.5
Maximum
3.5
7.5
11.
12.0
Minimum
130-139
5
3.8
8.0
11.8
13.2
Average
4.2
8.5
12.5
14.0
Maximum
.
3.4
7.0
11.0
12.0
Minimum
140-149
9
4.0
7.7
11.9
13.4
Average
4.6
8.4
13.1
14.5
Maximum
3.2
7.8
11.5
12.5
Minimum
150-159
8
3.9
8.4
12.3
13.5
Average
4.5
9.0
13.0
15.0
Maximum
3.7
8.0
12.0
14.0
Minimum
160-179
6
4.0
8.2
12.4
14.6
Average
4.8
9.0
13.8
15.8
Maximum
180-200
6
3.8
7.0
11.0
14.0
Minimum
4.2
8.7
12.9
14.7
Average
4.5
9.7
13.4
15.3
Maximum
Females (51 cases).
Weight, pounds. Cases.
100-109 2
110-119 3
120-129
130-139
140-149
150-159
160-175
14
19
Mr.
Ml.
T. D.
L. D.
3.2
6.7
9.9
12.0
Mininmm
3.3
6.8
10.2
12.1
Average
3.5
7.0
10.5
12.3
Maximum
3.0
7.0
10.0
11.5
Minimum
3.1
7.6
10.7
11.9
Average
3.2
8.0
11.1
12.4
Maximum
2.3
6.4
10.2
10.5
Minimum
3.5
7.5
11.0
12.2
Average
4.2
8.6
12.2
13.8
Maximum
3.0
6.4
9.6
11.2
Minimum
3.4
7.8
11.2
12.4
Average
4.0
8.8
12.6
13.3
Maximum
2.6
7.0
10.0
12.2
Minimum
3.5
7.6
11.1
12.7
Average
4.1
8.3
11.8
13.2
Maximum
3.1
7.6
10.9
12.3
Minimum
3.6
8.0
11.6
12.9
Average
4.8
9.3
12.8
14.2
Maximum
3.5
6.5
10.6
11.8
Minimum
3.8
7.9
11.7
12.6
Average
3.8
8.5
12.3
13.0
Mean
4.1
9.0
12.8
13.2
Maximum
I Claytor and Merrill: Am. Jour. MqcI» Sq., 1909, New Series, cxxxviii, p. 554.
THE HEART AND GREAT VESSELS
128 • THE CHEST
Perivertebral at Mediastinal AbsceiiB.— ^Perivertebral abscess will
usually give a more or less fusiform shadow appearing on both
sides of the central shadow unless it occurs behind the heart. It
must not be confused with the shadow of the aorta. Inasmuch as
they practically always result from a lesion in the spine, the recog- -
nition of a destructive process in the vertebrae is of considerable
aid in the d
ayphilitic aortitis. A
EBOphagus. — In an occasional case of cardiospasm the esophagus
may be dilated to such an extent as to appear as a long, smooth
shadow curving outward into the right lung fields. It may be
recognized by the fact that it continues upward above the clavicles
and by the use of a barium meal. It must not be forgotten that
diverticulum of the esophagus may simulate mediastinal tumor,
capsulated empyema and aneurysm.
THE HEART AND GREAT VESSELS 129
Diaphragm. — Normally the diaphragm curves smoothly from the
pericardium downward to form a sharp angle with the pleura.
The right side is higher than the left (one or more centimeters), and
in some cases shows several small curves near the dome due to
inequalities in the liver which have no significance, Fluoroscopically,
it should move freely and equally on the two sides both on quiet
and deep respiration.
Fio. 106. — Aneurysm of the ascending ftorta.
Changes in Ovtlitie, — Marked irregularities on the surface of the
liver may be transmitted through it. Bands of adhesions to the
pleura or the chest wall may elevate small string\- or triangular
areas.
Changes in Mobility . — Slight limitation of motion may be observed
when the patient is breathing quietly, which disappears completely
with deep respiration. Bilateral limitation of motion may be due
130 THE CHEST
to emphysema, ptosis, ascites, jjeritonitis, pieuritis at the base of
both iungs, or fibrosis from an old inflammatory process. When
unilateral, we must look above the diaphragm for tuberculosis or
disease of the pleura on that side or below it for an inflammatory
process such as a diseased appendix or gall-bladtler, subdiaphrag-
matic or liver abscess. Paradoxical excursion of the diaphragm is
seen in paraljsis of the phrenic nerve and diaphragmatic hernia.
The affected side rises during inspiration and falls during expiration.
a well as pus. The plate
Changes in Fosxtum. — It is low in ptosis and emphj-sema. It is
high in adiposity, ascites and subphrenic abscess, e\entration and
hernia of the diaphragm. Eventration and hernia are both more
common on the left side. In eventration, although considerably
elevated, its contour is preserved and movement is normal in direc-
tion though limited. In hernia its outline is obscured and its move-
ment paradoxical. In both cases the barium meal will demonstrate
the position of the abdominal viscera.
Pleural Effusions. — Pleural effusions obliterate the costodiaphrag-
matic angle if small or the entire diaphragmatic shadow if they are
LUNG FIELDS 131
extensive. It is worth noting that in rare cases fluid may be
obtained from a chest that is roentgenologically negative.
Subdiaphragmatic Abscess. — Subdiaphragmatic abscess causes
marked upward displacement of the shadow of the diaphragm.
The top is usually considerably flattened and excursion is abolished.
Encapsulated fluid above the {liaphragm may strongly resemble
subdiaphragmatic effusion.
LUNQ FIELDS.
Teclinic. — I,ung examination should include both fluoroscopy and
plates, preferably in the erect position. When the patients can
hold their breath, stereoscopic plates have great value but they are
not necessities. In certain conditions examination in the prone,
oblique and lateral positions should be made. It is usually advis-
able to take both anteroposterior and postero-anterior plates. The
132 THE CHEST
number and position of the plates to be taken may be determined
at the fluoroscopic examination.
Normal Lung. — ^The normal lung markings consist of small areas
of density at the hilus which often show calcified spots, and strands
of density corresponding to the bronchial tree spreading out through
the lung fields for a considerable distance but never quite reaching
the pleura. The descending bronchi on both sides are usually more
dense than those above. The fields are of equal density on the two
sides. They are slightly obscured by the pectoral muscles and in
the breasts in postero-anterior views and there is usually some slight
haziness in the left base in the region of the apex of the heart.
Pathological Changes. — Diffuse increase in density on one or both
sides is found in thickened pleura, fluid, consolidation or bronchial
stenosis. A general increase in radiability is due to emphysema.
Local areas of increased radiability may be due to pneumothorax
or cavity formation. Localized areas of increased density are most
likely to be abscess, localized pneumonia about a foreign body or
malignancy.
Increase in size of the root shadows mav be due to infection or
tumor.
Increased thickening of the bronchial markings means infection
or fibrosis. Fine mottling along the bronchi is usually due to the
early manifestations of tuberculosis. Fine mottling in the lung
tissue usually means tuberculosis, fibrosis or malignancy. Coarse
mottling in the lung tissue is due to bronchiectasis, tuberculosis
or metastatic malignancy. Displacement of mediastinal contents
occurs with eftusion, adhesions, fibrosis and tumors. In the case
of tumors, displacement is often toward the side affected by the
growth.
Pleura. — ^Thickening occurs as a result of inflammation and may
obscure all of one or both chests or may be limited to the base or
apex. The shadow is fairly dense although the ribs can usually be
seen through it. A thin, curved, white line, convex upward, extend-
ing across the chest is occasionally seen as the end-result of an
interlobar pleurisy. Adhesions appear as strands of increased
density. At the apex theu* appearance may suggest cavities.
Pleural Exudate. — An effusion or empyema usually gives a shadow
of extreme density located at the base, obscuring the ribs and
diaphragm with a superior margin which curves upward toward
the chest wall in the axilla, unless pneiunothorax is present, when it
will^show a fluid level which changes as the patient's position is
LUNG FIELDS 133
shifted. In the prone position the shadow is uniform tliroughout
the chest and often resembles that of thickened pleura. If an effu-
sion is extensive, there is usually displacement of the heart and great
vessels. The apex is usually clear. In young children fluid may
appear as a dense area along the periphery of the lung field.
Encapsulated fluid gives a dense, sharply defined shadow in con-
tact with the pleura. It is most common at the base, along the
axillary border or between lobes. When the collection is between
lung and diaphragm it may simulate subdiaphragmatic abscess.
Fio. lOH. — Pneumothorax, with complete collapse of the left liinR.
Fnenmotfaorax. — Pneumothorax is characterized bj- the presence
in the peripherj' of the lung field of an area of greatly increased
radiabilitj- from which the lung markings are absent. Its borders
are sharply defined and consist of the walls of the chest cavity and
the margins of the compressed lung. When the pneumothorax is
complete and there are no adhesions, the lung collapses to a lobu-
lated mass at the hilus in which can usually be seen the sug^Jestion
0. — Old empyema, with calcification in the rigbt pleura
WNG FIELDS 135
of lung marking. In the presence of pleural adhesions where the
<;oiIapse is incomplete, the shadow of the pneumothorax may be
divided by bands which give it a sacculated appearance and pneumo-
thorax and lung tissue may overlap each other. A small localized
pneumothorax may be difficult to detect unless it is seen in profile;
otherwise it appears as an area of somewhat increased radiability
overlaid by normal lung markings. This should not be confused
with large cavities which occur in the substance of the lung and may
or may not have well-defined borders.
Calcifications frequently appear in the pleura in a form of ragged
plaques or lines which occur in any portion of it.
FiQ. 111. — Peribronchial tuberculosis. Advanced tuberculosis two years later.
Tuberculosis. — The primary focus in tuberculosis is probably in
the periphery of the lung but it is not always evident. However,
we see an increase in the root shadows as a result of glandular
involvement which, particularly in children, is often marked. In
the acute stage their outlines are blurred and indistinct. If healing
occurs the shadows gradually diminish in size, increase in density
and sharpness of outline, and subsequently show areas of calcification.
As the infection progresses, the next change is general thickening
13r> THE CHEST
of the bronchial markings along the track of the disease, usually
toward one or both tops. When this has occurred the patient will
usually show dullness at the affected area clinically. Because of
the normal thickening towanl both bases the stage is difficult to
recognize when the extension is downward but it is much less com-
mon in this situation. Plates of most adult lungs show a certain
amount of thickening of the bronchial markings as a result of pre-
vious infections and have no particular significance. When due to
Fid. 112. — Tuberculosis at both apincs.
tuberculosis, the changes are permanent. The demarcation between
the normal and the pathological is not sharp and it takes consider-
able experience in the observation of plates, combined with all that
can be found by clinical methods, to establish a correct diagnosis.
If the process continues, small bead-like masses appear along
the course of the thickened bronchial shadows and fan-shaped areas
of filmy density may be seen with their bases on the pleura and
apices, extending inward toward the thickened markings. These
fan-shaped areas are probably the earliest evidence of definite
LUNG FIELDS 137
involvement of the lung parenchyma, but unfortunately they are
not commonly seen and they may occur in other infections.
The next stage is the appearance through the diseased area of
finely stippled grayish spots, apparently independent of the bronchial
markings now extended to the peripherj' of the lung. These spots
mean definite involvement of lung tissue and at this time rales are
beginning to be evident upon clinical examination. This charac-
teristic fine mottling is the only sure basis for a roentgen diagnosis
of active tuberculosis. It is seen in its most typical form in the
cases of miliary tuberculosis.
With the further progress of the disease there occurs an enlarge-
ment and effusion of these spots and their extension to new areas,
resulting in coarse mottling and finally evidence of cavity formation.
138 THE CHEST
Areas of healing may occur at any stage, or progress and healing
may be simultaneous so that it may be impossible to decide from
roentgen evidence alone whether a case is active or quiescent. In
general, active lesions are dim, gray and blurred; healed ones are
more dense and sharply outlined.
The only condition which must be differentiated from extensive
tuberculosis is that seen in pneumonoconiosis, where the fibrous
changes and symmetrical portions of both lungs east a cotton-like
Fiti. 114. — Lobar pneumonia. The process is in the lower part of the rieht upper lobe.
shadow very similar to that of fibroid tuberculosis. However, the
apices are usually not involved and the patient will give a history
of having worked underground or in a dusty occupation and his
physical signs are not those of a tuberculous process of similar extent.
Miliary tuberculosis presents a characteristic, fine, hazy mottling
scattered throughout the lung fields which must be differentiated
from metastatic malignancy and from pneumonoconiosis. Meta-
stases in rare cases appear as definite small discrete areas of increased
LUNG FIELDS 139
density scattered throughout both lungs, but the spots, while approx-
imating those of miliary tuberculosis in size, are more dense and
more sharply outlined. From pneumonoconiosis it may be differ-
entiated by the fact that it is a more diffuse process involving all
portions of the lung, whereas pneumonoconiosis tj^ically involves
symmetrical areas and spares the apices. The mottling in the latter
is much finer and the dense spots are smaller than those seen in
tuberculosis.
Lobar Pneumonia. — Lobar pneumonia is characterized by areas of
increased uniform density which are sharply defined and, when fully
developed, usually occupy the position of a lobe. In the early
stages the shadow, while uniform, is less dense and may be triangular
in shape with the base on the pleura and the apex toward the hilus.
The lung markings distributed to this area are thickened and the
140 THE CHEST
hilus giands are enlarged. It has been observed in children that
dullness and changed breath and voice sounds are not ordinarily
perceptible until the shadow reaches the hilus.
The character of the shadow changes with the progress of the
disease and as resolution appears it becomes distinctly mottled.
After the shadow itself has disappeared, thickened bronchia! mark-
ings or large glands may persist for a considerable time. It must be
differentiated from fluid where the shadow is more dense, does not
conform to lobar outlines, and displaces the heart and vessels.
Branchopnennumia. — Bronchopneumonia occurs more frequently
than is generally thought. Owing to the absence of physical signs,
the diagnosis may depend largely upon the roentgen examination and
the history. The appearance is that of single or multiple areas of
increased density with hazy outlines, usually situated near the course
of the larger bronchi. The differentiation from abscess, bronchiec-
tasis and malignancy depends largely upon the clinical history.
LUNG FIELDS 141
ITiiTeBolved Fneumonia. — Unresolved pneumonia gives a shadow
resembling that of pneumonia. It must be distinguished from an
interlobar empyema, tuberculous pneumonia, or bronchial stenosis
largely by the clinical and laboratory findings. It has been noted
that unresolved pneumonias may disappear after mild roentgen
radiation.
Bronchitis. — Bronchitis, when acute, gives no charaxrteristic pic-
ture. The chronic inflammations appear as an increase in the size
and density of bronchial markings and glands.
1 the right chest.
Lung Abscess. — Lung abscess usually follows influenza or the
inspiration of infected material at operation or of foreign bodies.
Clinically it is a disease of symptoms rather than physical signs, so
that the roentgen examination is of the greatest help in indicating
the site and extent of the process from its early stages. The lesions
are usually single, although they may be multiple and may occur
in either Imig field, showing, however, a decided preference for the
bases, particularly the right. They assiune the form of irregular
areas of increased density which are most marked at the center,
142 THE CHEST
fading out toward the periphery. Cavity formation is extremely
common in the areas of infiltration. When filled with fluid they are
indistinguishable from the general shadow about them but the
larger ones become very evident when filled with air, particularly
if they certain sufficient fluid to cause a fluid level. They are seen
as round areas of greatly diminished density and, if a fluid level is
present, its surface shifts according to the position of the patient.
Small cavities may be entirely overlooked. The bronchial markings
distributed to the areas involved are enlarged and coarse and the
hilus shadows are increased in size. Abscesses may persist for a
long time as areas of thickening or heal spontaneously without leav-
ing a trace of their presence on the roentgenogram. Their localiza-
tion is often disappointing to the surgeon because of the zone of
pneumonic infiltration about them which magnifies the area of
involvement. Abscesses may be confused with tuberculosis, broncho-
pneumonia and bronchiectasis. The similarity to tuberculosis
lies in the occurrence of cavities. In tuberculosis there is other
roentgen evidence of the disease in the form of characteristic mot-
tling elsewhere in the lungs and especially at the apices. Abscess
is more common at the bases and the apices arfe clear. Broncho-
pneumonia may be differentiated by the fact that it gives a shadow
of more uniform density and there is no cavity formation. Bron-
chiectasis is usually a diffuse process and the bronchial changes are
more extensive. However, the two conditions blend into each
other at times.
Bronchiectasis. — ^The characteristic picture in a well-advanced
case is an extensive thickening of the lung markings along the
course of the larger bronchi and enlargement of the hilus glands
with the presence of single or multiple areas of increased density
in the lung fields near the bronchi, which may show considerable
change in plates taken before and after evacuation. Cavities can
often be demonstrated. In the early stages the picture is much
less characteristic and depends upon the demonstration of small
ring-like shadows of dilated bronchi which, however, are usually
obscured by the infiltrated lung about them.
Foreign Bodies. — Foreign bodies most commonly lodge in the right
bronchus and may be recognized if of sufficient density to cast a
shadow. Their presence may be the cause of an area of increased
density due to a localized pneumonia about them, to abscess forma-
tion or to collapse of one or more lobes as a result of broncho-
stenosis. Examination for foreign bodies should include observa-
LUNG FIELDS 143
tion of the entire respiratory tract from different angles, a lateral
view of the chest is often very helpful, any inspection of the larynx
and the neck should be included.
Fia. lis.— Bronc
BrtBichostenosis. — Bronchostenosis gives a uniform dense shadow
throughout the area supplied by the affected bronchus and the
movements of the diaphragm are limited on the affected side. It
occurs as a result of inspired foreign bodies, aneurysm, tumors or
lues.
Gangrene. — Gangrene casts an extensive shadow which may
occupy one entire lung field. Its characteristic features are the
144 THE CHEST
presence of large irregular areas of diminished density and a general
coarse mottling of the lung. The heart and mediastinal contents
are not displaced. This appearance may be simulated by a lung
which has recently expanded after a prolonged pneumothorax.
Primaiy MaliKnaiiGy. — Primary malignancy of the lung is rare.
It is practically always unilateral. The usual growth is a carcinoma
which occurs in two types, nodular and infiltrating. The former
consists of dense, rounded masses, sharply marked off from the lung
tissue, occurring near the hilus. Ragged, irregular cavity formation
in the tumor mass sometimes occurs. In the infiltratmg type, the
tumor arises from a bronchus and infiltrates the lung along the
bronchial ramifications. The edges of the growth are apt to be
smooth except along the advancing margin toward the periphery
of the lung. These growths may also extend toward the root and
form large masses at the hilus. Collapse of the lung with displace-
LUNG FIELDS 145
ment of the heart to the affected side may take place. Fluid in
the pleural space occurs early.
Metastatic Malignancy. — Metastatic malignancy appears in three
forms. In the first there is progressive enlargement of the hilus
shadows which is unrecognizable in the early stages and unmis-
takable in the later ones when large masses have developed at the
lung roots and usually an effusion at one or both bases, A second
Fio. 120. — Malignant
and perhaps more common form is that in which the growths take
the form of multiple, thin, rounded plaques of variable size, with
sharp margins which are scattered throughout the lung fields.
In the third type there is a fine mottling throughout the lung fields
which may suggest miliary tuberculosis, but the small areas of
increased density are a little larger, more dense, and more sharply
outlined than those of tuberculosis. Two or more of these forms
may occur together,
10
Fto. 121. — Metastasis. Malienaiit disease of the lung and pleura.
Fi<3. 122. — Metastatic cardnoma involving the bones. Iudbb and pleura.
LVNG FIELDS 147
Sjrphills. — There is considerable discussion un the subject of lung
syphilis but undoubted cases have been reported. It is evidenced
in three types. In the first, there is a general thickening of ail of the
bronchial markings, particularly marked toward the hilus, giving
a fan-shaped shadow radiating out into the lung fields. In the
second, supposed to be gunimata, there are one or more dense dis-
crete masses to he made out in the region of the hilus. The third
form occurs as a diffuse shadow obscuring one entire side of the
chest which may clear wholly or in part under appropriate treat-
ment. One characteristic feature of these patients is that the lesions
are much more extensive than their condition would lead one to
suspect.
EchmocoGcus. — Echinoeoccus occurs as dense, circular, sharply
defined areas of increased density within the lung field. They may
or may not have an evident cystic wall and ordinarily are not con-
Fia. 134j— EchinoooccuB cyat at the base of the right lung.
THE HEARTLAND GREAT VESSELS 149
nected with the mediastinum. If rupture of the cyst has occurred,
the picture will simulate that of lung abscess.
Aetmomycoais. — Actinomycosis usually occurs in the form of a
lung abscess and diagnosis Is made bacteriologically.
Fnfiumonoconiosis (Anthracosis,* QiaUcosis). — Pneunionoconiosis
may occur as a diffuse, fine mottling symmetrically distributed
throughout both lungs. The apices may be involved although such
is not usually the case. The picture is very suggestive of miliary
Fiu. 126.— Pottery workers' lungs. Pneumonoeoniosis.
tuberculosis. However, there will usually be a long history of
occupational exposure to dust and there is little or no clinical evi-
dence of a process as extensive as the roentgenogram would indicate,
the mottling is more dense and the areas are smaller, more sharply
defined, and more uniform in size than those of tuberculosis.
Another form of this disease is seen frequently in gold mine and
pottery workers, andappears as adiffuseprocess involving both lungs,
particularly the upper lobes, and from the plates alone cannot be
distinguishe<l from fibroid phthisis.
150 THE CHEST
BIBLIOGRAPHY.
Adler, Isaac: Primary malignant growths of the lungs and bronchi, Longmans,
1912.
Howell, W. W. : Studies in bronchial glands, Am. Jour. Dis. Children, 1915, x, p. 90.
Morse, J. L.: Case of congenital heart disease. Am. Jour. Dis. Children, 1915, x,
p. 27.
Jackson, H.: Multiple metastatic sarcomas of the lungs. Jour. Am. Med. Assn.,
1916, Ixvi, p. 833.
Miller, C. L. : Use of the x-ray in the diagnosis and study of pulmonary tubercu-
losis, Intemat. Clin., 1916, Series 26, iii, p. 109.
Van Zwaluwenburg, J. G.: The value of the orthodiagraph. Jour. Michigan Med.
Soc, 1910, ix, p. 211.
Pancoast, Henry K.: Roentgen diagnosis of pulmonary tuberculosis. Am. Jour.
Roent., September, 1917.
Moore, Alexander B.: Roentgen diagnosis of non-tuberculous disease of the lungs,
Journal-Lancet, July 1, 1917, xxxvii, p. 430.
Crane, A. W.: Roentgenocardiograms, Jour. Am. Med. Assn., October 14, 1916,
Ixvii, p. 1138.
Banjamin and Lang: Enlarged thymus in children. Am. Ped. or Arch. Ped., 1917.
Dunham, Kennon: Pulmonary tuberculosis, stereoroentgenography, Southworth
Company, Troy, N. Y., 1915.
Wessler, H.: The role of the roentgen ray in diagnosis of obscurer forms of heart
disease. Am. Jour. Roent., November, 1915, ii.
Brown, Percy: The recognition of pleural disorders by x-rays, with special refer-
ence to empyema, Boston Med. and Surg. Jour., 1915, clxxiii, p. 802.
Holt, Oliver P. : Multiple metastatic sarcomas of the lungs, with report of a case,
Jour. Am. Med. Assn., 1916, Ixvi, p. 171.
Watkins, W. W. : Roentgen diagnosis of lung syphilis. Am. Jour. Syph., 1917, i,
p. 760.
Keilty, Robert A.: Primary endothelioma of the pleura. Am. Jour. Med. Sc,
June, 1917, p. 180.
Boardsman: Pneumonoconiosis, Am. Jour. Roent., 1917, iv, p. 292.
Hertzler, A. E.: Dermoids of the mediastinum. Am. Jour. Med. Sc, 1916, clii,
p. 165.
Dunn, C. H.: Tuberculosis, Am. Jour. Dis. Children, 1916, ii, p. 85.
Mason, H. H. : Lobar pneumonia in children. Am. Jour. Dis. Children, 1916, ii,
p. 188.
Kanoky, J. P.: Thyroid tumors, Surg., Gynec. and Obst., 1916, xxii, p. 679.
Post, A.: Syphilis of the lungs, British Med. Surg. Jour., 1916, clxxiv, p. 876.
Baetjer, W. A.: Pulmonary tuberculosis, Internat. Clin., 1916, xxvi, iii, p. 124.
Wood, N. K.: Syphilis of the lungs, British Med. Surg. Jour., 1916, clxxv, p. 677.
Simon, C. E.: Yeast infection of the lungs. Am. Jour. Med. Sc;, 1917, cliii, p. 231.
Scott, E., and Forman, J.: Primary carcinoma of the lungs. New York Med.
Rec, 1916, xc, p. 452.
Hulst, H.: Roentgenological diagnosis of tuberculosis of the lungs. Am. Jour.
Roent., 1916, iii, p. 465.
Dietlen: Miinchen. med. Wchnschr., 1913, clx, p. 1763.
Vaquez and Bordet : Le Coeur et I'aorte: ifitudes de Radiologic Clin.
Jaugeas: Precis de Radiolog. Tech. et Clin.
Bietlen, H. : Deutsch. Arch, f . klin. Med., 1906-1907, Ixxxviii, p. 55.
Holzknecht: Fortschritte a. d. Geb. d. Roentgenstr. Erganzungheft, 6, p. 117.
Guttman: Ztschr. klin. Med., 1906, Iviii, p. 353.
Groedel, F. M.: Die Roentgendiagnostic der Herz- und Gefasserkrankungen,
Berlin, 1912, pp. 14-16.
De la Camp: Verhand. f. d. Cong. f. miinchen. Med., 1904, xxi, p. 208. Con-
clusions of R6sum6.
A. Kohler: Teleroentgenography, Deutsch. med. Wchnschr., 1908, xxxiv, p. 186.
Dietlen: Orthodiagraphie und Teleroentgenographie als Methoden der Herz-
messung, Munchen. med. Wchnschr., 1913, Ix, 1763-1766.
Albers, Schonberg: Die Roentgentechnik.
CHAPTER VIII.
GASTRO-INTESTINAL TRACT.
Technic. — Both fluoroscopy and plates are necessary for adequate
examination of the gastro-intestinal tract. Fluoroscopy gives infor-
mation in regard to mobility and function which cannot be secured
from plates, and plates give details of structure which may be over-
looked on the screen so that the methods are complementary. The
value of fluoroscopy depends upon the experience of the man who
is doing it, and when fluoroscopy is referred to hereafter it is under-
stood to mean that of a thoroughly trained operator. With a good
screen examination, six or eight plates should be sufficient in
most cases. The secret of success in this work is thoroughness,
which is more essential here than in any field of roentgenology.
Examinations must be frequently repeated and the patient ade-
quately studied before an opinion is rendered. As far as possible,
a routine technic should be employed throughout. There should
be no preliminary catharsis. A standard meal of uniform amount
and composition should be administered to the patient at about
his customary meal time. The barium may be given in 8 ounces
of buttermilk or potato starch gruel and the original meal may be
followed along its course or the double meal may be employed.
In the latter method the patient should receive his barium in a
carbohydrate breakfast of at least 16 ounces, reporting for exami-
nation six hours later, when the position of the morning meal is
observed and a second standard meal administered. This latter
method is the one most in use in the larger clinics, perhaps because
of the saving in time it effects. It will be found thoroughly prac-
ticable in most cases. The patient should be examined in the stand-
ing, prone, supine and right lateral positions. A brief knowledge
of the clinical history is essential, and whether it be secured before
or after the roentgen examination is a matter of personal preference,
but the roentgen findings and the history must be correlated at some
time before a diagnosis is made. The accuracy of the method will
vary with the personality and training of the observer. The diag-
152 G ASTRO-INTESTINAL TRACT
noses of the average man will be about 75 per cent, cofreet. With
the best roentgenologists under the most favorable circumstances,
roentgen findings in this field should be 85 to 90 per cent, correct.
ESOPHAGUS.
The esophagus is grossly outlined with the ordinary barium meal.
For more prolonged observation, particularly in cases of suspected
new growth, a mixture of barium sulphate and mucilage of acacia or
gelatin is of great value. In the right oblique diameter the normal
esophagus is easily seen throughout its course. It presents a slight
indentation at the level of the arch of the aorta and curves forward
behind the heart to enter the stomach. It is smooth in outline and
the opaque mass passes readily through it with a momentary pause
at the arch and a longer delay at the eardia.
ESOPHAGUS 153
PathoIoi:ical Esophagus. — The esophagus may be greatly dilated
in cardiospasm or benign stricture. In the former, a glass of hot
water may relax the spasm and allow part or all of the meal to enter
the stomach. There is no discoverable Irregularity In outline and
the shadow ends at the cardia in a smooth, funnel-shaped mass.
Dilatation of the esophagus occurring as a result of cardiospasm may
be so great that the margins of the esophagus overlap the lung field
on the right side. In these cases there may be a delay of the meal
above the cardia for hours or days. Malignant tumors of the cardia
of sufficient extent to cause obstruction can, as a rule, be recognized
by irregularities in outline of the barium mass in the lower esophagus
or stomach.
154 GASTRO-INfESTJNAL TRACT
Changes in Potdttoo. — The esophagus may be displaced by medias-
tinal tumors, aneurysms, eflfusion, fibrosis or diseases of the spine.
FiQ. 129. — Spasm of the middle third of the eaophagua suggesting malignant
disease.
Outline. — I/regularities in outline are most commonly due to
carcinoma which produces a persistent defect that is annular and
ragged or mottled. It is most commonly found in the lower half of
the esophagus. Scar tissue within the esophagus, ulceration or the
ingestion of corrosives results in multiple constrictions through its
rticulum of the esophagus.
Fm, 131. — Malignant diaeoae of the esophagus at the middle third.
156 G ASTRO-INTESTINAL TRACT
course. The contraction of extra-esophageal fibrous tissue may
result in constriction or sacculation.
DiTerticula. — Diverticula may be found anj'where in the course
of the esophagus, most commonl\' the upper and lower ends. They
appear as rounded pouches which overflow into the esophagus
through an ojwning at one side. It may be necessary to view the
patient from several angles to bring this opening into profile. They
remain partially filled after the remainder of the meal has passed on.
The liquid meal is to be preferred, as solid masses may not enter
the pocket. In rare cases the meal may be seen to enter a descending
bronchus as a result of broncho-esophageal fistula, usually due to
carcinoma.
STOMACH.
In the standing position the normal stomach hangs more or less
centrally in the abdomen with the lesser curvature above the level
Fig. 132.— Normal atomach.
of the crests of the ilia. The greater curvature lies at a variable
distance below the lesser. The form and position of the stomach
STOMACH 157
are determined by the architecture of the individual, the tone of
the gastric wall, the tension of the abdominal muscles, the pressure
of neighboring organs and the amount of the meal. Thin individuals
with a narrow costal arch have long central stomachs which hang
low in the pelvis. In broad, fat individuals with a wide costal arch
and in those of strong muscular development the stomach is high
FiO. 133. — Hyperpcriatalaia in an otherwige jioriiial stomach.
nnd transverse. In asthenic states it is low and, because of the lack
of tone, the meal settles in the lower pole, allowing the walls of the
cardia to collapse. In the prone position the stomach swings up
under the liver, lying more transversely. When empty, its walls
are in appo3iti<m except at the cardia which is dilated by the
gas bubble. As the stomach fills, the meal collects in a funnel-
shaped shadow below the gas bubble and gradually fills out the
158 G ASTRO-INTESTINAL TRACT
body and antrum. In atonic stomachs the meal passes rapidly to
the lower pole which enlarges out of proportion to the body.
The outline is smooth except for indentations due to peristalsis,
and a ^'ariable amount of irregularity on the greater curvature due
to pressure from the colon and spleen. Small transient indentations
occur on the margms of the antrum near the pylorus. They are
most common on the lesser curvature and are without significance.
Fig. 134. — Normal stomach deformed by pressure. Plate taken with patient prone.
Normal peristalsis begins at about the middle of the lesser curva-
ture with a shallow depression corresponding to it on the greater
curvature. The waves travel toward the pylorus without inter-
ruption. They become progressively deeper as they pass forward
and may bisect the barium mass at the upper limits of the antrum.
If the pylorus opens, the antrum then contracts as a whole, forcing
its contents Into the duodenum. If not, the waves move on to
STOMACH
159
the pylorus. Peristaltic waves occur at intervals of about twenty
seconds, varying with the patient and the meal used. Ordi-
narily no more than two or three waves are visible on a stomach
at the same time. They are increased in number and depth in the
prone position and may be strongly affected by mental states, being
increased by rage or inhibited by fear or nausea.
Fig. 135. — Tracing of normal stomach.
Pathological Stomach. — The stomach is increased in size when
dilatation has occurred as a result of pyloric obstruction or in con-
ditions where there is a general loss of muscle tone. It is diminished
in size (1) as a result of increased tone from strong muscular develop-
ment or as a reflex from disease of the duodenum, gall-bladder or
appendix, and (2) as a result of infiltration of the wall as seen in
ulcer, carcinoma, adhesions, syphilis and linitis plastica.
160
GASTRO-INTESTINAL TRACT
Changes in Position. — ^The stomach is displaced upward and to
the right where there are adhesions to the liver as a result of gall-
bladder disease or from the presence of a large accumulation of gas
in the splenic flexure or tumors in the left upper quadrant. In some
cases of appendiceal disease or adhesions the lower pole is swung
over toward the right iliac fossa. It may be displaced and rotated
upward on its long axis in case of adhesions to the anterior abdominal
wall. General gaseous distention of the intestine or fluid in the peri-
toneal cavity crowds the stomach upward against the liver. Displace-
Incisutxt
Fig. 136. — Tracing of stomach, showing a small ulcer on lesser curvature near the
pylorus. There is no visible crater.
ment downward (ptosis) is of no importance unless accompanied by a
six-hour residue or definite clinical evidence of abnormal function.
It may be shifted downward and to the left by enlargement of the
liver or tumors in the right upper quadrant. In pyloric obstruction
where dilatation has occurred the stomach shadow often appears
farther to the right than normal, but this is due to dilatation of the
antrum and is not a true displacement of the entire stomach.
Changes in Outline. — Changes in outline occur (1) as a result of
spasm. This may be localized as seen in the narrow contractions
STOMACH
161
near the pylorus or in the upper portion of the body of the stomach
where the greater curvature is drawn in toward the lesser over a
space of a few millimeters. These spasms may be reflex or be due
to the ttritation of a small ulcer or new growth at that level. Spasm
may also be extensive, obliterating the entire antrum, for example.
Here again it may be entirely reflex or be due to an associated lesion
pylorus
Fig. 137. — Tracing of stomach, showing penetrating ulcer of lesser curvature.
Patient prone.
of the stomach wall, which is often a difficult matter to decide.
Functional spasms usually are transitory so that repeated observa-
tions of the patient will frequently settle the matter. Antispas-
modics, such as belladonna or papaverin, may be employed, but
they are not conclusive because of the fact that at times they relax
the spasm associated with a lesion of the wall as readily as those
due to functional causes; so that the question of the presence or
11
162
G ASTRO-INTESTINAL TRACT
absence of a lesion must depend upon other evidence than that of
spasm. (2) As a result of gastric lesions. Under this heading
come the contracted, rigid, smooth lesser curvatures with absence
of peristalsis seen in ulcer and carcinoma; the presence of the
crater of a penetrating or perforating ulcer projecting from the gas-
tric outline on the lesser curvature or posterior wall; marked
Fig. 138. — Stomach showing penetrating ulcer of lesser curvature. Patient standing.
irregularities of carcinoma which vary according to the size, shape
and position of the tumor. These deformities are usually either
annular or due to the presence of irregular masses invading the
barium mixture, leaving ragged holes or markings suggesting finger
prints. We may also have the local contractions due to an ulcer
with its associated spasm; or the extensive defects of lues, suggest-
STOMACH
163
ing ulcer or carcinoma. Another deformity is that which occurs
as the result of contraction of scar tissue in the gastric wall, produc-
ing a so-called hour-glass stomach. This deformity is constant in
all positions. (3) Defects due to extragastric causes such as tumors
or pressure as, for example, the gall-bladder which produces a
rounded depression in the region of the pylorus, or pancreatic tumors
which cause irregularity of the greater or lesser curvature, are not
orus
Fig. 139. — Tracing of stomach, showing large ulcer on lebser curvature.
constant in all positions of the patient. An enlarged liver may cause
defect in the antrum by compressing it against the spine. In plates
taken in the prone position the pressure of the spine against the
abdominal wall commonly causes a break in the barium shadow
overlying it. Perigastric adhesions, particularly those about the
pyloric end of the stomach, may produce ragged defects suggesting
carcinoma but as a rule they are not constant in all positions.
(4) Any solid material in the stomach, such as food masses, foreign
164
GASTRO-INTESTINAL TRACT
bodies, hair balls, and the like, may cause defects in the barium
mass resembling malignant disease. However, these irregularities
shift with changes in position of the patient and there is no inter-
ference with peristalsis. Papillomata produce a defect similar to
that seen in large foreign bodies, but there is little displacement of
Fig. 140. — Tracing of stomach, showing large saddle ulcer.
the defect with change in position of the patient, peristalsis is not
interfered with, and they are constant on repeated examinations.
Changes in Peristalsis. — Increase in the depth or speed of waves
may be due to reflex or irritative causes or compensatory to a
diseased pylorus. In the early stages of pyloric obstruction the
waves are deep and vigorous. They may bisect the stomach, giving
STOMACH
165
it the appearance of a row of balls. The waves also start higher and
more are visible at the same time. Peristaltic waves are lost in
achylia, in the stage of decompensation of pyloric stenosis, in infil-
Fig. 141. — Tracing of stomach, showing ulcer at fundus and large ulcer of the lesser
curvature involving the pylorus.
tration of the gastric wall, and in nausea, fear or faintness. They
are irregular where they encounter areas of infiltration in the gastric
wall or strands of adhesions and possibly in some functional dis-
turbances. Peristalsis is reversed in carcinoma and tabes.
Fia. 142. — Penetrating ulcer of the lessor ci
e and ulcer of the duodenum.
Fig. 143. — Lnrse saddle ulcer cauaing hour-glasa Btomoch.
STOMACH
167
Incisura
Fig. 144. — Cancer high on the lesser curvature. Note the large area involved and the
absence of a definite projection.
Inci^WHt, Pylorus
Fig. 145. — Malignant disease of the lesser curvature.
168
G ASTRO-INTESTINAL TRACT
Motility. — The normal stomach empties in three to six hours,
depending upon the amount and composition of the meal, the tone
of the stomach and its functional activity. If it empties in less than
three hours, achylia, an incompetent pylorus, duodenal ulcer or
gall-bladder disease is suggested. If there is a definite residue
(one-quarter of the original meal) beyond six hours and the patient
has taken no food or drugs in the meantime, one must suspect a
Fig, 146. — Tracing of the stomach, showing annular constriction of the media due to
cancer.
lesion in the stomach, reflex irritation of the pylorus (duodenum,
gall-bladder, appendix) or obstruction in the intestine below. In
rare instances delay may be due to acute illness, marked ptosis or
the action of certain drugs.
Carcinoma. — ^Because of the insidious onset of carcinoma, the
patients do not appear for examination until there is a well-estab-
lished lesion so that few early ones are found. The characteristic
findings are defects in outline, absent, sluggish, irregular or reversed
STOMACH 169
peristalsis, esophageal or gastric stasis (or early gastric emptying)
and loss of flexibility of stamach wall. The appearances seen vary
considerably with the type of growth and with its location. Car-
cinoma of the cardia is often difficult to visualize. In these cases
it is helpful to watch the first mouthfuls of barium entering the
stomach. The jet will be irregular instead of smooth and there
may be delay at the cardia. There will also be rigidity and deformity
of the fundus which does not change on deep inspiration. For this
observation the patient should lie on his back.
Fig. 147. — Extensive malignant disease of the media and antrum.
Large growths in the body and antrum are usually characteristic.
There is a ragged annular defect which is constant at all times and
in all positions. If the tumor is palpable it will be found to coincide
with the defect. Peristalsis is absent in the region of the growth
and may be irregular, sluggish or reversed elsewhere. Stasis is usual.
The differentiation is from ulcer, lues, adhesions and extragastric
tumors. Typical ulcers and typical carcinoma are easily distin-
guishable but borderline cases are often hard to identify. Carcino-
G ASTRO-INTESTINAL TRACT
matous ulcers may, like benign ulcers, be limited to one wall and
show a rigid area of infiltration with the pocket of a crater project-
ing from it. However, the crater is usually larger in carcinoma and
Pn
Fio. 149.^ — ^Molignant disease oi the p
; end of the stomach.
STOMACH 171
peristalsis will be diminished or irregular, while in ulcer it is apt
to be increased. Stasis may occur in both cases but is perhaps
more frequent in ulcer. Spasms and incisurse are much more
common in ulcer.
In lues the deformity is generally more irregular and the patient
is not so sick as he would be if the lesion were carcinomatous. The
defect is out of proportion to the symptoms.
Fio, 150. — Malignant disease o( the cardia, with
The defects in adhesions and extragastric tumors are usually
not constant in all positions.
Diffuse infiltration of the stomach wall occurs in scirrhous car-
cinoma, lues and linitis plastica (which may be one form of lues).
The signs are those of infiltration — a smooth, rigid outline with
absence of peristalsis and usually a contracted, rapid emptying
stomach.
Pyloric C&icinoma.^ — In well-established cases there is a definite
funnel-shaped defect and if the pylorus is involved, the outlet
172
G ASTRO-INTESTINAL TRACT
becomes rigid and the stomach may empty rapidly. Dilatation of
the stomach is rarely present. In early carcinoma at the pylorus
there may be a funnel-shaped defect which is not due to the actual
lesion, probably as a result of associated spasm.
Ulcer. — In general, ulcers are more readily found the closer they
are to the pylorus. Stasis is of more significance the nearer the
lesion lies to the sphincter, i. e,y if there is pyloric deformity and no
Fig. 151. — Tracing of stomach, showing typical deformity of cap due to duodenal
ulcer.
residue, it is not due to ulceration but to some other condition, most
commonly carcinoma or adhesions. The recognition of an ulcer
depends upon the presence of a crater which can be filled with
barium and brought into profile and upon the presence of associated
spasm, increased peristalsis and usually stasis. In some cases the
crater and spasm are absent although careful observation may reveal
the presence of a small area of induration indicated by a break in
peristalsis, or there may be no discoverable abnormality aside from
Deformed cap
*
'Pylorus
Fig. 152. — Tracing, showing type of duodenal ulcer.
i - pari duodermm
Fig. 153. — Tracing, showing type of duodenal ulcer.
174
GASTRO-INTESTINAL TRACT
Fia. 154. — Tracing of stomach, showing the deep, vigorous peristalsis of duodenal
ulcer.
Fig. 155. — Tracing of the stomach, showing stoma and position of bismuth in small
bowel after gastro-enterostomy.
STOMACH 175
a residue. However, the latterare not usually surgical ulcers so that
failure to identify them is not of as great importance. Ulcers may
be divided into mucous, indurated, penetrating and perforating.
The mucous type is usually indicated by an incisure opposite
the lesion and may or may not have accompanying hyperperistalsis
and stasis. They are often missed.
Fig. 156. — Duodenal ulcer showing typical deformity.
In the indurated form, one sees an area of infiltration on the
lesser curvature which, if extensive, may cause considerable shorten-
ing of this curvature. ITiere will be a break in peristalsis at
the site of the lesion, hyperperistalsis and stasis. Spasm is not
usually present. When it does occur it takes the form of local
incisurse opposite the active edge. They may cause irregularity of
the greater curvature from contraction of scar tissue which extends
out around the body of the stomach. If they occur at the pylorus
there is failure of the antrum to contract and stasis is marked. The
176 GASTRO-INTESTINAL TRACT
first swallow of barium may collect in a small pool at the site of the
lesion due to the slight spasm which holds up its progress at first
but which disappears as the stomach fills.
Penetrating ulcers have all the signs of the indurated form and,
in addition, a mass of barium projecting from the rigid area which
corresponds in size and shape with the crater of the lesion. Although
they are often found on the posterior wall surgically, they usually
appear on the lesser curvature during the roentgen examination.
A lateral view may at times be necessary to adequately visualize
these lesions and should be a part of the routine examination which
as a matter of fact should include careful observation from every
angle in at least three positions — prone, supine or standing. These
protrusions must be differentiated from the duodenojejunal flexure
which is often projected just above the lesser curvature. Rotation
of the patient and deep inspiration will usually enable one to deter-
mine whether or not the mass is actually projecting from the gastric
shadow or is independent of it.
Perforating ulcer shows, in addition to the signs of a penetrating
ulcer, the presence of a gas bubble outside the stomach wall above
the mass in the crater.
Syphilis. — Its radiographic appearance is practically that of car-
cinoma except that mottling of the barium mass and stasis are
STOMACH 177
uncommon. The extent of the lesion is out of proportion to the
patient's symptoms. The age of the patient, the history and the
laboratory findings must be relied upon for corroborative evidence.
Appropriate treatment improves symptoms and may or may not
affect the roentgen picture.
Fia. 158. — Poatoperotive ulcer of the stomach (recurrent). The conatrictioo is
probably the result of the operation. The projection just below it is the crater of a
Linitis Plastica. — Linitis plastica is believed by some observers to
be a late stage of a luetic process. It is a fairly rare condition in
which the gastric wall is infiltrated by dense fibrous tissue which
178 GASTRO-INTESTINAL TRACT
contracts the stomach down to a small, rigid tube high up under
the liver, and through which the meal pours in a few minutes.
Foreign Bodies.— Hair balls and metal articles are occasionally
reported. Whether or not they are in the stomach may be deter-
mined by changing the position of the patient, by inflating the
stomach with air and the routine barium meal. Hair balls present
a characteristic appearance and the barium adheres to them, out-
lining their structure for some time after the meal has passed on.
Fia. 159. — Specific stomach.
Polypi.— Polypi of the gastric wall are comparatively rare. They
may be multiple and when demonstrable, appear as smooth, rounded
holes in the barium shadow which remain constant with changes
in the position of the patient. Peristaltic waves are not interfered
with. The condition must be differentiated from foreign materials
in the stomach, such as food masses and from extragastric tumors.
STOMACH 179
Their constancy is the best evidence. In the late stages, if extensive,
they may cause obstruction and be mistaken for mahgnancy.
The stomach after gastro-enterostomy is usually smaller and
higher. It empties rapidly, depending somewhat upon the size of
the stoma. There is little peristalsis visible. When seen it usually
passes over the entire lower part of the stomach to the pylorus,
forcing the barium mixture through unless it has been closed at
Fig. 160.^Dilatjxtion of the jejutium due to obfltruction from malignant disease.
the operation or by disease. Usuallj' the stoma can be demon-
strated and its size, position and contour noted. A loop of the
jejunum passing from behind the stomach shadow may lead to errors.
The observations to be made in the order of their importance are
emptyingtime; shape and position of thestoma; type of peristalsis;
size of stomach; whether or not food leaves through the pylorus,
and the appearance of the duodenal loop.
180 G ASTRO-INTESTINAL TRACT
DUODENUM.
The normal first part of the duodenum is a smooth, rounded,
triangular shadow, at times connected with the stomach by a thin
line of barium in the pyloric canal when the sphincter is open. Its
relation to stomach, gall-bladder and liver varies with the type and
position of the patient and the size and shape of the stomach and
liver. It has a peristalsis of its own and its filling and emptying
are controlled both by the pyloric sphincter and a constrictive action
of the junction of the first and second portions. The rapidity of
filling and emptying depends largely upon the character of the meal,
being much more rapid in the case of watery and carbohydrate
mixtures than when proteins are present. It may be considerably
enlarged in atonic individuals. Enlargement may also occur as a
result of adhesions or bands about the duodenum or ulcer of the
second portion. It may be contracted as a result of spasm, scar
tissue in the wall or adhesions about it. Defects in outline may be
due to pressure as, for example, smooth rounded depression due to
the gall-bladder and the small indentation on the inner margin due
to the bile duct. Scars and the spasm from ulcers cause irregular
deformities which produce the familiar coral-shaped shadow.
Rarely, as a result of perforation of such an ulcer, there may be a
pocket filled with barium between the duodenum and the liver or
colon. In some cases of perforation, free gas has been demonstrated
in the peritoneum above the liver. Adhesions usually produce slight
irregularities which are not constant. Spasm may produce exten-
sive changes in the shape of the duodenal bulb. It is usually reflex
from a lesion of the gall-bladder or the appendix. Very rapid empty-
ing where the meal shoots through the cap rapidly is seen in gastric,
pyloric and duodenal ulcer. Delayed emptying may be due to
obstruction in the duodenum or the intestine lower down, but usually
occurs reflexly as a result of gall-bladder or appendiceal disease.
Ulcer. — The signs of ulcer are deformities in outline, changes in
motility already mentioned, in addition to changes in gastric per-
istalsis and motility. The deformities in outline must be differen-
tiated from those due to spasm as a result of gall-bladder or appendix.
The deformity of ulcer is constant, whereas that due to spasm will
vary or disappear at different examinations. It is probable that a
part of the deformity seen in duodenal ulcer is due to local spasm
accompanying the lesion.
ILEUM 181
Adhesions. — Adhesions may produce slight irregularities in the
cap which are not constant with change in position of the patient
and there is usually fixation of the bulb. Constricting bands may
be found anywhere in the course of the duodenum. Evidence of
their presence is seen in dilatation and delay in motility, a common
form of which is the pendulum movement of masses of barium to
and fro in the second and third portions. The meal passes as a
flocculated mass through the second and third portions of the
duodenum with considerable rapidity so that they are less well
outlined than the first portion. The entire second and third por-
tions are well outlined only when there is a rapidly emptying
stomach or in cases of obstruction from adhesions or pancreatic
disease. Delay in any portion of the duodenum, pendulum move-
ments of the barium mass, visible and reverse peristalsis are sug-
gestive of spasm or obstruction. Ulcer is rare in this portion of the
duct although craters have been seen. The ampulla of Vater may
be dilated and appear as a definite spot of barium a few millimeters
in diameter along the descending portion. Diverticulse are occa-
sionally seen. They appear as rounded masses in close proximity
to the duodenum. Duodeno-gall-bladder fistulse have been dem-
onstrated.
JEJUNUM.
The jejunum normally appears as coils of fine, feathery flakes
of the meal due to the rapidity of its progress. It is never outlined
except in pathological conditions, the most common of which are
peritonitis, acute or chronic, and obstruction from bands or tumors.
A tumor sufficient to cause obstruction is nearly always palpable.
In peritonitis and obstruction the flocculent appearance is lost and
the coils are dilated. Gastrojejunal ulcers may occasionally be
made out at the site of gastro-enterostomy. They appear as per-
sistent irregularity in outline in the region of the stoma which are
sometimes rather difficult to visualize. Changes in gastric peris-
talsis and motility are the rule.
The roentgen evidences of gastrojejunal ulcer are gastric stasis,
increased gastric peristalsis, deformity of the stoma, and localized
tenderness.
ILEUM.
The normal ileum is seen as a coil of intestine containing dense masses
of barium lying low in the pelvis with a loop running up to terminate
182 G ASTRO-INTESTINAL TRACT
in the cecum. Palpation is unsatisfactory except iii its terminal
portion owing to its depth in the pelvis. It is smooth in outline
with transverse contractions which are continually changing. It
may begin to fill within an hour after the meal has reached the
stomach and is entirely emptied by eight to ten hours after eating.
The head of the meal should have passed through it at six hours.
Dilatation occurs as a result of obstruction from adhesions or bands.
Disease in the ileocecal region usually causes fixation and tender-
ness of the terminal ileum. A delay of over six hours in entering the
cecum or beyond ten hours for complete emptying of the ileum is
suggestive of disease in the ileocecal region, in which case there is
usually an associated fixation and tenderness of the terminal ileum.
APPENDIX.
The normal appendix fills and empties during the presence of
barium in its vicinity and should be visible if persistently and care-
fully looked for. It is freely movable and not tender and should
be empty when the cecum has emptied. It may present one or more
constrictions which are without significance. When it is or has
been the seat of disease, it either never fills or fills irregularly and
contains a residue after the cecum is empty. There may also be
tenderness and fixation of cecum and terminal ileum, stasis in the
ileum, stasis and hyperperistalsis in the stomach, spasm of the
duodenum, and at times stasis in the tip of the cecum after a meal
and after enema. An incompetent ileocecal valve is often associated
with such an appendix. Stones and foreign bodies are sometimes
demonstrated in appendices and may be mistaken for ureteral stones.
•
CECUM.
The normal cecum is smooth with transverse constrictions and
is freely movable vertically and laterally but varies greatly in size,
position and mobility. A filled terminal ileum is often necessary
to identify it positively. It may be dilated in cases of obstruction
in the distal colon or in spastic constipation. It may be contracted
by extensive adhesions about it. Changes in outline which are best
demonstrated by enema are due to adhesions, to carcinoma which
produces large, irregular defects, or to inflammatory masses as a
result of tuberculosis or a chronic appendix, which may produce large
defects resembling carcinoma, but careful observation will usually
show them to be outside the colon. The normal cecum is never
empty when barium is present in both ileum and ascending colon.
COLON.
The colon varies greatly in size and position from hour to hour
and in different mdividuals. The outline Is smooth and broken by
haustrel segmentations. The meal normally reaches the splenic
flexure in twelve to eighteen hours and the colon is entirely clear
in from twenty-four to seventy-two hours. Movements of the colon
are: (1) haustrel churning, that is, formation and reformation of
haustrel contractions and (2) antiperistalsis or anastalsis. A con-
traction ring exists at about one-third of the distance between the
1S4 G ASTRO-INTESTINAL TRACT
hepatic and splenic flexures and from this point antiperistaltic
Waves run slowly backward to the eecum. (3) Pendulum move-
ments where large masses of contents swing back and forth through
short distances; they are usually soon followed by (4) mass move-
ments where haustrel markings disappear and large masses of barium
are rapidly propelled through a considerable portion of the colon.
In outlinuig the colon by enema it takes a few minutes to complete
Fio. 162,— Hirsohprung's disease. Idiopathic dilatation of the colon.
the filling of the rectum and sigmoid, after which the fluid should run
over readily to the cecum. The pelvic loop of the sigmoid as it
distends should rise well out of the pelvis. If it is retained in the
pelvis, pelvic adhesions should be suspected.
Variations. — The position of the colon may be reversed so that
the ascending colon lies on the left side in cases of transposition
of viscera and it may not rotate completely during the process of
COLON 185
development, or the ascending colon may not be completely formed
so that the cecum lies in the region of the gall-bladder. The sig-
moid is subject to great variation in length and amount of omentum.
In cases of so-called redundant sigmoid it may be found anywhere
in the abdomen.
Changes in Size. — The colon may be dilated as a result of con-
genital malformations, so-called megacolon or Hirschprung*s dis-
ease, or as a result of obstruction from bands or tumors. The
caliber of the transverse and descending portions is uniformly
diminished in spastic constipation.
Changes in Position. — Changes in position are not important unless
they are permanent and fixed as, for example, sigmoid to the gall-
bladder region or the appendix region.
Changes in Outline. — In observations after barium meals the
colon will often show irregulai^ defects due to the presence of fecal
matter. They are not permanent and in case of doubt an opaque
enema will rule out pathology. Defects are seen best after enema.
The common ones are the annular, ragged, funnel-shaped deformi-
ties due to carcinoma and the constrictions caused by bands of
adhesions. Multiple small buds are sometimes seen along the course
of the colon, particularly in its descending portion, which represent
barium-filled diverticulse. They may be overlooked if the only
observation of the colon is twenty-four hours after the meal. The
barium-filled colon may overlap and obscure them so that where
their presence is suspected the patient should be seen after the colon
is empty, as small residues may remain in the diverticulse for several
days after the colon is clear as small, round, dense masses scattered
along the course of the colon. They are sometimes brought out by
an enema when a meal has failed to reveal their presence. It has
been noted that there is a complete absence of segmentation in
severe cases of colitis.
Changes in Motility. — Decreased emptying time occurs in achylia,
in conditions which produce a rigid, incompetent pylorus, and in
colitis. Increased emptying time or constipation appears usually
in three forms, spastic, atonic and rectal. The spastic type is the
result of increased tone of the transverse and descending colon
shown by a diminution in caliber and changes in haustrel segmen-
tations which are fewer in number and increased in width. The delay
in these cases may be extreme, barium remaining in the colon as
late as a week after the meal. The atonic type is characterized by
a large, flabby colon and is comparatively rare. It may be seen in
186 GASTRO-INTESTINAL TRACT
asthenic states where there is a general loss of tone. In the rectal
type there are large masses of barium high up in the rectum and
sigmoid occupying most of the pelvis. There is, of course, more or
less delay in eases of obstruction due to adhesions or malignancy.
BECTUAf.
The rectum appears as a smooth, S-shaped mass, occupying a
considerable portion of the pelvis. Defects in outline are due to
carcinoma which show the ragged, annular lesions typical of the
disease. I'lceration due to lues or tuberculosis may be evidenced
by more or less uifiltration of the wall which becomes rigid. The
diameter of the intestine is ihminished rather uniformly throughout
the area of the lesion. Pressure from inflammatory masses or tumor
in the pelvis may deform or displace the rectal shadow.
Fig. 163. — This plate showa a fairly typical group of gall
GALL-BLADDER.
Visualization of the gall-bladder is a matter of thorough, careful
technic and a certain amount of luck. The patient must suspend
respiration completely and the exposure and position of the central
GALL-BLADDER 187
ray may be just right for the particular patient. It is an exaggera-
tion to say that every gall-bladder which can be visualized is patho-
logical. However, it is undoubtedly true that a large proportion
of pathological gall-bladders can be visualized by careful work.
The shadow of the gall-bladder is rounded and sharply margined;
it varies greatly in size and position; it may be found anywhere
from the costal margin to the crest of the ilium. Gall-stones may
be recognized if they contain a sufficient amount of calcium salts,
which unfortunately is true in only 20 to 30 per cent, of the cases.
They appear as single or multiple shadows which may be the
typical faint ring, a dense homogeneous mass, or a mottled area
188 GASTRO-INTESTINAL TRACT
of density due to many small stones packed together. Great care
must be taken to resist the tendency to make positive diagnosis
of gall-stones from any faint shadows in the gall-bladder region.
Shadows of stones are often very faint but they at least should
show definite rings and lie entirely within the limits of the gall-
bladder before they can be diagnosed as stones. The proper
significance of the negative diagnosis should be realized and
insisted upon at all times. A negative diagnosis is of no positive
value, for stones may be present and cast no shadow. Further-
more, the patient's sjinptoms may be due more to associated
pathology in the gall-bladder than to the stones. Patients occa-
sionally refuse a needed operation because stones have not been
demonstrated by the roentgen method. They should be warned
BIBLIOGRAPHY
in the beginning that gall-stones may not show. When gall-bladder
disease is suspected, a routine gastro-inteatinal examination should
Fio. 106. — Calcified retroperitoneal ulands rcaemblins a gflll-stoae,
always be done to determine the incidence of adhesions and reflex
gastric disturbances such as spasm or stasis.
BIBLIOGRAPHY.
Cannon, W. B,; The mechanical facttita of digestion, New York, Longmans, 191!.
Williama, F. W. ; Roentgen rays in medicine and surgery, New York, 190.1.
Carman, R. D., and Miller, A.: Roentgen diagnosis of disease of the alimentary
canal, Philadelphia. 1917.
Holzknecht: G.: Recent advances in the Roentgen examination of the diRestivc
tract, Bcri. Win. Wchnscbr., 1911, No. 4; Arch. Roent. Ray, July, 1912.
Uoliknecht, G.: Roentgen diagnosis of the stomach. Arch. Roent. Ray, 1911,
liv, p. 206.
Holzknecht, G.: Det normale Magen nach Fonn, Lage und Groase, Mitt, a. d.
Lab. f. Rad. Diag., 1906, i, p. 72.
Holzknecht, G.: Die normal Peristaltik des Colon, Miinchen. mcd. Wchiischr.,
1909, Ivl, part 2, p. 2401; Arch. Roent. Ray, 1909-10. xiv, p. 273.
Holiknecht, G.: See p. 2.
Holsknecht, G., and Luger, A.: Zur Pathologic u. DJagnostik des GaGtrospasmua,
Mitt. a. d. Greni. der Med. u. Chir., 1913, xxvi, p. 669.
190 G ASTRO-INTESTINAL TRACT
Holzknecht, G., and Sgalitzer, M.: Papaverin zur roentgenologisch6n Differential-
diagnose zwischen Pylorospasmus und Pjdorusstenose, Miinchen. med. Wchnschr.,
1913. Ix. p. 1989.
Singer G., and Holzknecht, G.: Radiologische Anhaltspunkte zur Diagnose der
chronischen Appendizitis, Miinchen. med. Wchnschr., 1913, ii, p. 2659.
Hertz, A. F.: Constipation and allied disorders, London, 1909.
Hertz, A. F.: Chronic intestinal stasis, British Med. Jour., 1913, i, p. 817.
Hertz, A. F.: X-ray diagnosis of gastro-intestinal conditions, with special refer-
ence to appendicitis. Arch. Roent. Ray, 1914, xix, p. 249.
Case, J. T.: Stereoroentgenography of the alimentary canal, 4 parts, Troy, New
York, 1914-15.
Codman, E. A. : Diagnosis of diseases of the stomach and intestines by the ar-ray,
British Med. Surg. Jour., 1912, clxvi, p. 155.
Leonard, C. L.: Radiography of the stomach and intestines. Am. Jour. Roent.,
1913, i, p. 5.
Beclere (Paris): Les Rayons de Roentgen et le diagnostic des affections thora-
ciques, Paris.
Beclere: Rapport sur I'exploration radiologique dans les affections chirurgicales
do I'estomac et de I'intestin, Tr. Assn. Fran^aise de Chir, October, 1912.
Holzknecht, G.: Das normale roentgenologische Verhalten des Duodenum,
Zentralbl. f. Physiol, 1909, xxiii, p. 974.
Case, J. T.: Roentgenologic aspects of intestinal stasis, Med. Clinics, Chicago,
1915-16, i, p. 829.
Keith, A.: Interpretation of certain x-ray signs of intestinal stasis, Proc. Roy.
Soc. Med., Electrotherapeutic Section, 1915.
Hertz, A. F.: Ileocecal sphincter, Jour. Physiol., 1913-14, xlvii, p. 54.
Hertz, A. F., and NeWton, A.: Normal movements of the colon, Jour. Physiol.,
1913-14, xlvii, p. 57.
Barrett, G. M.: Linitis plastica, Jour. Am. Med. Assn., 1916, Ixvii, p. 276.
Cole, L. G.: The diagnosis of post-pyloric (duodenal) ulcer by means of serial
radiography, Lancet, 1914, R. 44, p. 1239.
Imboden, H. M.: Roentgen diagnosis of lesions of the vermiform appendix,
Am. Jour. Roent., 1915, ii, pp. 581-91.
Pfahler, G. E. : The Roentgen ray in the diagnosis of gall-stones and cholecystitis,
Joiu*. Am. Med. Assn., 1914, cxiii, pp. 304-6.
Barclay, A. E.: The stomach and esophagus, Macmillan Company, New York.
Caldwell, E. W.: The safe interpretation of roentgenograms of the gall-bladder
region. Am. Jour. Roent., 1915, ii, pp. 816-819.
Schwarz, G.: Roentgen shadow, with chronic gastritis, Wien. klin. Wchnschr.,
1916, xxix, p. 1554.
McMahon, F. B., and Russell, D. C: Chronic colitis and its roentgenologic
findings. Jour. Lab. and Clin. Med., ii, p. 328.
Basch, Seymour: Diverticulum of the duodenum, Am. Jour. Med. Sc, 1917,
clxxx, p. 833.
Geis: Acute tuberculosis of the stomach. Long Island Med. Jour., 1916, p. 84.
Sailer, J.: Linitis plastica. Am. Jour. Med. Sc, 1916, cli, p. 321.
Le Wald: Pyloric stenosis. Am. Jour. Obst., 1916, p. 1162.
Baetjer, F. H., and Friedenwald: Roentgen ray in gastric cancer, Johns Hopkins
Hosp. Bull., 1916, xxvii, p. 221.
Kerley, C. G., and Le Wald, L. T.: Digestive disorders in children. Jour. Am. Med.
Assn., 1916, Ixvii, p. 1569.
Homans, J.: Congenital transduodenal bands, British Med. Surg. Jour., 1916,
clxxv, p. 665.
White, F. W.: Syphilis of the stomach, British Med. Surg. Jour., 1917, clxxvi, p. 11.
Eusterman, G. B.: Syphilis of the stomach, Am. Jour. Med. Sc, 1917, cliii, p. 21.
Smithies, F.: Syphilis of the stomach. Am. Jour. Syph., 1917, i, p. 100.
Cadwallader, R.: Hirschprung's disease. Arch. Ped., 1916, xxxiii, p. 665.
Basch: Primary benign growths in the stomach, Tr. Am. Gast.-Intest. Assn.,
1915, xviii, p. 37.
Stewart, W. H.: The value of the roentgen examination in obstruction of the
esophagus, Arch, of Diag., 1913, vi, pp. 309-314.
Mills, R. Walter: "The Relation of Bodily Habitus to Visceral Form, Position,
Tonus and Motility." Ame?:, Jour, RqeRt,, ApiU, 1917.
CHAPTER IX.
GENITO-URINARY TRACT.
Preparation of the Patient. — ^The preliminary preparation of the
patient is a matter of opinion. If it is thought advisable, a vege-
table cathartic or oil should always be recommended. Mineral
salts and enemata are particularly to be avoided, the former because
of their tendency to fill the intestine with fluid and the latter because
they are seldom entirely expelled and air is usually introduced along
with them. Fluid or air in the intestine may entirely obscure the
kidneys and cause a confusing shadow. Excellent plates may often
be obtained with no preparation.
Technic. — Examinations should always include both kidneys, the
course of the ureters and the bladder. Suspicious shadows and most
positive findings should be checked up with a second examination
on another day. This work requires plates of the best technical
quality. Any evidence of respiration or other motion on a roent-
genogram should cause its rejection. Plates of the bladder area
should be made in both anteroposterior and postero-anterior posi-
tions. The ideal plate should be of moderate density, thin rather
than over-exposed and, as Leonard pointed out long ago, should
show clearly the last two ribs, the transverse processes of the
vertebrse and the margin of the psoas.
THE KIDNEYS.
The normal kidney is of the familiar form, in length approximately
equal to three vertebral bodies — the twelfth thoracic and first and
second lumbar — and of smooth, regular contour. The right lies
1 to 2 cm. lower than the left, and is less frequently seen. Visibility
depends upon the amount of fat around it. Kidneys are not particu-
larly movable in the normal individual. At the most they will
drop not over 1 cm. in the change from the supine to the standing
position. In young children they are lower than in adults. They
lie close to the margin of the psoas and are crossed by the shadows
of the last two ribs.
192 GENITO-URINARY TRACT
Changes in size of the kidneys are not diagnostic. The shadow
may have been distorted or enlarged b\' the size of patient or posi-
tion of tube; or a kidney may be hj-pertrophied as a result of disease
in its fellow, while on the other hand, the shadow may be of normal
size but the kidney be badly damaged.
Changes in shape are due to tumors, cysts, or infections and
anatomical variations. They may be found in the pelvis, they may
fuse across the vertebne, there may be only one kidney present
and an additional ureter may be attached to a kidne\'.
Fig. 107. — Position and outline of normal kidoeyB, with the patient standing.
Changes in density will be found extremely unreliable in diag-
nosis. While it is true that in rare cases tuberculosis of the kidney
may be suspected from the presence of a mottled shadow of increased
density, in general, mottling will be found to be due to intestinal
contents. The principal value of the roentgen examination lies
in the detection of stone. In good hands, probably 80 to 90 per
cent, of all kidney and ureteral (not bladder) stones will show.
Their visibility depends upon the technic, preparation and size of
patient and the composition and size of the stone. The first two
THE KIDNEYS 193
factors may be controlled by repeated examinations and in regard
to the last point, the order of visibility is as follows: phosphates
and cystine very dense, oxalates next and urates last, which have
little if any greater density than that of the soft tissues. Stones
which lie in large inflamed kidneys may be so obscured by the
general density about them that they are not visible. Furthermore,
the shadow of a stone may overlie a rib or transverse process and
be overlooked. It sometimes happens that a stone previously
invisible will receive a coating of thorium during pyelography and
become evident. They usually occur in the region of the pelvis
and lower calices. They may be round, although they are usually
irregular and sometimes assume the form of a cast of the pelvis in
which they are located. It must not be forgotten that a single
shadow may represent multiple stones. Discrete shadows scattered
through the periphery of the kidney shadow suggest a kidney dis-
GENITO-UBINARY TRACT
Fig. 169. — Large'braDching calculi in both kidneya.
FiQ. 170. — Unusual typos of kidney stones. The faceted BtoneH in the right suggest
gall-stones, but the position and wide curve of the catheter prove they are in the
kidney pelvis.
THE KIDNEYS 195
tended by back pressure with stones separated by fluid. Large
dendritic stones mean that the kidney has suffered severely.
Shadows which may be confused with stones are: (1) those due
to material in the bowel, fecal masses, fruit pits, enteroliths, opaque
salts, such as bismuth and barium (particularly residues in diver-
ticulse of the colon), Blaud's pills, salol capsules. The appendix
often lies in close relation to the right ureter and foreign bodies
or enteroliths within it may be mistaken for ureteral calculi. (2)
Gall-stones which can usually be differentiated by their structure
and shifting position with reference to the kidney area on plates
taken in the anteroposterior and postero-anterior diameters. (3)
Calcified glands which have a spongy appearance usually sufficient
to identify them. They occur along the course of the root of the
mesentery, in a line from the left kidney to the anterior right sacro-
iliac, and in the neighborhood of the iliac vessels, differentiated by
shifting position. (4) Tuberculous foci in the kidneys may calcify
and give shadows resembling those of stone. (5) Calcification in
carcinomatous masses in the pancreas or glands may be a rare cause
of confusion. (6) The tip of a transverse process may be so much
more dense than the rest of it that it may suggest a stone. (7)
Small areas of density in the spleen may overlie the upper portion
of the kidney. (8) Calcification in a blood clot or about a foreign
body may simulate a stone if it overlies the kidney. (9) Mention
must also be made of the shadows cast by fibromata, scars and even
dressings on the back which may be recorded on the plate as areas
of increased density. (10) Artefacts in plates due to thin spots in
the emulsion or small areas which are unequally developed may Be
a source of confusion.
Pyelography. — Pyelography is not a procedure to be undertaken
without due consideration and caution. Severe reactions cannot be
entirely avoided although a careful technic will do much to prevent
them. The most important single precaution to be observed is to
allow the solution to flow in very slowly under a slight gravity
pressure and to stop as soon as the patient complains of pain in
the kidney. Perhaps the best medium to use is a 15 per cent,
thorium solution, as it is cleaner, more fluid and less toxic than the
silver salts. •
The outline of the kidney pelvis as obtained by this method
varies greatly. The normal pelvis is somewhat lily-shaped with
the ureter corresponding to the stem. The pelvis presents a more
or less rounded border, into which the ureter blends on the inner
GEN 1 TO-URINARY TRACT
Pio. 171. — Large stone in the urinary bladder.
F[<i. 172. — Injected kidney pclvicea. The abnormal shape is due to anntumical
THE KIDNEYS 197
margin. Arising from its outer edge are a variable number of pro-
cesses projecting into the kidney substance (the major caiices) from
the tips of which arise small further projections called minor caiices,
(with cupping between). The pelvis may be more or less globular
or consist entirely of two or more branches. The errors which must
be guarded against are incomplete filling of the pelvis, usually due
to spasm of the ureter or pelvis brought on by too rapid disten-
tion, compression from neighboring organs, extrarenal tumors and
rotation of the kidney.
Fio. 173. — Hydronephrosia, demonstrated by injection with thorium.
Anomalies. — Aberrant positions of the kidneys and multiple
ureters are perhaps best brought out by this method which is more
accurate than plain roentgenology with or without opaque catheter.
Hydronephrosis. — Hydronephrosis shows all degrees of change
from blunting of the minor caiices to the formation of a large sac,
depending upon the site of the obstruction and the length of its
existence. With obstruction near the kidney the characteristic
early change is blunting of the minor caltces. With obstruction
near the bladder, on the other hand, dilatation of the pelvis and a
certain amount of rounding of its outline is the characteristic find-
198 GEN ITO-URI NARY TRACT
ing. Ill the later stages of the process both major and minor ealiues
may disappear and the thorium collect in a pool in the sae with
remains of the kidney. The discovery of a stone in the ureter is
confirmatory evidence of the process in the pelvis.
In inflammatory conditions the chief ehai^ is in the major
calices which are apt to have irregular, moth-eaten edges and to be
increased in length and width. In the later stages they may show
rounded dilatations at their extremities. The form of the pelvis
varies according to the amount of destruction of the kidney sub-
stance and the amount of distention of the pelvis, ■
Fia. 174. — ^The injected pelvis of an infected kidney.
Tuberculosis.— The characteristic change here is lengthening of
the major calices with pronounced bulbous dilatation at the tips
and the occurrence of rounded masses of thorium in the cortex,
representing cavities communicating with the pelvis. Stricture of
the ureter may prohibit the filling of the kidney pelvis.
Growths. — Extrarenal and parenchjTnal tumors may cause
deformities in the pelvis and calices which are similar in all respects.
It is not always possible m the presence of a distorted pelvis showing
an irregular loss of calices to say whether it is due to incomplete
URETERS 199
filling, extrarenal tumor or a growth in the cortex. The amount of
deformity produced in the pelvis depends upon the size and loca-
tion of the tumor. A very characteristic picture is the irregular
prolonged extension of one or more calices to a considerable distance
beyond the usual limits in a normal kidney. When the whole
kidney is involved, the pelvis may be reduced to a small mass with
irregular strands of thorium stretching out from it in a spider-like
pattern. Polycystic kidneys produce a somewhat similar picture
as well as enlargement of the kidney outline, but here the defects
in the pelvic shadow are not so irregular and their margins show the
rounded indentations of the neighboring cysts. Furthermore, the
process here is usually bilateral. The ureter is long and curves over
the enlarged lower pole of the kidney which may extend far enough
inward to throw the shadow of the ureter over the spine.
Papillomata. — Papillomata in the pelvis may produce round holes
in the thorium shadow. Stones in the pelvis or calices produce an
intensification of thorium shadow at that point.
URETERS.
The course and condition of the ureters may be very well out-
lined provided they can be kept filled with thorium during exposure.
This may be a somewhat difficult matter in the normal ureter if the
catheter is too small to occlude the lower end. Injection has these
advantages over the use of radiographic catheters: the ureter lies
in its true course and does not conform to that of the rather rigid
catheter, and changes in diameter and irregularities in outline are
well brought out. Apparent kinking due to the angulation in the
ureter produced at the tip of the catheter does not occur, whereas
true kinks are readily recognizable. Abnormalities are fairly
common, as has already been mentioned, consisting of multiple
ureters. Irregularities in outline are usually the result of infection,
most commonly of tuberculous origin which usually appears first
in the lower portions of its coiu'se. Dilatations may be true diver-
ticute which contain stones or the enlargement above an obstruc-
tion as a result of pressure from tumors or adhesions, the latter
being particularly common following infections of the vas deferens
in the male and pelvic cellulitis in the female.
The course of the ureter is downward across the transverse pro-
cesses of the lumbar vertebrae and sacro-iliac joints to the pelvis, then
curving inward and forward toward the bladder. There are four
Fio. 175.— SmaU 8(
Fin. 176.— A cnlcifipd mesenteric Bland augiieating a
202 GENITO-URINARY TRACT
points of narrowing where stones are prone to lodge: (1) the uretero-
pelvie junction, (2) where they cross the iliac vessels, (3) just out-
side the bladder, (4) the papilla within the bladder. Stones will
be foimd most commonly at (1) and (3). They are easily over-
looked when lodged near the iliac vessels, because their shadow is
projected on to that of the sacrum. They may be projected by
an increased tilt of the tube. The shadows of ureteral calculi are
oval or enlongated and are irregular in outline and density. Their
long axis lies in the direction of the course of the ureter. Shadows
which may be confused with them, in addition to those enumerated
before, are hypertrophic changes upon the vertebrae or pelvic bones,
arteriosclerosis of the pelvic arteries, calcified fibroids, calcified
ovaries, dermoid cysts and phleboliths. Phleboliths are small, cir-
cular or oval, sharply outlined calcifications usually multiple, which
occur in the pelvis in the region of the ischial tuberosities. They
are calcified thrombi on the distal side of the valves ia the plexus
of veins in the pelvic cellular tissue about the bladder and rectum.
They are very common and are constaotly being mistaken for
ureteral calculi. The distinguishing characteristics of a calculus are
that it is not so sharply outlined, that it is more apt to be oval
than round, and that it lies in the course of the ureter which passes
above and internal to the area where phleboliths lie. Furthermore,
phleboliths seldom occur singly.
In case of doubt the patient should be examined with an opaque
catheter in the ureter, preferably stereoscopically, in order to deter-
mine the presence or absence of obstruction as well as the relation
of the suspected shadow to the ureter.
BLADDER.
The outline of the partially filled bladder may be made out in
many pelvic plates but may be readily visualized by filling it with
air or dilute thorium. Stones in the bladder are occasionally not
visible because a large percentage of them are urates. Important
characteristics of bladder stones are that they are of fairly large
size, are oval, and lie with their long axis transversely in the pelvis.
The bladder may be outlined by thorium (u^ally 10 per cent.)
or by air. Large diverticula are usually well brought out by
moderate distention with thorium. They appear as knobs on either
side or behind the main shadow and may be larger than the bladder
itself. Trabeculation of the bladder wall is sometimes suggested
by irregularity of the outline, particularly along the sides. In some
y filling the bladder wilb
y means of the radiographic
204 GEN ITO-URI NARY TRACT
cases, particularly of tuberculosis, distention of the bladder may
cause the solution to run up a dilated, irregular ureter and visualize
it and the kidnej' pelvis when catheterization is impossible. In
children where it is difficult to catheterize the ureters, they may
sometimes be similarly filled by distention of the bladder in cases
of obstruction at the neck of the bladder due to congenital valves
in the region of the verumontauum. Congenital anomalies are
sometimes encountered, such as hour-glass bladder and patent
urachus which gives a thin line of solution extending upward toward
the umbilicus.
Fig. 181. — Papillomatoua tumor
Tumors may be extensive enough to produce defects in the
thorium shadow, although it is unusual. A better method for their
demonstration, which is equally useful in the case of stone, is to
inflate the bladder with air and secure stereoscopic plates. Hyper-
trophied prostates may be well outlined by inflating both the bladder
and the rectum with air.
REFERENCES 205
MALE GENITALS.
Small multiple calculi occur in the prostate and may be mistaken
for urinary concretions. The vas deferens and seminal vesicles,
when injected with silver solution, show a certain amount of dis-
tortion as a result of vesiculitis. This procedure will probably
never come into extensive use.
FEMALE GENITALS.
Calcification is often seen in fibroids in the form of round, irregu-
larly calcified masses, often multiple and occupying any portion
of the pelvis. In rare cases the ovaries may be calcified. They are
oval, flattened, spongy masses suggesting glands lying internal to
and above the ischium. They may be mistaken for ureteral stones.
Attempts have been made to inject the uterus and tubes with opaque
solution but the technic is still undeveloped.
REFERENCES.
Cabot, Hugh: Modern Urology, Philadelphia.
Beer, E. : Relative values of the roentgen rays and the cystoscope in the diagnosis
of vesical calculi, Jour. Am. Med. Assn., 1913, Ixi, p. 1376.
Braasch: Jour. Am. Med. Assn., October 9, 1915.
Cabot, Hugh: Jour. Am. Med. Assn., 1915, Ixv, p. 1233.
Holland: XVIIth International Congress of Medicine, London, 1913, Section 22,
Radiology, p. ii, pp. 87-100.
Keen, Pfahler and Ellis: Jour. Am. Med. Assn., 1914, viii, p. 1047.
Dodd, W. J.: Roentgenology of the urinary tract, Modern Urology, Philadelphia.
Braasch, W. I.: Pyelography, W. B. Saunders Company, Philadelphia, 1915.
Hyman, A., and Jaches, L.: The roentgenographic diagnosis of prostatic enlarge-
ment by means of air inflation of the bladder, Surg., Gynec. and Obst., 1914, xix,
p. 407.
INDEX.
Abnormal fusing malformations, 32
Abnormality of heart, congenital, 124
in outline of verteorae, 36
Abscess, alveolar, 91
bones, 52
of lung, 141
mediastinal, 128
perivertebral, 128
subdiaphragmatic, 131
Absence of long bones, partial or com-
plete, 30
Achondroplasia, 78
Acromegaly, 75
Actinomycosis of the bone, 62
of limg, 149
Adhesions, duodenal, 181
perigastric, 163
of pleiu-a, 135
Alveolar abscess, 91
Aneurysm, 125
Anomalies of bones, 29
of dentition, 90
of genito-urinary tract, congenital,
197
of kidney, 197
of ribs, 28
Anthracosis, 149
Antispasmodics, gastric, 161
Aorta, diffuse dilatation of, 125
Aortic disease, 124
Aortitis, specific, 125
Appendix, normal, 182
pathological, 182
Arch, dilatation of, 124
Arthritis, atrophic, 99
gonorrheal, 101
hypertrophic, 97
pyogenic, 100
villous, 104
Atomic colon, 185
Atrophic arthritis, 99
Auricular fibrillation, 124
B
Barium meal for examination of gastro-
intestinal tract, 152
Bladder, diverticulae of, 202
outline of, 202
stones, characteristics of, 202
Bone abscess, non-virulent, 52
virulent or fulminating type,
52
blisters in syphilis, 58
cysts, 63
changes in density of, 50
in outline of, 50
in phosphorus poisoning, 62
diffuse density of, 50
diminution in size of, 50
disease of, 50
gumma of, destruction due to, 59
feprosy in, 62
normal, 50
oidiomycosis of, 62
signs of pathological process in, 34
spongy, areas of increased density
in, 23
texture of, 50
spotted density of, 50
syphihs of, 57, 59, 104
congenital, 59
tuberculosis of, 101
tumors of, rarer, 71
tjrphoid in, 61
Bones, anomalies of, 29
detached, 29
diminution in size of, 50
fusion of, 30
margins of, roughening of, 20
size of, increase in, 50
supernumerary, 30
Brain tumor, 84
Bronchial glands, calcification of, 21
Bronchiectasis, 142
Bronchitis, 141
Bronchopneumonia, 140
Bronchostenosis, 143
Bureae, calcification of, 109
Calcification of bronchial glands 21
of bursa), 109
of costal cartilage, 20
of larynx, 20
208
INDEX
Calcification of mesenteric glands, 21
of ovaries, 205
of pineal glands, 86
syphilitic, 58
Calcifications, 20
Carcinoma of cardia, 168
metastatic, 70
of pylorus, 171
of skull, 69
of spine, 69
of stomach, characteristic findings
in, 70
Carcinomatous ulcers of stomach, 170
Cardia, carcinoma of, 168
Caries sicca, 56
Carpal centers, time of appearance of,
32
Cecum, change in outhne of, 185
normal, 182
Chalicosis, 149
Charcot joints, 97
Chest, glands of, enlargement of. 111
technic in examination of, 120
time of exposure for examination
of, 121
tumors of, 112
Chondrodystrophy fetalis, 78
CoUes' fracture, 39
Colon, atonic, 185
change in motihty of, 185
in outUne of, 185
in position of, 185
in size of, 185
examination of, barum enema in,
184
normal, 183
spastic, 185
method of examination by barium
enema, 184
Congenital abnormahty of heart, 124
anomahes of genito-urinary tract,
197
dislocations of hip, 48
elevation of scapula, 29
syphilis of bone, 59
Costal cartilage, calcification of, 20
Cyst of lung, echinococcus, 147
Cysts, bone, 63
dermoid, 114
Diaphragm, changes in mobihty of, 129
in outhne of, 129
in position of, 130
normal, 129
Dilatation of ileum, 182
Dislocations, before and after reduc-
tion, 49
of first cervical vertebra, 45
of hip, congenital, 48
Displacement of sacro-iliac joint, 47
of semilunar cartilage in carpus, 47
of upper cervical vertebrae, 45
Diverticulae of bladder, 202
Duodenal adhesions, 181
diverticulae, 181
scars, 180
spasm, 180
ulcer, 180
Duodenum, defects in outhne of, 180
irregularities in outline of, 180
normal, 180
Dysplasia, periosteal, 78
Echinococcus cyst of lung, 147
Elevation of scapula, congenital, 29
Emphysema, 111
Empyema, 132
Encapsulated fluid, 133
Enchondromata, 62
Epiphyseal ossification, 31
separations, 47
Epiphyses, tuberculosis of, 53
Esophagus, change in position of, 154
dilatation of, 128
diverticulae in, 156
examination of, 152
pathological, 153
Extragastric defects, 163
Extrarenal tumors, 198
Dactylitis (spina ventosa), 56
(syphihtic), 57
Defective plates, errors due to, 25
Defects in outUne of rectum, 186
Delayed union, 32
Dentition, anomaUes of, 90
table (Thoma), 90
Dermoid cysts, 114
Failure of union, 32
Fibromata of skin, 24
Fluoroscopic examination of heart and
gi;eat vessels, 118
of gastro-intestinal tract, 151
of lung, 131
Foreign bodies in limg, 142
examination for, 142
in stomach* 173
Fracture, Colles', 39
lines, obhteration of, 34
Pott's, 42
Fractures, classification of, 37
hnes mistaken for (nutrient artery),
19
INDEX
209
Fractures of skull, 35
of teeth, importance of roentgen
examination in, 91
Fragilitas ossium, 78
Functional spasms (gastric), 161
Fusion of bones, 30 •
G
Gall-bladder, examination of, posi-
tion for, 186
pathology of, 188
position for examination of, 186
Gall-stones, detection of, 187
Gangrene of lung, 143
Gas in intestinal tract, 25
Gastric antispasmodics, 161
outline, significance of irregulari-
ties of, 162
peristalsis, changes in, 164
normal, 158
spasm, 160
lilcer, 172
wall, polypi of, 178
Gastro-intestinal tract, examination of,
method of, 151
position for, 151
fluoroscopic examination of,
151
syphiUs of, radiographic ap-
pearance of, 176
ulcers of, penetrating, 176
perforating, 176
Gastrojejimal ulcers, 181
Genito-urinary tract, anomalies of,
congenital, 197
examination of, preparation
of patient for, 191
phlebohths in, 202
technic in elimination of, 191
tumors in, method of demon-
strating, 204
Glands of chest, enlargement of, 111
Gonorrheal arthritis, 101
Gout, 97
Great vessels, examination of, 114
normal, 123
Gumma of bone, destruction due to, 59
Heart, abnormality of, congenital, 124
block, 124
dilatation of, 124
examination of, 114
fluoroscopic examination of, 118
measurements of normal (Claytor
and Merrill), 126
normal, 123
14
Heart, normal, measurements of (Clay-
tor and Merrill), 126
valves, diseases of, 124
Hemophilia, 106
Hemorrhages, subdiu-al, 85
Hip, dislocations of, congenital, 48
fractures, failure of union in, 45
Hydrocephalus, 83
Hydronephrosis, 197
Hypernephroma, 72
Hypertrophic arthritis, 97
Hypertrophy of prostate, 204
Ileum, dilatation of, 182
normal, 181
Impacted teeth, 90
Intestinal tract, gas in, 25
Jaw, osteomyeUtis of, phosphorus
poisoning and, 95
Jejunum, normal, 181
pathological, 183
Joint lesions, symmetrical, 60
unilateral, 60
sacro-iliac, displacement of, 47
Joints, Charcot, 97
tuberculosis of, 53
Juxta-epiphyseal lesion in syphilis, 60
Kidney, anomalies of, 197
change in density of, 192
in shape of, 192
in size of, 192
normal, 191
pelvis, outline of, 195
of papillomata in, 199
tuberculosis of, 198
Kidneys, polycystic, 199
Larynx, calcification of, 20
Leprosy in bone, 62
Linitis plastica, 177
Lipomata, 114
Lobar pneimionia, 139
Limibar cmrvre, exaggerated, 28
Lumbosacral junction, articulation at,
variations in, 28
Lung, abscess of, 141
fields, examination of position for,
131
210
INDEX
Lung fields, position for examination
of, 131
fluoroscopic examination of, 131
foreign bodies in, 142
examination for, 142
gangrene of, 143
metastatic malignancy of, 145
normal, 132
pathological changes in, 132
primary maUgnancy of, 144
syphilis of, 143
tuberculosis of, 135
miliary of, 138
M
Mastoids, 90
Mediastinal abscess, 128
masses, 111
tiunors, 125
Mesenteric glands, calcification of, 21
Metastatic carcinoma, 70
Mucoceles, 89
Multiple cartilaginous exostoses, 63
Myeloma, 72
Myxoma, 73
r?
N
Nutrient artery, 19
Odontoma, 95
Oidiomycosis of bone, 62
Orthodiagraphy, 116
Os calcis, separation and delayed union
in epiphysis of, 48
Ossification center of tibial tubercle,
delayed union of, 48
Osteitis deformans, 65
fibrosa, 63
Osteochondritis deformans (Perthe's
disease), 106
desiccans, 106
Osteogenesis imperfecta, 78
Osteomalacia, 79
Osteomata, 62
Osteomyehtis, characteristics of, 51
of jaw, aue to phosphorus poison-
ing, 95
Osteopsathjn-osis, 78
Osteosarcomata, 67
Ovaries, calcification of, 205
Oxycephalus, 84
Facet's disease (osteitis deformans),
65
Papillomata in kidney pelvis, 199
Parenchymal tumors, 198
Pericarditis, adherent, 124
with effusion, 124
Perigastric adhesions, 163
Periosteal dysplasia, 78
sarcoma, 68
Periostitis, syphihtic, 57
Peristalsis, changes in gastric, 164
normal gastric, 158
Perivertebral abscess, 128
Perthe's disease, 106
PhleboUths, 22
in genito-urinary tract, 202
Phosphorus poisoning, change of bone
in, 62
osteomyehtis of jaw and, 95
Pineal glands, calcification of, 86
Plates of symmetrical parts, importance
of, 48
Pleura, adhesions of, 135
thickening of, 132
Pleural effusion, 130, 132
Pneumoconiosis, 149
Pnemnonia, lobar, 139
unresolved, 141
Pneumothorax, 132, 133
Poisoning, phosphorus, change of bone
in, 62
osteomyehtis of jaw and, 95
Polycystic kidneys, 199
Polypi, 89
of gastric wall, 178
Pott's fracture, 42
Prostate, 205
Prostatic hypertrophy, 204
Pulmonary tuberculosis, 135
Pulp stones, 91
Pyelography, 195
Pylorus, carcinoma of, 171
Pyogenic arthritis, 100
Pyorrhea, 91
R
Rectum, defects in outline of, 186
normal, 186
ulceration of, 186
Renal calculus, detection of, 192
Ribs, anomahes of, 28
Rickets, 75
Roentgen anatomy, importance of, 33
Round-celled sarcoma, 67
s
Sacro-iliac joint, displacement of, 47
Sahvary calcuh, 95
Sarcoma, periosteal, 68
round or spindle-celled (medul-
lary), 67
INDEX
211
Scapula, elevation of, congenital, 29
Scars, duodenal, 180
Scorbutus, 76
differential diagnosis in, 77
Sella turcica, 85
faulty technic 'in securing
views of, 86
importance of stereoscopic
views in examination of, 85
Semilunar cartilage, displacement of, 47
Seminal vesicles, 205
Shadows due to metallic salts, 25
in genito-urinary tract other than
renal calculi, 195, 198
Sinuses, frontal, 86
position for examination of, 86
variations of, 89
Skin, fibromata of, 24
warts of, 24
Skull, carcinoma of, 69
fractures of, 37
Spasm, duodenal, 180
gastric, 160
Spindle-celled sarcoma, 67
Spine, carcinoma of, 69
syphihs of, hypertrophic changes
in, 61
tuberculosis of, 55
Stomach after gastro-enterostomy, 179
carcinoma of, characteristic find-
ings in, 70
change in outhne of, 160
in position of, 160
examination of, position for, 156
foreign bodies in, 178
motility of, 168
normal, 156
pathological, 159
ulcers of, 169
carcinomatous, 169
Subdiaphragmatic abscess, 131
Subdural hemorrhages, 85
Supernumerary bones, 30
Synovitis, 109
Syphihs of bone, 57, 59, 104
congenital, 59
. of gastro-intestinal tract, (radio-
graphic appearance), 176
juxta-epiphyseal lesion in, 60
of limg, 147
of spine,hypertrophic changes in,61
Syphihtic calcification, 58
dactyhtis, 57
periostitis, 57
Table of dentition (Thoma), 90
of ossification centers, 30
Tabulation of findings in common bone
lesions for differential diagnosis, 80 ' Warts of skin, 24
Teeth, 90
fractures of, importance of roent-
gen examination in, 91
impacted, 90
imerupted, 90
Tele-roentgenology, 118
Teratomata, 112
Thickening of pleura, 132
Thoracic wall, pathological processes
in. 111
Thymus, enlarged, 111
normal. 111
Thyroid, interthoracic. 111
normal. 111
Tibial tubercle, separation of, 48
Tuberculosis of bone, 101
of joints and epiphyses, 53
of kidney, 198
of lungs, 135, 138
miUary, 138
of spine, 55
Tubes (female genitals), 205
Tumors of bone, rarer, 71
brain, 84
of chest, 112
extrarenal, 198
mediastinal, 112
parenchymal, 198
Typhoid in bone, 61
Ulcer, duodenal, 180
gastric, 172
Ulcers of gastro-intestinal tract, pene-
trating, 176
perforating, 176
gastrojejunal, 181
of stomach, 169
carcinomatous, 169
Unerupted teeth, 90
Unresolved pneumonia, 141
Ureteral calculus, distinguishing char-
acteristics of, 202
Ureters, course of, 199
dilatation of, 199
irregularity in outhne of, 199
Uterus, 205
Vas deferens, 205
Vertebra, first cervical, dislocations of,
45
Vertebrae, upper cervical, displacement
of, 45
Vertebral bodies, extra, 26
Villous arthritis, 104
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