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Twenty-five patients with severe jaundice were studied prospectively with computed tomography (CT), gray-scale ultrasonography (USG), and percutaneous transhepatic cholangiography (THC). Nineteen had obstruction of the biliary tree. The differentiation of obstructive from hepatic parenchymal causes of jaundice was 72% accurate with USG, 92% with CT, and 96% with THC. Biochemical studies when used alone were 72% accurate. Although the precise location of an obstructing lesion was determined in 12/19 cases by CT and 9/19 by USG, the cause was established in only 5 by CT and 7 by USG. THC was 100% successful in establishing both cause and site of obstructive jaundice without significant complications.

The term minimal deviation hepatoma has been applied to a specific clinical, pathological, and angiographic entity. It is a tumor, composed of atypical cells, which is neither frankly malignant nor so well organized as a benigh tumor. This lesion occurs in females with otherwise normal livers and has a relatively benign course, although life threatening hemorrhage may occur. The diagnosis may be strongly suggested in the presence of hypervascularl or hypovascular discrete masses without evidence of frank malignancy, with a defect in the colloid liver scan and with normal liver function tests. Surgical resection when possible and aggressive chemotherapy may be corrective in many cases.

Examination of the postoperative stomach is a difficult and often confusing procedure. Traditional methods of investigation have depended on using small amounts of barium as well as appropriate pressure and positioning. The authors feel that the well-established technique of double-contrast radiography of the upper gastrointestinal tract (with appropriate modifications) is both easier and more diagnostic; moreover, with the exception of suspected perforation or anastomotic rupture, there are no contraindications to the use of gastrointestinal hypotonia, distension, and barium coating of the mucosa regardless of the presenting symptomatology or the acuteness or chronicity of complaints.

Presentation of Case A 67-year-old man was admitted to the hospital because of abdominal pain. For many years he had had attacks of nausea and vomiting, without pain. Ten years before admission his...

The axial pancreatic view is a simple adjunct to the barium meal examination for detecting enlargement of the pancreatic body and tail. By.aligning the x-ray beam with the long axis of the pancreas, the pancreatic body-tail is visualized as a cylinder on end. Local impressions on the stomach and quantitative enlargement of the pancreatic body-tail space without local impression can be shown. These findings are reliable signs of pathology even when the upper gastrointestinal examination with lateral views is otherwise normal. Clinical and cadaver radiographs demonstrate the advantages of this view over the supine translateral view.

In our experience, one of the most common diagnostic errors is the failure to detect a cecal cancer that coexists with a cancer of the distal colon (Fig. 1). There are two causes of this failure: (1) The radiologist does not fill the proximal colon after discovering the distal cancer because of concern that inspissation of barium may make a partial obstruction complete or because he fails to appreciate the frequency of multiple cancers. (2) The fecal matter in the colon proximal to the sigmoid lesion obscures the cecal lesion, or the tumor is falsely assumed to be a fecal mass. Simultaneous multiple cancers are termed synchronous, as opposed to metachronous cancer, which indicates that the second growth has appeared later in time. Heald and Bussey,lS analyzing a series of 4884 patients with large bowel cancer from St. Mark’s Hospital in London, found a 3.5% incidence of synchronous and 1.6% of metachronous cancers. Similar figures have been reported by others. ‘+v~ Patients with ulcerative colitis and familial multiple polyposis have been excluded from these series. Thus, if a large bowel cancer is detected, there is about a 3.5% risk that a second cancer is present (Fig. 2). The second cancer was detected by barium enema in only 5 of the 157 patients with synchronous cancers in the St. Mark’s series. One or more benign neoplasms (adenomatous polyps) was associated in 75% of the patients with synchronous cancers, which is three times the incidence in single cancers.

A prospective statistical study of 429 patients was undertaken to determine if the axial pancreatic view would improve detection of pancreatic body-tail enlargement. This view is produced by directing a roentgen-ray beam along the axis of the pancreatic body-tail cylinder. On this view and on the supine translateral view, a pancreatic body-tail space can be identified as a subdivision of the retrogastric space. When the pancreatic body-tail enlarges, this space selectively enlarges. The percentage change of this space is particularly impressive on the axial pancreatic view, where 10 of 12 pancreatic body-tail neoplasms were detected with only a 1.8 per cent false positive rate.

BENIGN AND malignant lesions involving the anterior mediastinum de novo or by extension are potentially serious and may become symptomatic by compromising vital structures. Although the severity of the symptoms may be roughly correlated with the extent of the tumor, a mass may attain considerable size before symptoms become manifest and, conversely, a small asymptomatic lesion may result in numerous anatomic and hemodynamic abnormalities not appreciated on routine studies. In order to utilize these secondary manifestations to better define obvious masses and thereby to establish criteria for the identification of more obscure lesions, we simultaneously opacified the anterior mediastinal vessels and the great vessels on the side of the dominant mass by means of ipsilateral brachial arteriography and sternal venography. Although the internal mammary arteries (1, 4) and veins (2, 5) have previously been individually outlined, the value of their simultaneous opacification had not been studied. It was felt tha...

An unusual complication of the roentgen examination of the colon results from mucosal rupture which allows some of the barium to dissect into the colonic wall. Usually, no symptoms are associated with the initial mucosal tear itself. Pain and local tenderness do not occur until minutes or hours later. The roentgen appearance of intramural or submucosal barium may be quite characteristic and easily recognized. An outstanding feature is a transverse striated pattern, probably produced by the inner circular layer of muscle fibers. Our experience with 3 patients with this complication is presented. Case I: H. A., a 63-year-old Negro female, was a frequent visitor to the Outpatient Department because of discoid lupus erythematosus and rheumatoid arthritis. For two and a half years an asymptomatic rectal prolapse of 1 to 1 1/2 inches had been observed. In April 1966, findings on sigmoidoscopy to 25 cm were negative except for a pedunculated polyp 1.2 cm in length, at 15 cm. On microscopic examination this was p...

Summary 1. The technique of radiocardiographyhas been employed to study twenty-two children with normal hearts and 100 children with congenital heart disease. 2. Different types of radiocardiograms were obtained in patients with patent ductus arteriosus, tetralogy of Fallot, Eisenmenger complex, and tricuspid atresia. 3. This method may be useful indifferentiating patients with Eisenmenger complex from those with tetralogy of Fallot. 4. Although the exact physiologicalphenomena responsible for the types of curves obtained are not known, preliminary evidence suggests that the radiocardiogram is predominantly a reflection of the blood flow in the right heart.

Of 27 patients with acute rectal hemorrhage studied by emergency selective arteriography, the bleeding point was demonstrated in 18. Fifteen of these were in the colon, and 13 were secondary to diverticulosis. Twelve of the offending diverticula were located to the right of the splenic flexure. Nine were in the ascending colon. Emergency arteriography was the only method that consistently demonstrated the bleeding point in these patients. The location of the majority of bleeding diverticula in the ascending colon weighs strongly against the use of emergency sigmoid colectomy in this group of patients.

The pancreas has remained the last of the viscera to defy direct radiographic study. Neither conventional nor special radiographic technics have led to its specific, reproducible, or consistent delineation. Heavy metal derivatives have proved too toxic (10); radioisotopic scanning has been relatively nonspecific (1); selective arteriography (5, 11) as well as retroperitoneal air insufflation combined with tomography (9), have resulted in only limited success. Attempts to induce the incorporation of iodinated compounds have met with failure with the exception of reports in the French literature (6). It is the purpose of this paper to present the initial results of our work with a method of direct visualization of the pancreas by reflux of contrast material from the duodenum. The reflux method also represents an additional mode of study of the biliary collecting system. Method and Results Laparotomies were performed under Nembutal anesthesia in 7 different adult mongrel dogs of both sexes weighing 45–65 pou...

Primary gastric stump cancer has been defined as a primary carcinoma of the gastric remnant, arising at a minimum of 5 years following a partial gastrectomy, in which the resected portion of the stomach was shown microscopically to be free of malignant disease.Our experience with 12 patients with this entity is presented. Two additional patients developed gastric cancer following a gastroenterostomy.An abnormality was detected in 9 cases and correctly diagnosed as cancer in 6 instances. Retrospectively, abnormalities were present in all 12 patients.Review of the world literature tends to support the concept that patients who have had a partial gastrectomy for gastric ulcer are more likely to develop gastric cancer than those who were operated on because of a duodenal ulcer.

The method of detecting and localizing brain tumors by external measurement of radiations emitted by radioactive di-iodo-fluorescein concentrated within the tumor was originated by G. E. Moore and his group at the University of Minnesota in 1947 (3). They first reported on a group of 77 cases, including 49 verified tumors, of which 25 (51 per cent) were correctly localized. A more recent report from this group concerned 26 proved brain tumors from a group of 71 patients studied, of which 17 (65 per cent) were correctly localized (4). The interest in this diagnostic method was heightened by a paper of Ashkenazy, Davis, and Martin (1), who attained an accuracy of 91 per cent in 95 patients with verified brain tumors. Woolsey, Thoma, and Mack (12), using the same method, reported a series of 114 patients with 30 verified brain tumors, of which 24 were correctly localized. Svien and Johnson (8) in a preliminary study found the method appproximately 40 per cent accurate. Schlesinger (5), in discussing his expe...

Cerebral angiography is becoming a common diagnostic procedure for three principal reasons: First, it is now recognized that disorders and malformations of the cerebral vascular system occur far more frequently than was generally believed. Second, angiography affords the best and, in most instances, the only means of demonstrating and localizing these abnormalities. Third, the improvements in the technic of injection of contrast media, and more especially the development of equipment for the automatic serialization of x-ray exposures, have made angiography a practical procedure. We have had very few indications for injecting the vertebral arteries which supply the posterior cerebral arteries and those in the posterior fossa, and for that reason this discussion will be confined to the technic and results of injection of the internal carotid arteries. Contrast Media The choice of a contrast medium is limited to 35 or 50 per cent diodrast, 50 per cent neo-iopax, and 24 to 26 per cent thorotrast. Recently we ...

The duodenal loop was distended between intraluminal balloons while using pharmacological relaxants topically and parenterally. Filling defects in the duodenum noted in upper gastrointestinal series represented pathological lesions if they were not obliterated by the distension. The normal papilla of Vater everts, while that with a stone or tumor behind it does not. Reflux pancreatography was attempted. Pharmacological agents which promoted duodenal hypotonia and reflux passage of contrast media through the sphincter of Oddi musculature in dogs proved ineffective in humans. Reflux opacification of the pancreatic duct of diagnostic quality was possible in patients who had a diverticulum in the ampulla.

The true incidence of webs in the hypopharynx and upper esophagus is not known, as many are probably not detected by the routine radiological examination of the upper gastrointestinal tract. This is particularly true if the patient has no symptoms referable to deglutition. Since the introduction of cineradiologic technics in the Columbia-Presbyterian Medical Center five years ago for the routine examination of the upper gastrointestinal tract, the detection of webs has increased sharply. During the ten-year period, 1950–1960, only 9 patients with webs were discovered, while during the past five years, 44 additional examples of this lesion were detected, 15 during the immediate past year. This fact prompted a review of 53 cases with radiographically demonstrable webs in the pharynx or upper esophagus that have been seen during the past fifteen years, in order to assess the clinical significance of the finding (Table I). Clinical Material The ratio of whites and Negroes was 30 to 23 and of males to females ...

The posterior indentation of the barium column of the pharyngoesophageal junction, which can be observed in 4 to 5 per cent of cineroentgenographic examinations of this area, is produced by the cricopharyngeus muscle. Despite the frequent absence of definite associated symptoms, it is not a normal finding and probably represents reliable evidence of neuromuscular dysfunction of deglutition. This may be an important factor in the pathogenesis of Zenker's diverticula since configurations which may represent the transition from a cricopharyngeal impression to a diverticulum have been observed.

Water soluble contrast material infused into the pancreatic duct is followed rapidly by roentgenographic visualization of the urinary tract in the dog. Iodinated contrast materials have been found to exhibit the property of opacity on electron micrographic study so that their location can be established. Biopsy specimens of the pancreas obtained at the time of infusion of contrast material demonstrated opaque material on electron microscopic evaluation. Simultaneous renal biopsies showed similar material in the brush border of the proximal convoluted tubule before it was visible roentgenographically.Evidence is presented to document the pancreatic ducto-interstitial-venous pathway postulated in 1909 by Herring and Simpson.3The observation that iodine containing roentgenographic contrast agents are visualized with the electron microscope offers wide possibilities for obtaining multiple static views of rapidly evolving physiologic processes.

Congenital tricuspid atresia is a complex congenital malformation manifested in a variety of forms. As Edwards and Burchell (8) point out, certain features are common to all cases: (1) atresia of the tricuspid valve, (2) atrial septal defect, (3) a large mitral orifice, and (4) hypoplasia of the right ventricle. Thus the venous return from the systemic circulation flows from the right auricle via the atrial septal defect to the left auricle, where it mixes with arterialized blood entering the left atrium through the pulmonary veins. It then enters the left ventricle, which functions as a single ventricle. Since the left ventricle expels blood into both the pulmonary artery and the aorta, cases of tricuspid atresia may be further subdivided according to the manner in which the blood is distributed through them to the two circulations. The traditional criteria for this subdivision have been the absence or presence of transposition of the great vessels and/or pulmonic stenosis. Thus, in Group I-a of Edwards ...

Primary thoracic vascular tumors are uncommon; primary thoracic hemangiopericytomas are rare. Many of the early cases were unrecognized or were grouped under the general heading of vascular neoplasms. Because of the malignant potential, however, it is essential that hemangiopericytoma be recognized as a separate entity. Only 8 cases of primary thoracic hemangiopericytoma have appeared in the literature. Eleven additional cases are now presented, bringing the total to 19 (Table I). These include 4 hospitalized patients and 7 additional ones referred to Presbyterian Hospital (New York) for consultation and review.2 Hemangiopericytoma has no predilection for age or sex; it was congenital in 3 of Stout's patients. In cases of thoracic hemangiopericytoma, the age range was from ten to seventy-five years, with an average of forty-six years. Distribution Since its original pathologic description (38), hemangiopericytoma has been reported in various sites including the skin (33), superficial soft tissues (11, 13,...

Primary pneumatosis intestinalis occurs most frequently in the colon of adults and is usually cystic. This condition is relatively benign, and frequently resolves spontaneously. Pneumatosis intestinalis of the small intestine of infants is nearly always secondary to a serious underlying disease of the gastrointestinal tract. In the premature infant, it is usually associated with an underlying necrotizing enterocolitis. Small intestinal involvement, in the adult, is associated with a variety of conditions, many of them serious. The distribution of the gas is usually linear. Air in the portal system is a grave prognostic sign and generally indicates intestinal necrosis. An example of survival of a patient with gas in the portal system is reported.

Experience with the use of thorium dioxide sol (Thorotrast) in the roentgen demonstration of accessory spleens is described. The importance of the application of this technic to the clinical management of patients with hematologic relapse following splenectomy is emphasized and illustrative case reports are presented. Nine patients were given thorium dioxide in an attempt to demonstrate an accessory spleen. A remission was induced in 1 patient with acquired hemolytic anemia, who had failed to respond to splenectomy, by removal of an accessory spleen demonstrated with thorium dioxide. A second patient with hereditary spherocytosis who relapsed seven years after splenectomy was shown to have an accessory spleen. Seven patients with idiopathic thrombocytopenic purpura who had relapsed following splenectomy were given thorium dioxide and in no case was an accessory spleen found.

Summary 1.The hazards of the barium enema examination have been reviewed and our experience with 13 patients has been presented. 2.The probable etiological factors were overinflation of a balloon catheter (six cases), enema tip trauma (four), elevation of intraluminal pressure (two), and proctoscopic biopsy (one). 3.Intraperitoneal perforation is a serious complication and was followed by death in four of six inf ants and one of five adults. 4.Extraperitoneal perforation is a relatively benign complication. 5.In three patients perforation occurred in colons that were not diseased. 6.Balloon catheters should not be used in infants, and only with caution in adults, particularly in a colostomy or in the presence of colonic disease. 7.Awareness of the hazards and prompt recognition of complications will minimize the associated morbidity and mortality.

Four cases of adenocarcinoma of the appendix which were demonstrated radiographically prior to surgery are reported. Preoperative diagnosis of carcinoma of the appendix is difficult because the radiographic appearance is similar to other lesions including inverted appendiceal stump, mucocele, cecal polyps, and intussusception of the appendix. Carcinoma of the appendix may have the clinical appearance of appendicitis. This results either from perforation of the gut wall by tumor with resultant abscess formation or obstruction of the appendix by tumor with subsequent appendicitis.

A rare form of hypertrophy of the pyloric muscles, occurring only in adults, is focal hypertrophy or torus hyperplasia. Four examples are described thus bringing the total reported cases to 27. Five of the 13 patients examined roentgenographically demonstrated a flattening of the distal 1 to 2 cm. of the lesser curvature of the antrum and asymmetric widening of the interval between the stomach and base of the duodenal bulb.

1. Eleven cases of involvement of the cervical spine by Paget's disease are reported.2. Three patients had evidence of spinal cord compression confirmed by operative or autopsy findings while a fourth is experiencing symptoms probably resulting from subluxation and mild compression.3. The roentgenographic appearance may closely simulate osteolytic or osteoblastic carcinoma and may be difficult to recognize as Paget's disease. Involvement of the neural arch, particularly when accompanied by involvement of the spinous process, points strongly toward Paget's disease, since it was present in 9 of the 11 cases.

The radiological appearance of hypertrophy of the pyloric muscle in the adult is characteristic according to many authors, and yet a preoperative diagnosis is seldom made with confidence. Kirklin and Harris (35) in their classical study of 81 patients predicted that a crescentic indentation of the base of the duodenal bulb in conjunction with prepyloric narrowing would prove to be pathognomonic of this condition even though only 1 of their 81 reported cases had been correctly diagnosed before operation. The accuracy of the roentgen diagnosis has not improved, however, according to more recent reports. Because of this diagnostic dilemma and the relative infrequency of the condition, the experience with this entity at the Columbia-Presbyterian Medical Center was reviewed. Clinical Material The roentgenograms and hospital records of 27 patients were studied and the essential data were tabulated (Table I). Only those subjects with histologically proved pyloric muscle hypertrophy and roentgenograms available f...

IT HAS BEEN repeatedly shown that with supervoltage equipment it is possible to damage deep-seated organs without injuring the skin. The total dosage that can be delivered to a neoplasm is thus no longer dependent upon skin tolerance but upon the tolerance of deep-lying tissues in the path of the beam. Since any tissue can be destroyed by radiation, the definition of radioresistance is a relative matter; in the past it has been defined chiefly in relation to skin tolerance. Since the advent of supervoltage therapy, there is an urgent need for quantitative knowledge regarding the dose of radiation that the different tissues can tolerate without irreversible changes that result in serious loss of function. In our experience in the treatment of intrathoracic cancer with the betatron, a major limiting factor has been the tolerance of the esophagus. During the past two years, among the patients whom we have treated for carcinoma of the lung, there were 20 who could not be adequately treated without inclusion o...