to remember that you are differentiating various physical conditions
of the lungs and endeavoring to interpret these in terms of patho-
logical entities. Very frequently the interpretation cannot be made
accurately, and no attempt should be made to so interpret the find-
ings without careful correlation with the other clinical findings, such
as history, etc.

If one has had considerable experience in examination of disease
of the thorax, he is inclined to thoroughly scrutinize the region of
the diaphragm in every instance and to carefully observe the degree
of visibility and the form and the excursion of the diaphragm.

Pulmonary tuberculosis is diagnosed by the x-ray only in so far
as we care to interpret certain physical conditions, which are thus
beautifully shown as tuberculous and assume that these conditions
are always caused by the bacillus of Koch.

Personally I would hesitate to make a diagnosis of pulmonary
tuberculosis in any but the most advanced stages by means of the



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 27

Roentgen ray findings alone. Taken in conjunction, however, with
the physical signs, temperature and weight record and history,
trivial x-ray findings may, when so associated, acquire great signifi-
cance and enable the all important early diagnosis of tuberculous
infection in many patients to become an accomplished fact.

It, of course, is ridiculous to state that we do not see the tuber-
cular bacilli with the x-ray. Neither do I believe that we see a
peculiarly-shaped habitation of the bacilli as one might expect to see
musk rat homes, nor do I believe that there is any strictly pathogno-
monic pulmonary change attributable solely to the tubercle bacilli
with one hundred per cent, of accuracy, but the fact remains that
there are several rather characteristic pulmonary changes which we
have learned by experience to expect to see in patients suffering
from tuberculosis and have come to attribute these changes to the
pathology of the disease.

The earliest of these changes is the so-called fan, so well de-
scribed by Dunham, best seen in thin chests and early cases. This
should only be studied in excellent stereoscopic plates.

Dunham says, "the characteristic tuberculosis plate marking con-
sists of a fan-shaped density with the base of the triangle toward
and near the pleura, the apex toward the hilum and connected to the
hilum with a heavy trunk. The pathological lesion within the lung
which causes the fan-shaped density is a cone that has its base to
the pleura and its apex toward the hilum. The density within this
fan-like area varies greatly. The radiating linear markings may
either be interwoven and broadened, studded, obscured by a filmy
cloud effect, mottled, matted together or entirely blotted out. One
of the most striking characteristics of the tuberculosis picture is the
varying degree of change in the different trunk groups in contrast
to the general homogeneous change in diseases which might simulate
tuberculosis, also the lack of continuity with which the trunks may
be involved. Thus we may have the vetebral and second interspace
trunks on the right side involved and only the first interspace trunk
on the left side. Further, it is very striking to note the constancy
with which early or slight lesions in the adult are limited to the
trunks of the lower lobes.

"If the fine linear markings of a given trunk are fuzzy or are
faintly obscured by a cloud effect and the fan appears to be wide
open, active tuberculosis is suggested On the other hand, if the
linear markings beyond the trunk and the fan are partially closed, a
healed lesion is suggested. This condition is emphasized if it is



28 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

accompanied with heavy, coarse interweavings which reach to or
near the periphery. The heavy trunks between such areas and the
hilum are usually broad and dense."

Practically this fan-shaped appearance is that which would be
caused by any low grade inflammatory process which has spread
by continuity of mucosa.

In advanced instances of the disease you see :

1. Dunham's fans

2. Lung suppuration

3. Tuberculous adenopathy

4. Thickened pleura

5. Formation of cavities

6. Local pneumonias

The degree of activity of a tuberculous lung lesion is inversely
proportional to the distinctness of outline or limiting border. If
outline is sharp, disease is quiescent; but if it shades off into outly-
ing tissue, it is active.

The above cannot be seen on the screen, but you should use low
unit radiation for fluoroscopy and should make stereoscopic pictures
for final detail.

1. Patient should not breathe (Diaphragm is indicator, if vis-

ible)

2. Patient must not move

3. If active tuberculous area will be smoky, foggy, hazy,

blurred, indistinct
If disease is quiescent plates will show

1. Sharp demarcation

2. Sharp contrast

3. Dense small shadows

4. Xo fog, smoke or haze

5. Dense shadows of regular outline and sharp demarcation

denote healed process

DIFFERENTIAL DIAGNOSIS

Localized long suppuration resembles alveolar tuberculosis, but

1. It is confined to one or more areas

2. Fan-shaped area larger

3. Does not extend to periphery of lung

4. Whole process denser

5. Patients are very sick



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 29

IIILUS TUBERCULOSIS

1. Is a disease of childhood

2. Is a peribronchial tuberculo-adenopathy

Glands break down, liquefy and break through into a bronchus
and by extension now becomes an alveolar tuberculosis. It may
never go on to above extent and rarely does. If outline be indis-
tinct and blurred, process is active. If dense clear cut outline, gland
is probably calcified, healed and quiescent.

WARNING

Any infectious disease of childhood or bronchial irritation of
inflammation will enlarge the peribronchial glands, but these will
usually promptly clear up as convalescence progresses.

FOREIGN BODIES IN RESPIRATORY PASSAGES

Nature — Anything small enough to get in by inspiration.
Location — From nose downward (never be satisfied with

screen examination solely).
Favorite location is behind the heart shadow; more go down
right bronchus.
Always make lateral and two antero-posterior views to locate a
foreign body which is transparent to x-ray.

1. History

2. Area of atelectasis or lung suppuration with foreign body

at handle of fan

3. Two antero-posterior views should be made — one with ster-

num on plate, one with back on plate

If small enough to go through the larynx it may be found in the
trachea, bronchus or lung. The foreign body may be expected to
gravitate downward until it reaches a bronchus whose size prevents
admission.

The foreign body may be opaque or transparent to the x-ray, but
it requires localization irrespective of this fact. On several occa-
sions a foreign body supposed to be in the lung has been found in the
nose and on many occasions in the bowel. The screen is not of
much avail in this particular instance, and it is much more satisfac-
tory to make very rapid plates of the chest, making two antero-pos-
terior and one lateral.

If a foreign body is transparent to x-ray, it may reasonably be
expected to cause irritation at its seat with some resulting inflamma-



30 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

tion and possible blocking of the bronchus, resulting in atelectasis,
and later localized suppuration.

My associate, Dr. Grier, has published in the American Journal
of Roentgenology, the results of our experience in the examination
of very many instances of foreign bodies of various types in the air
passages. It is, therefore, unnecessary for me to add anything to
what he has said. ("Roentgen Examination of Foreign Bodies."
G. W. Grier, M.D.)

THE HEART

Roentgen examinations of the heart are performed for the pur-
pose of obtaining the following data :

Size, shape, position, condition of aorta, presence or absence of
pericarditis.

Size — It seems to me that clinicians should be interested in this
if only to determine whether or not a heart is of sufficient size to
take care of the circulatory requirements of the individual under
examination without being expected to unduly exert itself. This
is simply a problem in hydraulics, and I am quite certain that any
observer will, in a short time, have his attention called to this fact.

On making a rapid fluoroscopic observation of a heart, having
previously examined the individual and taken his blood pressure,
the observer should be able to state whether or not, in his judgment,
any given heart is sufficiently large for its work. If the heart is
over size, it is from dilatation or hypertrophy. If it be hypertro-
phied its behavior, its muscular action, its excursion, its apical re-
traction will immediately proclaim it such. Similarly, if it be
dilated, the very lack of the foregoing characteristic muscular activ-
ity will inform the observer of that fact. A dilated heart gives the
impression of a heart in chronic diastole. When a healthy heart,
whether hypertrophied or not contracts the apex tracts. The
activity of the heart is determined by the retraction of the apex, the
diminution in size or change in area, and change in position of the
heart due to its systolic rotation on the great vessels on which it is
suspended, in conjunction with the rate of contraction and expansion.

The only way to learn anything about this particular branch of
medicine is to carefully and intelligently examine the heart by every
method available, then study the same heart with the screen and in
this way acquire the ability to interpret for yourself the visualiza-
tion of the heart in action so beautifully seen upon the screen.

The shape of the heart varies greatly. You will soon be able



THE AMERICAN CONGRESS OX INTERNAL MEDICINE 31

to divide them into transverse, vertical, globular, drop and com-
pressed.

Drop heart has no pathological signification. It is usually small
and occurs in patients having long trunks and general visceroptosis.

The transverse heart on the other hand indicates a distinctly
dangerous cardiac condition. It is observed most frequently in
those men whose abdomen exceeds in circumference their chest,
who are what are commonly known as "stomach athletes." These
are the types recorded in the daily print as dying of acute indiges-
tion or cardiac failure immediately subsequent to an elaborate
banquet.

A displacement of the heart is, of course, immediately observed;
pleurisy with effusion, particularly right-sided pleurisy may cause
considerable displacement.

The congenital dextracardia is always worthy of comment, but
the marked cardiac displacements are those observed as a result of
rearrangement of the thoracic contents due to old chronic fibroid
phthisis.

Pericarditis with effusion is very frequently overlooked and
very often diagnosed as a simple Cardiac hypertrophy. It is well
to remember that the re-entrant angle, which is found by percus-
sion and which is found to have disappeared upon percussion in
this condition has not actually disappeared but is rather accentuated
when the heart is examined upon the screen. This confusion is
bound to cause mistakes. The diagnosis of pericarditis with effu-
sions is rather better made by the fact that a portion of the heart
shadow, its auricular shadows and shadows of the great vessels
at the root of the heart, is almost lost, due to the distension of the
pericardium with fluid. Moreover the cardiac activity is very
greatly reduced, apparently the apical retreat being no longer
noticeable.

The various changes in contour of the heart consequent to
valvular insufficiency would require an afternoon for their dis-
cussion. Moreover they have been already beautifully described
in Roentgen literature. They will, therefore, not be further con-
sidered.

The aorta is best inspected by means of the screen and consid-
erably more attention should be paid to determination of aortitis
than has been done in the past. The writer claims that an early
determination of aortitis with proper treatment, thereof, would
result in an increasing rarity of aneurysm.



32 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

Any deviation in size or shape of the aorta requires explanation
but it does not necessarily mean aneurysm.

The size, shape and position of the arch is best studied before
the screen and no diagnosis of aneurysm should ever be made until
the superior portion of the arch has been studied in the lateral
position.

Syphilitic aortitis may be frequently diagnosed upon the screen
by marked increase in the density of the descending aorta.

Expansile pulsation of aneurysm means an impulse synchronous
with the heart beat. It must be remembered that transmitted im-
pulse is imparted to any tumor in the mediastinum which may be
in contact with the aorta. The following table may also note the
differences between tumors of the mediastinum and aneurysm.

ANEURYSM

Regular outline, spherical

Pulsatile and expansile

Painful when producing pressure

Atrophy of bone

Bruit marked

Density high

Cardiac dyspnea

Cardiac hypertrophy

Cough brassy

Shadow continuous with aorta

Density high

TUMORS

Outline irregular or spherical

No bruit

No cardiac hypertrophy

No cardiac dyspnea

Often metastatic

Rapid onset

Irregular density

Aorta can be differentiated sometimes from tumor

Density may be low
No mention has been made of mediastinal abscess, the result of
caries of the cervical or dorsal spine, and when such a diagnosis
is made it is usually an accident.



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 33

The writer realizes thai many books could be written on the
subjects touched upon and the idea of this paper is simply to re-
awaken the internist to the value of the lluoroscope and plate in
the examination of the chest as a means of stimulating his acuity
in other methods of physical examinations as well as the advantage
of having all the possible evidence in any given case.

No roentgenologist can make successful studies of the chest
unless he be enough of an internist to appreciate all the various
forms of pathology which one may expect to find therein.

Xo roentgenologist can make successful studies of the chest
in having been associated with many excellent internists, men well
informed as to gross pathology, symptomatology, etc. Anything that
he knows along this line is due to his past association with such
men as C. Q. Jackson, Litchfield, McKelvy, Lichty, Alexander,
Jones. Mercur, Klotz, MacLachlan and many others.



A RESUME OF THE ROENTGEN FINDINGS IN ABDOM-
INAL PATHOLOGY

By WILLIAM A. EVANS
Detroit, Mich.

Your president, in his address last year, paid tribute to the sci-
ence of roentgenology in this fashion "To it internal medicine
owes much, not only in indicating new avenues of progress, but
as well in scientific demonstration of the verity of what empirically
we have established as facts in internal medicine, and we have
made but a beginning." But many roentgenologists have become
so enthusiastic over their method of examination they have for-
gotten the ordinary clinical methods and even gone so far as to
hold in disdain the work of the clinician. There is certainly no
basis for such self-glorification, for sober consideration of our
results must convince us that our conclusions are drawn falsely.

It is in this spirit of humility that I address this meeting. I
hope to present some of our problems and, at the same time, to in-
dicate how you, as internists, can help advance our specialty and
thus advance medicine generally. But my humility must not
prevent my giving expression to thoughts which came to me during
my recent review of the late literature on differential diagnosis of
abdominal conditions. In one of the volumes of "monographic



34 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

medicine" published in 1916, the author dismisses the subject of
roentgenology of the gall bladder with these words: "An x-ray
made by an expert will sometimes show the shadow of a gallstone."
Roentgen aid in gastric cancer receives the consideration, "Exam-
ination by x-rays shows an interference of peristalsis and some-
times notching of the stomach wall;" and in the differential diag-
nosis of chronc appendicitis, no reference whatever is made to the
roentgen ray. Apparently this writer has not had the advantage
of association with, and the co-operation of a competent roentgen-
ologist, and neither has he followed roentgen literature, for other-
wise the work of George, Case, Carmen, Crane and many others
must have shown him the merits of roentgenological study of ab-
dominal pathology. I trust the time will soon come when an author
will not have the temerity to disregard so thoroughly and com-
pletely such a valuable aid in differential diagnosis as the roentgen
method has proven itself to be.

It will not be possible for me to take up in detail any organ or
group of organs. I will rather have to be content with suggesting
the possibilities and problems in the demonstration of lesions of
the several abdominal structures. Before taking up the individual
headings, it should be understood that the roentgen study is car-
ried out, in the first place, by both the fluoroscopic and the roentgen-
ographic methods. Both methods have their indications and merits,
but one cannot be used to the exclusion of the other. It should
also be understood that the examinations are made both in the
upright and horizontal positions, and that suitable considerations
have been paid to the preparation of the patient.

Diaphragm. In the study of the diaphragm, the fluoroscopic
method is the most useful and the erect position is preferable for
such study. The first thing to be noted is the contour and relative
height of the diaphragm lines, and then the contour, in detail, of
each diaphragm. The height of the diaphragm lines is varied by
abdominal conditions, such as enlarged liver, enlarged magenblase,
distended splenic flexure, subphrenic abscess, or, in fact, any large
abdominal tumor, or even effusion. When the diaphragm on either
side shows waves or undulations, one can strongly suspect either
abdominal or chest pathology. The structure of the diaphragm and
its enervation renders certain fibres subject to irritation from
abdominal organs, and it is the reflex irritation from abdominal
lesions which produces the irregular contraction of the diaphragm
muscles and, as a result, the mammillations. This condition has



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 35

been especially noted in gastric ulcer. The plate method of exam-
ination is of particular value in determining the presence of a
subphrenic abscess. In this case, it is customary to look for a
bubble of gas, this appearing between the pus level and the dia-
phragm, the presence of air permitting the pus to assume a straight
line, and this rinding may be overlooked in the fluoroscopic observa-
tion. Usually the condition of the patient does not permit the
erect posture for but a brief period, and this, in itself, would force
the using of plates.

Pancreas. The study of the pancreas is rendered difficult both
by its structure and its relations. Well-developed cysts of the head
of the pancreas have been recognized during a roentgen examina-
tion, by the fact that there has been a displacement and change in
the relations of the pylorus and duodenum. Carcinoma of the pan-
creas has also been diagnosed by the disturbance in outline and
relations of the duodenum produced by the presence of a new
growth.

A careful search of the literature failed to reveal a report where
pancreatic calculus had been demonstrated by the roentgen method
of examination, but there is no reason why these should not be
demonstrated, and no doubt the shadows have been overlooked or
confused with gallstones or other abnormal shadows. In this in-
stance, it would seem that with the co-operation of the itnernists,
cases showing pancreatic disease should be referred to the roentgen-
ologist for a careful study of the pancreatic region for calculus.

Liver. The indications for roentgenologic hepatic study are
limited. An enlarged liver is demonstrated at times on account of
the distortion of the diaphragm line or from the displacement of
the abdominal contents. In our service, we were able to demon-
strate that a large tumor in the upper right quadrant was probably
a cyst of the liver, this being verified by operation.

Gall Bladder. For some years, the study of the gall bladder by
the roentgen examination was confined simply to the demonstra-
tion of calculi and adhesions. Until recently, no routine examina-
tion of the gall bladder region was made, the question of adhesions
being determined during the study of the duodenum. It has been
the custom for some time to describe the so-called gall bladder
position of the duodenum, in its relation to the pylorus, and also
to explain certain deformities of the duodenum by periduodenal
adhesions complicating a cholecystitis. When the duodenum was
held toward the median line, and somewhat upward, when the



36 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

pylorus extended a little far to the right, when the mobility of the
duodenum was reduced, and when there was tenderness associated
with manipulation of the duodenum, we have assumed that there
was gall bladder disease from the demonstration of an occasional
gallstone, and these rather accidentally, we have advanced to the
position where some roentgenologists report the demonstration of
at least fifty per cent, of gall bladder deposits. One worker has
stated that his percentage is eighty per cent., but he published no
figures to support his statement. However, in our reports, we
always call attention to the fact that negative evidence of gall-
stones simply indicates that no stones are present which have a
lime content of two and a half per cent, or more.

But what is probably more important than the demonstration
of gallstones is the demonstration of the gall bladder itself. While,
as far as we know, we have never been able to demonstrate a nor-
mal gall bladder, we are certainly finding on properly exposed plates
outlines which have been proven to be cast by a pathologic gall
bladder. The conditions demonstrated have included hydrops of
the gall bladder, empyema of the gall bladder, and chronic thick-
ening of the gall bladder wall. Inasmuch as the normal gall blad-
der is at least very seldom demonstrated, we can safely assume that
the shadow of the gall bladder definitely indicates pathology.

Spleen. The differential diagnosis of tumors in the upper left
quadrant can be aided by the demonstration of the splenic outline.
In order to show this organ, it is necessary to distend the stomach
with gas, and also to have considerable liquid in the stomach. With
the patient on the right side, with the above conditions complied
with, the splenic outline is frequently very well shown.

Peritoneum and Mesentery. The roentgen method of examina-
tion is frequently useful in the differential diagnosis of extravisceral
new growths. The usual findings are those of a displacement of
the stomach, small intestine, or colon, these, of course, being studied
best by being outlined with the usual opaque salt. We have been able
to diagnose differentially a low abdominal mass as a dermoid cyst,
since we identified shadows in the tumor region which were those
of teeth. The very important subject of adhesions in the abdominal
cavity, of course, is best studied by this method of examination,
fluoroscopy alone being the most satisfactory procedure, inasmuch
as this permits of palpation and the demonstration of pain points.
The distribution of the barium in tubercular peritonitis is char-
acteristic, there being filling and distention of certain loops of



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 37

the small bowel with barium, and distention of other loops with
gas.

Urinary Tract. The question of the roentgen diagnosis of urinary
calculi is so well known that the matter will be given little consider-
ation here. In these cases, the value of the roentgen examination
is not in the diagnosis of a calettlus, but more to serve as a guide
in treatment ami a guide in prognosis. By no other method of exam-
ination can the size, shape and number of stones be learned.

The question of referred pain in renal calculus should be men-
tioned at this time. In our service, I recall four cases in which
the symptoms were all on one side, and the examination revealed
a shadow of calculus on the opposite side. This does not neces-