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VALUE OF F'LUOROSCOPY IN THE DIAGNOSIS OFABDOMINAL CONDITIONS

L. J. CARTER, B.A., M.D., C.M., F.A.C.P.

Brandon, Man.

6 6 LUOROSCOPY" is the method of makingstudies of opaque objects by passing

through them the x-rays and observing the imageproduced on a fluorescent screen. Non-opaqueobjects, such as hollow organs of the gastro-intestinal type, may be examined by filling themwith material which is opaque to the x-rays.The fluoroscopic method has met with prejudice

in many quarters, owing to the ill effects of x-rayexposure in the early days, when the need ofadequate protection was not understood. Withthe protection afforded to-day there should be nodanger to either patient or operator. The patientis exposed to amounts of x-ray that can exerciseno harmful effect A current of two to five milli-amperes with a voltage correspondng to a threeto six-inch spark-gap is all that is required witheven the heaviest patient There is no dangerto the operator, with the fluorescent screen cov-ered with lead glass on the operator's side, if heis careful to keep the size of diaphragm so regu-lated as to keep the emitted rays well within theborders of the lead glass. Manipulation of thepart being examined behind the screen is donewith a wooden spoon, or with the hand of theoperator, protected by lead-rubber gloves. Al-though the work is done in a dark room, there isno reason why adequate ventilation cannot alwaysbe obtained.

Fluoroscopy being purely a subjective method,the value of the findings depends entirely uponlthe personal equation. Upon the ability of theoperator to interpret correctly the images seenupon the fluorescent screen, and upon the carewith which he makes the examination, dependsthe value of the findings. This is not the field forthe x-ray technician. The sole function of thex-ray technician is the miaking of good x-rayplates. The interpretation of those plates, as wellas the interpretation of fluoroscopic images, shouldbe made only by a physician. That physician

Read at the Manitoba Medical Association, November19th, 1920.

must not only be well versed in the anatomy,physiology and pathology of the organs underexamination, but must also have special trainingin the x-ray appearances of normal and diseasedtissues and organs.The committed which allotted the subject of

this paper has given happy expression to the rela-tionship between "fluoroscopy" and "diagnosis`by entitling the paper, " The Value of Fluoroscopyin Diagnosis." There is no such thing as " fluoro-scopic diagnosis." There is no such thing as anx-ray diagnosis, except possibly in the fracture ofbones and the detection of metallic foreign bodies.Fluoroscopy is one of the factors contributing to-the building up of the diagnosis. Diagnosis is aconclusion reached after correlating the informa-tion obtained by all the available clinical methods.Careful history taking, painstaking physical ex-amination, accurate laboratory reports, are allpart of the clinical process. Co-ordinated withthese, as a fourth clinical procedure, stands thex-ray examination, including that most importantphase, fluoroscopy. The clinical picture shouldbe arrived at by correlating the information ob-tained from each of these methods and buildingall up into a complete diagnostic entity. If thisbe true, and we hope to be able to show that itis, then the clinician who arrives at a diagnosiswithout using fluoroscopy where fluoroscopy isavailable and indicated, is not only rendering hisdiagnosis less complete and exact, but is doing aninjustice to his patient.What information can fluoroscopy give us in the

examination of the abdomen? We shall answerthat question, not by attempting to show thesuperiority of fluoroscopy over other clinicalmethods, but by showing the contribution whichit can make toward the sum total of clinical in-formation obtainable in any given case.Under the heading "abdominal conditions" will

be comprised conditions obtaining in the gastro-intestinal tract, the gall bladder, the liver andspleen, the kidneys, ureters, bladder, and in the

CANADIAN MEDICAL ASSOCIATION MhEETING, HALIFAX, JULY 5th-8th, 1921

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female pelvic organs. With the exception of thegastro intestinal tract, including the gall bladder,fluoroscopy is not a primary diagnostic procedure.The liver and spleen throw shadows on the

screen, from which we may determine their posi-tion and size. Being placed well under the ribmargins they do not normally lend themselves topalpation. The kidneys occasionally may be out-lined in very thin subjects, and up and d'own ex-cursions synchronous with the movements of thediaphragm may be noted. The urinary bladderis not visible except when markedly distended wellabove the pubic crest, or when it is filled with anopaque substance such as is used in pyelography.Considerable information regarding the uretersand kidneys may be obtained by watching thepassage of an x-ray ureteral catheter under thefluorescent screen. Obstructions, such as calculior strictures, will be noted by the catheter stop-ping and bending. The excursions of the kidneysmay be noted by watching the catheter tips. Ifthese movements coincide with the excursions ofthe liver, kidney adhesions may be ruled out.This would negative almost any inflammatorykidney process, as such process is usually accom-panied by peri-renal adhesions. Standing thepatient on the feet will show bending of the cathe-ter if the kidney drops.The female pelvic organs are not visualized by

ordinary fluoroscopic methods.While it is true then that fluoroscopy has but a

limited application in the study of the organs justmentioned, yet note must be made of a newfluoroscopic method which promises to greatlyincrease the value of fluoroscopy in the study ofobscure abdominal conditions. This consists inthe distending of the peritoneal cavity with oxy-gen or CO.2 It throws into relief all the abdo-minal organs and makes it possible to visualizethem, just as the air in the lungs makes the heartand aorta outlines so outstanding.That part of the abdominal field which best

lends itself to study by fluoroscopic methods isthe gastro intestinal tract, with the closely alliedorgan, the gall bladder. As the result of somefive years' work, in which the number of the fluoro-scopic studies of the gastro intestinal tract hasrun up into the tens of thousands, the writer hasno hesitation in stating in the most emphatic waythat examination of the gastro intestinal tract bythe fluoroscope is absolutely indispensable. Andthis is not alone the writer's opinion, but it is theexpressed conviction of all who have had muchexperience with this diagnostic method.

Further, this fluoroscopic study of the aliment-ary canal, which should not be restricted to thosepatients who have abdominal symptoms, shouldbe used in every chronic condition which mightbe the result of toxic absorption from some focusof infection. There are no foci more potent inthe causation of general toxwemia than those foundin a chronically diseased gall bladder or appendix,or in a banded colon. Only recently a patientwith a clinical diagnosis of pernicious anemia, andwithout one gastric symptom or physical sign ofabdominal disease, was found to have a large in-operable carcinoma of the stomach. The correctdiagnosis would have been difficult, if not improb-able, without the x-ray examination. Chronicheadaches and backaches, so-called rheumatism,loss of strength and weight, cannot be correctlydiagnosed until after x-ray examination of thedigestive tract for possible foci of toxic absorption.Another thing that should be stated with all the

emphasis possible is that every x-ray study of thegastro intestinal tract should extend itself to everypart of that tract. For example, there could beno greater mistake than for a physician to send apatient complaining of stomach symptoms to thex-ray man for the examination of the "stomach"'only. In the great majority of cases stomachsymptoms are not dependent upon stomachlesions, but upon disease in other organs, chieflythe gall bladder and appendix. Every gastrointestinal examination should follow the opaquemeal from the cesophagus to the rectum, andshould be completed by an examination of thecolon by the opaque enema. This will take aboutfour days. But nothing short of the expenditureof this amount of time and energy and money willfurnish complete information, and incomplete in-formation with resulting mistakes in diagnosis maycost the physician and the patient more than adozen complete examinations.The technique, as practised in our clinic, for the

confplete examination, and the information lookedfor at each stage, are about as follows:At 9.00 a.m. the patient reports without break-

fast. If there i1 any suspicion of urinary tract orspinal disease, radiographs are made. If there isany suspicion of gall bladder disease, plates shouldbe made of the gall bladder region. A fluoroscopicexamination is made of the chest. The opaquemleal is given. The cesophagus and then thestomach are inspected during its ingestion. Irre-gularity of the cesophagus and cardiospasm arelooked for. The manner in which the stomachfills is often very instructive. In the atonic

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stomach the meal will sink to the bottom at onceand cause such a stomach to sag like a rubber bag.In the normal stomach the column of barium mix-ture will be held up by the tonic contraction of themusculature and all will fill gradually and evenly.In the stomach which is spastic and irritated fromsome disease condition, either intrinsic or referred,the musculature will be seen to contract in seg-ments so that when the first half-glass is swal-lowed it will look much like a rope tied into a suc-cession of knots. It is therefore in order to lookfor the causes, intrinsic or extrinsic, producingthis irritation. When the two glasses constitut-ing the opaque meal are taken, the stomach is in-spected for the niche, and the incisura caused byulcer, the accessory pocket caused by an ulcerthat has perforated and the defect of filling causedby malignancy. The size, position, shape, toneof the stomach, and the character of the peristalticwaves are noted. Palpation is done to determinemobility, and to detect any tender area. Inabout 90 per cent. of gastric ulcers there should besuggestive evidence, which when taken with theclinical and laboratory findings would lead to thediagnosis. In the great majority of such casesthe x-ray evidence is conclusive. Posterior gas-tric ulcers usually cannot be visualized, but maybe inferred from the combination of increasedperistalsis, localized tender area, with visible dila-tation of the second part of the duodenum causedby constriction or spasticity of the third part, asit passes behind the stomach at the ulcer site.

Filling defects of the stomach are nearly alwaysdue to carcinoma. Unfortunately there is littledifficulty in recognizing them, for the carcinomaof the stomach does not usually give rise to seriousgastric symptoms until it is advanced sufficientlyto show a very obvious filling defect. The ex-ceptions are the carcinomata at the pylorus.They may cause symptoms comparatively early,so that when there is suspicion of the slightestirregularity of outline or peristaltic wave at thepylorus, a number of plates should be taken formore intensive study. Any carcinoma capable ofbeing recognized by the surgeon at operation,should be capable of demonstration by the x-ray.Rarely filling defects may be due to inflammatoryadhesions from disease of adjacent viscera.A word may be said about the ptosed stomach.

It is one of the triumphs of x-ray that it has de-monstrated the fallacy of the old text-book pic-tures of the stomach. There is no set shape orposition for this organ. An individual's stomachadapts itself to the body profile. Our stomachs

are capable of as many physiological variations asare the noses on our faces. The stout individualhas a transverse stomach well above the umbilicus;the thin individual has a vertical stomach reach-ing normally even to four or five inches below theumbilicus. Between these extremes are all gra-dations. The only tests of the physiological posi-tion of the stomach are its ability to functionproperly, and its freedom from the production ofreflex nerve symptoms by dragging on its nervesupply. The test for the former is its ability toempty the meal on time; the test for the latter,when it is suspected, is the therapeutic one,support.

Passing from the stomach we next examine theduodenum. The first part, the duodenal cap, isthe usual site of ulcer. This is recognized by apermanent indentation in one of its borders, whichis tender to the touch. A duodenal cap that caneven once be filled well and appear perfectlyregular, cannot be the site of active ulcer. Duo-denal ulcer should be recognized fluoroscopicallyin nearly every case. Duodenal deformity may,however, result from other cauises. There maybe the scarring caused by the fibrous contractionof a healed ulcer. In such case pain on pressureis absent. The deformity may be due to adhe-sions resulting from old ulcer or from inflammatoryconditions originating in the gall bladder or colon.In either case there may be uniform deformity ofthe whole cap, such as a flattening horizontally orvertically. There will usually be fixation in anabnormal position either upward or laterally.Tenderness in the adjoining viscera with absenceof tenderness over the duodenum itself will besuggestive. Familiarity with the appearance ofthe duodenum leads one almost intuitively todifferentiate between the acute indentations ofulcer, and the flattened drawn-out appearance ofadhesions. Here again the x-ray findings mustbe linked up with the results of the laboratorytests and the study of the clinical history.Whenever a pathological condition of any kind

is even suspected in stomach or duodenum, radio-graphs should be made for the purpose of moreintensive study and of permanent record. Radio-graphs, without fluoroscopy, are valueless, unlessa large enough number are taken, to demonstratethat an apparent deformity is not merely a phaseof peristaltic activity.The demonstration of gall bladder pathology

by the x-ray has been a subject of much debate.Gall stones, owing to the absence of lime salts intheir formation, will show on the radiograph in

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only from 10 per cent. to 50 per cent. of the caseswhere they are present. Some claim to be ableto show on the plate the shadow of a diseased gallbladder, whereas it is claimed a normal gall blad-der will not show. In our attempts to demon-strate gall bladder conditions we rely more uponthe fluoroscopic examinations than upon theplates. As a matter of fact the demonstration ofgall stones would not be a matter of first import-ance if we could show them in 100 per cent. of thecases. In the first place, 10 per cent. of all autop-sies show gall stones, but only 10 per cent. of thegall stone carriers have ever suffered from gallstone symptoms. In the second place, biliarystasis and gall bladder infection usually precedegall stone formation. And the important thingis the demonstration of the infective process goingon in the gall bladder, which may at any time begalvanized into an acute inflammation by somecomplicating general or local infection. Whenpalpation in the right hypochondrium, under themargin of the 9th costal cartilage, elicits out-.spoken tenderness or muscle spasm, one can befairly sure that he is dealing with gall bladderpathology. When this palpation can be doneunder the fluorescent screen while the barium-filled stomach and duodenum or colon are differ-entiated by visualization from the tender area,the localization of the tenderness to the gall blad-der can be made with almost absolute certainty.When a first part of the duodenum is seen elonga-ted, flattened out and hitched up and to the rightin the gall bladder region or a second part of theduodenum is dilated and over visualized, or anhepatic flexure is seen immobilized in that loca-tion, one can definitely diagnose duodenal orsolonic adhesions to the gall bladder. When yourule out, as you can, pathology originating in theduodenum or cblon, the conclusion is evident thatthe basal condition is a cholecystitis or a peri-cholecystitis. In an analysis of the x-ray findingsin some thirty recent cases, where cholelithotomyor cholecystectomy, or cholecystostomy, had beendone, the fluoroscopic report showed tendernesslocalized to the gall bladder area in practicallyevery case. Where adhesions to duodenum,stoma]ch, or colon were found, fluoroscopy hasmade the additional showing of spastic duodenalcap, or elongated or flattened and hitched upduodenal cap, or over-visualized second portionof duodenum, or fixation of colon, with correspond-ing added tenderness on pressure over these ab-normal areas.

Five hours after the ingestion of the opaque

meal the patient again reports, when observationis made of the amount of barium in the stomachand small bowel. The stomach should be emptyand the meal should be massed in the coils of theterminal ileum.

Eight hours after the meal, observation is madeof the ileo-cacal region. The meal should benearly all out of the ileum, and the meal headsomewhere in the transverse colon. Note will bemade now of the mobility of the terminal ileum,caecum, and ascending colon. Frequently theappendix will be filled, and its mobility, positionand patency noted. The csecum will be examinedfor mobility, fixation, filling defects, size, positionand shape. Any tender areas will be definitelylocalized. Notes will be made and comparedwith findings of the twenty-four hour and forty-eight hour observations. At these later examina-tions the progress of the meal will be noted, andany malformation or malplacement of the colonstudied, while the entire large bowel will be pal-pated for tender areas.

Appendicitis, acute or chronic, can readily berecognized whether the appendix has filled or not.Tenderness originating at the ileo-cexcal junctionand differentiated from csecum and ileum byvisualization will usually be of appendiceal origin.The line of tenderness may proceed in any direc-tion, as the appendix may run anywhere from thegall bladder to the pelvis. Localized tendernessover the butt of a fixed cexcum may be due eitherto an inflamed appendix or to an inflammatoryconstricting band across the caecum. The lattercondition can be differentiated only by the opaqueenema.A barium filled appendix is not to be regarded

as pathological unless it is tender, or constricted,or bulbous, or fixeci, or remains filled after thecaecum has been emptied of its barium.

After the forty-eight hour observation thepatient is given a laxative, preferably castor oil.The following morning the colon is examined bymeans of the opaque enema. The opaque enemais by all means the most instructive method offluoroscopic study of the large bowel. The wholelarge bowel can be filled sLowly while under ob-servation. Notation will be made of the calibreof the colon, whether large, atonic, redundant, orspastic. Filling defects (usually indicating car-cinoma) and constricting bands, if present, will beobserved. Adhesions and tender areas will bedetermined by palpation. The competency ofthe ileo-cacal valve will be noted.We have reported elsewhere' the findings from

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the study of one thousand colons by the opaqueenema, and can only summarize results here: Outof the thousand colons examined, only 15 percent. gave normal findings. The ileo-caexal regiongave pathological findings equal in number to allthe rest of the colon. Of those pathological con-ditions in the ileo-caecal region the most frequentwere those causing ileo-caecal stasis, viz., con-st'icting bands involving either the butt of thecapcum, or the ileo-caecal region, or the terminalileum, or all. This banding cannot be demon-strated except by the opaque enema. That thesebands were actually present was confirmed byoperation, which bore out the x-ray finding withoutexception in oae hundred and thirty-five consecu-tive cases. That their removal is beneficial bothfrom the stahdpoint of the patient's comfort andthe lessening of toxemia, we haye accumulatingevidence. That these bands must be carefullydistinguished from chronic appendicitis is evid-enced by the number we see in patients who cometo us with the history of having had the appendixremoved with no relief of symptoms, but in whomthe subsequent severing of the bands gave com-plete relief.

Diverticulitis of the colon can rarely be seenunder the fluoroscope, but is demonstrated onplates taken any time after the twenty four-hourobservation of the opaque meal. Apart fromoperation it can only be diagnosed by the x-raymethod.Mention must be made of another recent

diagnostic achievement for which the x-ray alonecan receive credit, namely, the early diagnosis oftuberculous ulceration of the colon. The diag-nosis depends on the discovery that the colon, orthat part of it which is the site of tuberculousulceration (usually the ccum) will not retain thebarium filling which normally should be foundthere. Archibald2 in the address on "Surgery,"at the Canadian Medical Association meeting,1920, stated: "With the x-rays a very earlydiagnosis of colonic tubercular ulceration is poss-ible. I think it is not too much to say, that in noother part of the body, in the matter of obscure dis-eases, have the x-rays justified their use sofully."We have made reference to a new method of

fluoroscopic -study of the abdomin-al organs byfilling the peritoneal cavity with oxygen. Thismethod originated on the continent of Europe asfar back as 1902. The first report of its beingused in America for diagnostic purposes was pub-lished by Drs. Stewart and Stein, of New York, in

July, 19193. Dr. Orndoff, of Chicago, workingindependently, published reports in September,19194. Drs. Stewart and Stein say of this newmethod5: "Not only did we find the diaphragmcompletely separated from the liver and obtain adetail of the liver that had never before seemedpossible, but, in addition, we succeeded in actuallyoutlining the spleen with its pedicle, both kidneys,and the uterine appendages. Intraperitoneal ad-hesions, especially involving the anterior abdo-minal walls, were easily shown." Dr. Orndoffsays: "The procedure of producing pneumo-peri-toneum is not difficult. New findings are en-countered, which seem to invite the conclusionthat the basis for possible new clinical diseaseentities has been established, and that old diseaseentities will be relegated to obsolete classifications.Perihepatitis, perisplenitis, and pericolitis withperitoneal adhesions offer new phases for thestudy of functional pathology of these organs.Post-operative peritoneal adhesions to the anteriorabdominal wall may be prevented by keeping theperitoneal cavity distended with oxygen forthree to five days, or until the peritoneum ishealed."

Dr. Orndoff describes6 a further innovationwhich he is using in conjunction with pneumo-peritoneum in the fluoroscopic study of the abdo-minal organs. When he has inflated the peri-toneal cavity with oxygen, he inserts into this-distended cavity under fluoroscopic guidance aninstrument, which is really a modified cystoscope,.and obtains a direct view of the surfaces of theabdominal organs. This method enables him todiagnose by visualization such conditions astuberculous peritonitis, haemoperitoneum, extra-uterine pregnancy, pyosalpinx, ovarian cysts,hernia. The procedure hq calls "Peritoneoscopy."We have attempted in a very elementary way

to sketch some of the things which fluoroscopy isaccomplishing as an aid in the diagnosis of abdo-minal conditions, and have indicated some of thepaths along which further progress will be made.Among the discoveries of the future which willmake fluoroscopy still more valuable, we look forthe perfecting of an instrument which is even nowbeing used in some X-ray laboratories, the stereo-fluoroscope.7 When this machine is perfected, asit will be in the near future, the fluoroscopicshadows will be seen in perspective, depth will beadded to surface shadows. We hope that stereo-fluoroscopy will become as much superior to plainfluoroscopy as stereo-radiography is superior towthe flat view of the single radiograph.

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In the nmeantime we believe we have shownthat fluoroscopy, as we now practise it, contri-butes so largely to the sum total of informationobtainable regarding abdominal conditions, thatwe must demand for it a prominent place amongour diagnostic procedures. Along the path ofvisualized study of vital function lies the progressof the future, especially as regards our under-standing of the activity of the organs within theabdominal cavity. As Leonard has expressed it :."The living anatomy, physiology, and pathologyof the digestive tract has yet to be written, andthis can only be done as the results are determinedby the study of the living patient by the x-raymethod."

BIBLIOGRAPHY1. CARTER.-Fluoroscopic study of the large bowel by

the opaque enema, Jour. of Roentgenology, Dec., 1919.

CARTER.-Further report on the study of the colonby the opaque eneml, Canadian Med. Assoc. Jour., Dec.,1920.

2. ARCHIBALD.-Surgical treatment of Ulcerative In-testinal Tuberculosis, Canadian Med. Assoc. Jour., Sept.,1920.

3. Annals of Surgery, July, 1919.

4. ORNDOFF.-Pneumo-Peritoneum in x-ray diagnosis,Jour. of Roentgenology, Sept., 1919.

5. STEWART and STEIN.-Roentgen study of abdominalorgans following oxygen inflation of the peritoneal cavity,Amer. Jour. of Roentgenology, Nov., 1919.

6. ORNDOFF.-The Peritoneoscope, Jour. of Radiology,May, 1920.

7. HECK.-A Stereofluoroscope, Amer. Jour. of Roent-genology, Sept., 1920.

8. LEONARD.-Report on Radiography of Stomach-andIntestines, Amer. Jour. of Roentgenology, Nov., 1913.

HELP

MANY medicail students of the senior years, also several 1921 graduates, havemade application for appointments during the cominig summer.

Graduates.:-Available in June for indefinite periods.Undergraduates:-June till October in'clusive.Locum Tenens.-For whole summer or shorter peridds, suggest-

ing One Hundred Dollars per m6onth as re-munera'tion.

Assistants:-Largor number of applicants in this class-morebent upon gaining experience rather than emoluments.

For the convenience -of the profession and the students, the office of the On-tario Medical Association situated at 127 Oakwood Ave., Toronto, has un'dertakento act as a clearing house. Further particulars will be found elsewlsere in this issue.Hospitals requiring internes ate also invited to use the service.

The whole plan is an experlment, never ha,ving been undertaken previously,so far as can be ascertained. It appears to have particularly appealed to the students.The response from the profession will obviousjy indicate Success or failure of theunderhtking.