sarily mean that the pathology was entirely one-sided, but it does
mean that there can be a bilateral pathology with just unilateral
symptoms.

New growths and disease other than calculus can be well studied,
provided the proper technic has been carried out in obtaining plates
of the kidney regions. In the rare exceptions that the plates do
not show the kidney outline, one can usually suggest the presence
of a perinephric abscess. In this condition, there is usually a uni-
form density from the crest of the ilium on the affected side to
the last rib. In every other case, it is possible to obtain a kidney
outline, and unless the plates obtained show this, further exposures
should be made.

The invaluable aid rendered by the study of the filled bladder,
ureters and the pelves of the kidneys with an opaque solution is well
known, and nothing new has been recently brought out along this
line.

t In connection with bladder symptoms, by making posteroanterior
plates as well as anteroposterior, we have been able to demonstrate
the shadow of the prostate, both that of a chronic prostatitis and a
prostate modified by a new growth.

A relatively large number of cases are referred to the roentgen-
ologist for examination of the urinary tract with simply the history
of frequent urination, pain on urination and lumbar or inguinal
pain. Four years ago, in reviewing a large number of plates made
of cases referred for suspected calculus, I was struck with the large
number of spine lesions which could be detected on the plates made
of the midureter region. It occurred to me that possibly there was a
distinct connection between the spinal lesions and the symptoms of
urinary calculus, and a paper was written for the American Roent-



38 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

gen Ray Society under the title "The Syndrome of Urinary Cal-
culus Caused by Spinal Lesions." Since that time, when the exam-
ination for stone is negative, we feel it our duty to make a detailed
study of the lower spine and to report any changes found. It has
been clearly and definitely demonstrated that bone lesions of the
lumbar and lumbosacral regions frequently manifest themselves
in disturbances in kidney function, micturition and lumbar and
inguinal pain.

The variety of lesions producing these symptoms is great. Simple
displacements or rotations, inflammatory processes involving the
articular facets and anomalous development of the fifth lumbar
body or faulty development of the first sacral segment have all
been found in these cases. Of course, any pathology in the spine
which would cause an inflammatory reaction in the soft tissues could
be a factor in reflex irritation.

Gastrointestinal Tract. Before taking up the detailed pathology
of the gastrointestinal tract, the question of a method of examina-
tion should receive careful consideration. There are at present
two distinct methods of examination, one the so-called single meal,
and the other the so-called double opaque meal. Personally, I think
this is a very vital matter, and one that should receive the earnest
consideration of gastroenterologists, for until there is a standard
technic for the examination of the intestinal canal by the opaque
meal, there will be difficulty in correlating the results of the work
of different laboratories. Personally, I can see no objection what-
ever to the single meal, and believe it is the proper method of pro-
cedure. There is a distinct disadvantage in the double meal, in that
it is reasonable to suppose that a large dose of salt such as barium
or bismuth is bound to affect the reflexes of the intestinal canal.
In at least ninety per cent, of patients who are examined in our
laboratory for gastrointestinal conditions, we find that on the day
following the administration of the barium salt, the patients seem
to be markedly or even entirely relieved of their symptoms, this
improvement usually continuing for several days. In fact, we hear
frequently that patients having had the barium study do not return
to their physician, inasmuch as they have been entirely relieved
of their symptoms.

To be more definite, a case was referred a few days ago for a
gastrointestinal study, with the tentative diagnosis of gastric ulcer.
The first examination revealed a distinct pylorospasm, with delayed
emptying. The following day, a second opaque meal was given.



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 39

There was an entire absence of spasm, and a well formed duodenal
cap, and an even and normal escape of the gastric contents. The
condition in this case was not one of gastric ulcer, but was one of
gastritis secondary to a septic condition of the mouth.

The argument may be advanced that even a single meal inter-
feres with the normal function, and we presume that there is pos-
sibly some truth in this claim, and in many cases, the roentgenologist
does take into consideration the action of a large amount of barium
in the intestinal tract.

The objection to the single meal by the advocates of the two-
meal method is that the condition of the terminal ileum is the great-
est factor in reflex gastric conditions, and if the examination is made
with the terminal ileum empty, many pathological conditions would
be overlooked. Since in no other way can we be sure that the
terminal ileum contains food except that the food has an opaque
salt content, then it must follow that the detailed study of the
stomach should be made when it is determined that there is still
food content in the terminal ileum. Granting that the contention
of the two-meal advocates is correct, there is still no objection to the
single method in my mind, inasmuch as an examination begun
within twelve or fourteen hours of a meal would still permit us
to examine the stomach which would be under the influence of the
terminal ileum content, for a normal terminal ileum can have no
influence on the stomaach, and a disturbed ileum will show reten-
tion from the evening meal by the time of the morning examina-
tion. This, of course, would call for the gastric examinations to
be begun between eight and nine in the morning. This is one of
the problems which can only be settled by the aid and co-operation
of the gastroenterologist.

At this point, I would like to make a distinction in the cases
referred from the surgeon for examination and those coming from
the internist. From my experience, I find that the examination
of the gastrointestinal tract for surgeons is much easier than in the
cases sent from the internist. That is, with greater frequency do
we demonstrate actual lesions, while in the instance of cases re-
ferred from the internist, it is frequently a matter of disturbed
function. Little diagnostic skill is necessary in demonstrating
hour-glass contraction of the stomach or a perforating gastric ulcer,
or a chronic duodenal ulcer, or a large gastric carcinoma, or any
other lesion with gross anatomical changes. It is these cases which
have probably gotten the roentgenologist in the habit of making



40 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

a roentgen diagnosis, rather than simply reporting the roentgen
findings.

Another factor in the formation of the roentgen habit of making
diagnoses is the varying abilities of the men referring cases for
examination. The large majority of the cases coming to the office
have had practically no scientific examinations made, and the phy-
sicians referring the cases rely almost entirely upon the roentgen-
ologist for a diagnosis. I have been in the habit of dividing physi-
cians into three large classes, one class to whom is almost entirely
unknown the real scientific study of a case, a second class who
have kept abreast with the various advances in diagnoses, but
whose energies are so dissipated that they are not sufficiently
familiar with the roentgen findings reported to properly interpret
them, and then the third and smaller class, who use all the various
methods to obtain a diagnosis in a given case.

To the first class, we have, in the order of things, to make a
roentgen diagnosis, and in these cases we feel that we are entitled
to a history and also some of the other physical findings, and these
are made in a hurried way during the ordinary roentgenologic ex-
amination. This is, of course, not scientific, but most of you who
are familiar with general practice will appreciate the conditions
under which this plan is made necessary.

To the second class, we usually report our findngs, and interpret
them in the light of the patient's history and symptoms.

To the third class, we have adopted the method of simply re-
porting our findings, and contenting ourselves with making pos-
sibly a few suggestions. We believe that this third method is the
ideal one and that the roentgenologist should not be called upon
to make a definite diagnosis unless he has the privilege of going over
all the results of the other examinations.

A year ago, Charles H. Mayo, in an address before the American
Roentgen Ray Society, said "To stand well with the surgeon, the
roentgenologist should be specific in his conclusions, avoid verbose
description of his findings, and when unable to make a diagnosis,
frankly report the case as indeterminate." This should, and no
doubt does, apply equally well to the internist, and to you, as in-
ternists, then, I will state the roentgen findings of the more common
pathological conditions of the gastrointestinal tract.

The matter of size, shape and position of the stomach and the
matter of the length and relations of the component portions of the
colon have been demonstrated, we think, to be of little, if any,



THE AMERICAN CONGRESS OX INTERNAL MEDICINE 41

clinical value. As Mills of St. Louis pointed out, the contour and
relations of these organs simply conform to the patient's habitus.
The internist has not fully appreciated this condition, we believe,
for we are frequently called upon to determine exactly the above
mentioned points in connection with the stomach and colon. The
futility of the ordinary abdominal belt has also been clearly demon-
strated.

We can classify the findings in gastric ulcer under the two gen-
eral headings of direct and indirect, the direct being a demonstra-
tion of a definite change resulting from the ulceration, and the
indirect the disturbances in function. The most common direct
findings are (a) the bismuth fleck representing the ulcer crater, (b)
the Idling defect in the gastric outline, and (c) the organic deform-
ities other than defects, such as hourglass contraction. The in-
direct findings are (a) spastic manifestations, (b) abnormalities in
peristaltic waves, (c) disturbed motility, (d) unusual filling of the
duodenum and (e) pressure pain points.

The very complete work on gastric carcinoma which was pub-
lished by Dr. Smithies was recently reviewed, and I am in full
accord with all that he has stated as regards the value of the roent-
gen examination in gastric carcinoma. Still, in practice, it does
not work out as one would believe from reading Dr. Smithies'
comments. I am sure that every roentgenologist frequently is able
to demonstrate a gastric carcinoma when the condition was not
thought of clinically, even when the case had been worked up by
a competent internist.

The chief, and frequently the only finding in gastric carcinoma
is a filling defect. Depending on the location, there will be dis-
turbances in motility. For instance, with a carcinoma involving
the cardiac end of the stomach, there is usually early emptying.
In carcinoma involving the middle pole, the emptying time is fre-
quently not disturbed, and, of course, in carcinoma of the pylorus,
there is usually obstruction. Probably the chief values of the
roentgen ray in gastric carcinoma are the demonstration of the
exact location of the lesion, the possibilities of surgical intervention,
and the prognostic value.

Undoubtedly the majority of cases coming to the internist with
gastric complaints have conditions outside of the stomach which
produce the symptoms. The gastric symptoms resulting from small
intestinal, appendiceal and colonic conditions will be considered
separately under the several headings.



42 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

The interpretation of the findings of pylorospasm and gastric
retention should not be made without carefully considering the
question of these findings being the result of a gastric manifesta-
tion of tabes. Not infrequently we have suggested syphilis as being
the etiologic factor in pylorospasm and retention, and later tests
have proven our suggestion correct. The question of organic de-
formities of the stomach due to syphilis is one of importance. Un-
doubtedly a large number of cases presenting a tumor of the
stomach have been diagnosed as carcinoma, when in reality they
were the result of syphilis. The roentgenologist should always
suggest the necessity of differentiating between carcinoma and
syphilis by the other methods of examination.

The most constant and important finding in duodenal ulcer is
duodenal deformity. Following the classification by Carmen, of
the Mayo Clinic, there are four types of deformity, these depending
somewhat on the extent of the ulcer and on the amount of scar tis-
sue formation. The four types are the pine-tree, the niche type,
the incisura, and the small dense bulb.

The indirect evidences of duodenal ulcer are hypertonus, hyper-
peristalsis and hypermotility of the stomach, the six-hour residue
in chronic ulcer, antrum dilatation and gastric spasm.

The question of deformity of the duodenum cannot always be
explained by changes in the duodenal wall, for frequently the dis-
turbances in outline and in filling is the result of duodenal bands.
The duodenum also is frequently influenced by reflex conditions
from other abdominal conditions.

The cause of reverse peristalsis of the duodenum has not been
definitely determined. It is claimed by some that reverse peristalsis
is incident to respiration, but we are sure that this is not the case.
We have not had a sufficient number of observations of this con-
dition to determine its exact significance, if any.

Small Bowel. In the upper small bowel, comparatively few
lesions are found. Most frequently, the disturbance is the result
of adhesions, and this point has been mentioned elsewhere in this
paper. Constrictions resulting in obstruction have been demon-
strated, and it has been proved at operation that an ulcer has been
the basis of the pathology. Another infrequent finding is diver-
ticulitis, the identification of which should not be difficult.

Normally, the opaque meal will have passed into the colon at
twelve hours. Any residue after this time should, be classified
as ileal stasis. The importance of the ileal stasis as a factor in



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 43

gastric symptoms is second only to the appendix. ' The causes of
ileal stasis, as determined by the roentgen method of examination,
are adhesions and kinking, spasm of the ileocecal sphincter, and
incompetency of the ileocecal valve. Under the head of adhesions,
should, of course, come the atypical mesenteric bands known as
Jackson's membrane. The question of incompetency of the ileo-
cecal valve is most often demonstrated by means of the opaque
enema, but at times, by frequent observations of a given opaque
meal, it can be definitely shown that the cecal contents have been
regurgitated into the terminal ileum.

The importance of the appendix in gastrointestinal disease can-
not be overstated. The roentgen evidences of appendiceal disease
are, for the most part, direct. The most common is retention, the
degree of retention usually determining the importance of the
appendix as a factor in the gastrointestinal symptoms; (b) tender-
ness localized to the appendix; (c) kinking or angulation of the
appendix, indicating that appendiceal drainage would be imperfect ;

(d) irregular filling suggesting either concretions or constrictions;

(e) adhesions; (f) incompetence of the ileocecal valve; (g) dilated
duodenum with no other local pathology.

The most frequent indirect sign of appendicitis or even pathology
in the right lower quadrant is the so-called right-sided position of
the stomach. We frequently are able to suggest from the first
gastric study that the condition is one of right quadrant pathology
from the fact that the stomach is drawn downward and far to the
right.

In cases where the appendix cannot be seen, one is justified in
suggesting a diagnosis of appendicitis if there is tenderness of the
cecum on deep pressure, and if there is cecal fixation and retention,
or cecal spasm. We have also held that when manipulation of
the cecum or pressure over the cecum produces pain in the epigas-
trium, in the absence of other disturbances a condition of appen-
dicitis is probably present.

The question of the appendix filling with barium is one that re-
quiries further study. It is claimed by some workers that the fact
that the bismuth enters the appendix at all is evidence of pathol-
ogy. Others hold that this is probably normal and that the ques-
tion of pathology is dependent entirely upon how long the barium
remains in the appendix. This is one of the problems which we
think is worthy of a further study.

The importance of appendiceal retention in the absence of appen-



44 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

diceal fixation "or tenderness is undetermined. We frequently see,
especially in the aged, appendiceal retention for forty-eight or
seventy-two hours, and as far as we can determine, there were no
symptoms whatever from the appendix. In general, however, we
can state that an appendix which retains barium after the cecum is
empty can be definitely classified as pathologic. The assumption
that a diagnosis of appendicitis, without any modifying statement,
follows a demonstration of any of these conditions is no more cor-
rect than the assumption that because a gallstone has been demon-
strated, there is no other abdominal pathology, or even that the
stone is of diagnostic importance. In our opinion, appendiceal dis-
ease is quite often secondary to disturbances of the terminal ileum
and cecum, and appendicitis simply complicates rather than is the
occasion of the ileal or cecal pathology. This error explains the
large number of appendectomies which fail to relieve the symptoms
for which the patient was operated.

The differential diagnosis between gall bladder disease, ureteral
stone and appendicitis is greatly aided by the complete roentgen
study of the right side. We are all familiar with the high appendix
which gives a very clear clinical picture of gall bladder disease, and
also of the pathological retrocecal appendix which is with great dif-
ficulty differentiated from kidney or ureteral disease.

In connection with the colon, the most important condition for
the internist is colonic stasis. The most common cause of consti-
pation, as shown by the roentgen examination, is involvement of
the pelvic colon in adhesions. Aside from the fixation of the bowe'.
and tenderness associated with manipulation of the part, the pres-
ence of spasticity of the pelvic colon is always suggestive of adhe-
sions. The various deformities of the cecum, cecal fixation and
sharp angulations at the flexures are also associated with disturbed
colonic motility. The diagnosis of carcinoma or other new growths
involving the colon are diagnosed by the demonstration of a definite
defect in bowel outline or by an obstruction produced by the involve-
ment of the lumen with the tumor. The most satisfactory method of
examination of the colon for new growths is by means of the
opaque enema.

Numerous cases of constipation are demonstrated to be the result
of definite spasticity of the colon. It is our observation that spastic
constipation results in reflex gastric symptoms as a rule, while
general colonic statis is productive of symptoms of so-called auto-
intoxication.



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 45

As to the study of the colon to determine, if possible, the cause
of chronic diarrhea, the association of this condition with disei
of the appendix and with intestinal stasis is relatively common. The
intestinal stasis can be either the type associated with spasticity of
the colon or with dilatation.

I realize I have attempted the impossible in trying, in a brief
paper, to give a just consideration to my title. Hut I sincerely be-
lieve that if the internist will approach the subject as I have sug-
gested and become familiar with the full possibilities, and learn
to correctly associate the findings with the pathology and symptoms,
that the result will be advantageous. And further, there should be
no good reason for postponing the roentgenological examination
until all other tests have been carried out or diagnosis postponed
for further observation. This is a criticism which many internists
justly deserve, but one which will be surely avoided when the aid
we, as roentgenologists, can render, is fully appreciated.



THE VALUE AND LIMITATIONS OF RADIOTHERAPY
IN INTERNAL MEDICINE

By RUSSELL H. BOGGS
Pittsburgh

When I was requested to discuss the value and limitations of
radiotherapy to internists, I at once appreciated the fact it was not
until lately that the internists or consulting physicians realized the
value of this agent, though they often asked for a surgical con-
sultation in cases which were in no manner surgical. When you
stop to consider that over ninety per cent, of the cases of tubercular
adenitis can be permanently cured by the roentgen rays without
leaving any deformity, that the symptoms of exophthalmic goitre
are relieved in a large percentage of the cases, and that Hodgkin's
disease and lympho-sarcoma will disappear in nearly every case and
are not any more prone to recur than after a surgical operation,
then it is apparent this subject must be carefully studied by the
internist who may be compelled to consult with someone inex-
perienced. No one who has seen a large number of the cases
just mentioned, will fail to realize what an important place radium
and the roentgen rays take in many of the internal diseases. A
great deal of good work also has been done and reported on dis-



46 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

eases of the blood and blood forming organs, the value and signifi-
cance of which is not generally realized by the medical profession.

To-day the internist is taking perhaps the most important posi-
tion in the practice of medicine, and consultation with him is certain
to be of supreme importance in this class of cases. The internist
should be as adept in what can be accomplished by radiotherapy
as the surgeon should be in cancer. Most internists would not want
to decide on what should be done with cancer patients, and most
surgeons should not want to decide with the so-called internal dis-
eases. In the early clays of radiotherapy, before it had become a
specialty, this branch of medicine was usually left to the surgical
side of the hospital. It was very often forced upon the assistant
surgeon who was interested in surgery instead of radiotherapy,
and he frankly stated that he had no interest in this department.
Consequently he never studied the technic and usually did poorer
work after two or three years' experience than he did at first. The
assistant to the internist to-day would be in the same position.
Fortunately, it is realized that radiotherapy has become a strict
specialty. Unfortunately much of the work is being done by be-
ginners without a consultation with someone who has had the
proper experience.

In order to determine the therapeutical value of the roentgen rays,
it is necessary to study their physiological action. It has been
demonstrated that the same percentage of roentgen rays effect tissues
differently, and this explains how lymphatic glands will undergo a
degeneration, with almost an entire obliteration of the chain, with-
out seriously influencing the surrounding tissues. All tissues which
have undergone pathological changes react more quickly and in-
tensely. Both macroscopical and microscopical examinations show
how the rays act on the pathological and normal tissue. The select-
ive action of the rays for epithelial cells explains how certain dis-
eases are cured while others are unaffected.

The activity of development of the cellular constituents of a
part and the amount of cellular proliferation modify the reaction.
The more active the cellular proliferation, the more readily the
cells respond to radiation. The stage of maturity to which the