Fig. 1. Skiagram of Miss L. Age 24. Complained of constipation and pain in pelvic region, following opera tion, eight months before, for salpingitis and ovaritis. Subject to dysmenorrhea and had to stand to urinate. Mass palpated in left pelvic region. Radiogram revealed doubling of sigmoid. Our friends, the urologists, for several years have resorted to a similar method in the diagnosis of affections of the genitourinary apparatus, they injecting a solution of argyrol or some other silver salt before directing the x-rays. They have been so successful that a recent observer was able to see even the straight tubes of the kidney. In addition to my personal cases, I have time to quote only the following instances of the utility of the procedure under consideration: A Few Illustrations The first is reported by Wiesner in a recent number of the Munich Wochenschrift. Four weeks after an interval operation for appendicitis, a patient had attacks of colitis with fever. After filling the large bowel with an emulsion of bismuth subnitrate in oil, radiography disclosed a diverticulum on a level with the cecum and connected with the principal mass of intestines by a narrow neck. The author concluded that postoperative adhesions were present, kinking the bowel and causing the formation of a cul-de-sac in which fecal matter was stagnating. The abdomen was reopened and the diagnosis corroborated. The adhesions were removed, and, later on, the bismuth-x-ray method showed a normal state of affairs to have been reestablished. A similar case, in some respects, is re- . corded by Tousey in The Journal of the American Medical Association of March 9 of this year. A woman of 41 had undergone two laparotomies, the first one thirteen and the other seven years ago. After the last one she was troubled with constipation and prolapsus ani to such an extent as to suggest a kink in the sigmoid or invagination into the rectum. Fig. 2. Another skiagram of Miss L. taken after the application of a clip to the rectal valve. This had passed, relieving constipation somewhat but not helping otherwise. Later, opening of the abdomen revealed extensive adhesions around sigmoid, uterus and bladder. Surgical release of these caused great improvement. After an injection of bismuth per rectum, the radiogram showed no abnormality, except a strikingly empty part of the transverse colon where it crossed the spine. A certain portion was permeable, but subject to such pressure as not to be distended by the bismuth mixture. It did not seem possible this pressure could be caused by a tumor without other signs being produced. Another possibility was that the pressure was due to the convexity of the spine, but no compression had been applied to the abdomen, and similar appearances had been observed in other cases. Therefore, the diagnosis became narrowed down to pressure from adhesions. Laparotomy was performed so as to expose this portion of the intestine instead Fig. 3. Skiagram of Miss P., age 23, treated for obstinate constipation and abdominal pains, greatly exaggerated during defecation. Three large abdominal scars, 4, 5 and 8 inches long, made in operations for suppurating appendicitis and cecal abscess. Skiagram taken after removal of largest scar (along left rectus), the entire intestinal tract and omentum being bound down by adhesions. Improvement followed, but a similar operation on the two other scars (on the right side) was required later. Skiagram shows colon normal, except for some kinking at the hepatic flexure. of the lower part, as had been anticipated. An area of the omentum was found, 3 inches wide, bound down and firmly adherent to the transverse colon for about two-thirds of the circumference. This caused both compression and angulation, which were relieved by freeing the adhesions. The patient is now having movements of the bowels without a cathartic. The Method of Obtaining Radiograms Now to come to the technic: The patient's bowels are first cleansed by means of laxatives and injections. He Fig. 4. Miss N. Had been operated upon for chronic appendicitis and salpingitis. Extensive adhesions, causing obstruction and removal of portion of the small bowel. In the ascending colon is a large mass of feces which was not expelled by cathartics and enemas. Bismuth mixture did not pass beyond splenic flexure. Colon and rectum dilated. is then placed in the knee-shoulder position, and from 25 to 30 ounces of the mixture used for casting the shadow is injected into the large intestine. For this purpose I use an ordinary irrigator and short rectal tip. A long rectal or colonic tube for administering the injection is unnecessary. After the suspension is injected the patient lies on his right side for a few moments, so that part of the mixture may pass into the cecum. He is then placed, either in a dorsal or ventral position, on the radiographic table and the picture is taken. Instead of exposing a photographic plate, the fluoroscopic screen may be used. Obviously, however, a permanent photograph is better. With the improved methods now in use this requires but a few seconds' exposure, and can be preserved for comparison. In some cases, considerable information, especially in carcinoma of the colon, will be obtained by using the screen while the injection is being made. In such cases Haenisch has found that the flow is arrested at the site of the tumor, bulging out the bowel, then the injection suddenly passes on through the narrowed portion of the bowel in a thin narrow line. The Radiographic Injection In order for a radiogram of the colon to be secured, it is necessary that it contain some nontoxic substance that will not permit of penetration by the x-rays. While a number of substances can be used for this purpose, a 6- to 10-percent subcarbonate of bismuth emulsion is the one I have employed most. Subnitrate of bismuth is poisonous, either from absorption of the nitrates or from impurities found in it. Sulphate of barium is considerably cheaper, but not so satisfactory. Kaestle used oxide of zirconium, but this has no advantage over the subcarbonate of bismuth. In one of the recent books on diseases of the stomach and intestines, one written by Kemp-and, by the way, a most excellent work-this author states that "for locating the position of the colon, the Roentgen method is expensive and usually impracticable, as it gives no more information than that by inflation." That this view of Kemp is not quite accurate will be shown, first, by the photographs, which demonstrate conclusively a much greater store of information than is possible with inflation. The thoroughness of the injection is shown by the fact that, if the appendix is not behind the cecum, it will often be found filled with the bismuth Any additional cost is for the technic and skill of the operator. hardly see how one can consider this expensive or prohibitive. It seems a temperate estimate of the advantages of this method would be that it is the means of getting information obtainable in no other way, as to the shape, Fig. 5. Mr. B., age 28. Taken with the expectation of finding a normal colon. Gave a history of good health and regular daily evacuation until six weeks before, when he noticed sluggish action requiring cathartics. Skiagram shows beginning dilation of the cecum and in the hepatic portion of the transverse colon. situation, and caliber of the large intestine which were decidedly unexplainable, and up to the cecum. In conditions affecting the large bowel, it is not probable that we shall meet with so remarkable psychic effects as ensued in a patient of the Paris correspondent of The Boston Medical & Surgical Journal. This was a young woman with symptoms she was referred to a radiologist for examination, as to whether she had some malformation of the pharynx or esophagus. As a result, she was radically cured by the moral effect of this-to her-altogether unknown and mysterious procedure. 31 North State St. |