Leo G. Rigler

Spontaneous Pneumoperitoneum: A Roentgenologic Sign Found in the Supine Position1

The importance of the roentgen examination in the diagnosis of perforations of the hollow viscera has been repeatedly stressed and evaluated. In all cases in which a rupture of the stomach, small bowel, or colon, whether of spontaneous or traumatic origin, is suspected, the diagnosis can be made relatively certain by means of roentgen study. The roentgen findings depend upon the occurrence of a spontaneous pneumoperitoneum, gas from the gastro-intestinal tract escaping into the free peritoneal cavity. In all the literature on this subject it has been stressed that it is necessary to have the patient in the upright position in order that the gas may rise to the upper portion of the abdomen, coming to lie just inferior to the diaphragm. Thus the shadow of the gas can be made out by contrast with the diaphragm above and the denser shadows of the solid viscera below. When the upright position is impossible, it has been suggested that films might be made in the left lateral decubitus position, a postero-anteri...

The Roentgenological Manifestations of Pulmonary Edema

Considering the relative frequency of pulmonary edema, the paucity of references in the literature concerning its roentgen findings is astonishing. Standard texts on roentgen diagnosis contain only brief references to this condition; the descriptions in the literature deal largely with clinical cases, and few reports of cases verified by necropsy have been presented. Furthermore, the greatest emphasis has been placed upon a classical roentgen picture. In our experience there have been numerous variations from this typical appearance which we feel should be more fully described. Many of these variations simulate other pulmonary lesions to such a degree that frequent errors in diagnosis must result. For purposes of orientation, a brief review of the pathology and of the theories of the etiology of pulmonary edema must be undertaken. The pathology of pulmonary edema, consisting essentially of heavy, sodden lungs, with a microscopic picture of alveoli distended with serous fluid, is sufficiently well known to...

Traumatic Retroperitoneal Rupture of the Duodenum

THE duodenum, being protected by the liver, colon, transverse mesocolon, the mesenteric root, and the lower thorax, is but rarely ruptured by blunt traumatism of the abdominal wall. However, when the trauma is severe, the fact that the duodenum is fixed to the rigid spinal column favors its rupture. Only the uppermost first portion of the duodenum possesses acomplete peritoneal covering. The second and third portions are covered by peritoneum on their anterior aspect only. Hence the anatomic classification of retroperitoneal and intraperitoneal duodenal rupture. In 1895 Petry estimated the number of traumatic duodenal ruptures at 5 per cent of the injuries of the gastro-intestinal canal. In 1907 Hertle estimated its occurrence at about 10 per cent. Counseller, at a more recent date, also stated that the duodenum is involved in about 10 per cent of all cases of traumatic rupture of the bowel. In 1922 Furtwaengler gathered 118 cases.The incidence of duodenal rupture no doubt has increased tremendously with ...

Atypical Distribution of Pleural Effusions1

CERTAIN conceptions about the distribution of fluid in the pleural cavity have been maintained since the earliest studies in physical diagnosis. The development of the roentgen examination of the chest has served, in some respects, to substantiate these conclusions. There is a general idea, expressed in most textbooks, in the literature, and widely held by roentgenologists and physical diagnosticians, that liquids in the pleural cavity, in the absence of pneumothorax, take on a fairly definite, uniform appearance on roentgen examination. This appearance is described, typically, as a dense shadow which, in the early stages of an effusion, obliterates the normal aeration of the costophrenic angle; as the fluid increases, the shadow extends medially over the diaphragm and upward along the periphery of the chest. The upper surface of this density is concave, and the shadow rises higher in the lateral and posterior than in the medial or anterior portions of the thorax. When a massive effusion is present the en...

Benign Tumors of the Stomach1

The microscopic distinction between benign and malignant neoplasms of the stomach is occasionally impossible, often hazy, and, even in those instances in which it is clear-cut, there is a strong possibility that a lesion appearing benign may eventually become malignant. It would seem, therefore, almost foolhardy to attempt to distinguish them roentgenologically were it not for our experience which indicates that frequently, at least, even this differentiation may be made. The roentgenologic diagnosis “benign gastric tumor” has been confirmed frequently enough so that this terminology seems eminently justified. The demonstration by roentgen examination of the stomach of a benign tumor no larger than a hemp seed (2), or of a carcinoma which is barely distinguishable macroscopically (20), gives an indication of the possibilities of this method and lends encouragement to attempts at making such fine distinctions. An apt illustration of the faithfulness with which the roentgenogram may reproduce the gross path...

Roentgenologic Findings in Acute Obstruction of the Colon

THE active interest, in recent years, in the problem of obstruction of the small bowel, aroused by newly discovered methods of therapy and diagnosis, has served to obscure the importance of acute obstructions of the large bowel. Yet this condition presents a serious problem to the clinician, usually requiring emergency measures. It differs from a similar lesion at higher levels in the intestinal tract both in symptomatology and in treatment. Obstruction of the large bowel is not relieved to any degree by suction, so that temporization is usually unwise. For this reason it becomes necessary to make an accurate diagnosis at the earliest possible moment. Whether the obstruction be due to carcinoma, diverticulitis, benign stricture, volvulus, or to congenital anomalies, it is important for the surgeon to have as much information as possible concerning the nature of the pathologic process, the degree and position of the obstruction, and the possible etiologic factors. Toward achieving this end, the roentgen ex...

The Effects of Thorium Dioxide Sol (Thorotrast)1 on the Human Liver2

Introduction THE usefulness of thorium dioxide sol in the roentgen diagnosis of diseases of the liver and spleen has been well demonstrated by numerous articles in the recent medical literature (23, 24, 15, 16, 7, 33, 13). Its utility, however, has been greatly restricted by the fear, which has been so frequently expressed, that ill effects may follow its injection. The dangers associated with the use of this substance have been abundantly described and numerous conflicting opinions have been presented regarding the justification for its employment. While the original protagonists for the utilization of this colloidal suspension of thorium dioxide (thorotrast), Radt (24) and Kadrnka (16), apparently are satisfied that it presents no real danger; others, such as Anders and Leitner (1), Buchner (2), Cooke (4), Hanke (8), Shute and Davis (29), Pohle and Ritchie (21) and others, criticize the use of this material most emphatically. Naegeli and Lauche (20) take a middle ground, while numerous other authors, su...

Segmental Anatomy of the Lung

The conception of gross anatomy as a closed subject, whose investigative possibilities have been completely exhausted, has again been refuted by the studies of Boyden (1) and his associates on the segmental anatomy of the lungs. In recent years there have been two other important contributions to our knowledge of the anatomy and nomenclature of the lung. Brocks (2) work on the detailed anatomy of the lungs with particular reference to the surgery of lung abscess and pulmonary embolism has been reported in detail. Jackson and Huber (3) suggested a more rational nomenclature of the bronchi, especially as seen by the bronchoscopist. More recently, in a series of papers of great interest to all those concerned with pulmonary diagnosis and therapy, Boyden, Scannell, Hartmann, Smith, and Berg have made a most important contribution to the understanding of the anatomy of the lung. For the first time, in the 400 odd years since Vesalius, the detailed relations of the segmental bronchi, the accompanying segmental...

A method of double-contrast roentgen examination of the small intestine.

Advances in accuracy of diagnosis of lesions in the esophagus, stomach, duodenal bulb, and colon have far surpassed achievements in demonstration of organic lesions of the jejunum and ileum. Though great strides have been made by Mackie (25), Snell and Camp (39), Golden (19), Pendergrass and Comroe (31) and others in the demonstration of functional changes in the bowel, adequate examination of the small intestine and satisfactory delineation and demonstration of its lesions remain a challenge to the radiologist. There are three principal reasons for lack of progress in roentgen diagnosis of small bowel lesions: (1) the time-consuming nature of the examination; (2) difficulty in interpretation of minor changes in the bowel; (3) the extremely low incidence of organic disease in this part of the digestive tract, so that the examiner has little to show, in the way of positive diagnoses, for the effort expended in many examinations. It is the purpose of this paper to review the various methods of examination o...

Cholangiography and biliary regurgitation.

Cholangiography, the roentgen study of the biliary tract by means of the direct introduction of a contrast medium, may be accomplished in a number of ways and with a number of contrast substances. The material may be injected directly into the gallbladder or the common duct—immediate cholangiography—at the time of a surgical exploration of the biliary tract. Roentgenograms are then made on the operating table (Fig. 1). More commonly the injection is made postoperatively through a drainage tube previously inserted into the gallbladder or the common duct—delayed cholangiography. Recently some efforts have been made to inject a radiopaque substance into the gallbladder before operation. This can be accomplished by either of two procedures. A catheter can be placed in the gallbladder through a simple abdominal incision. Cholangiography is then done and the situation of the biliary tract determined (Fig. 2). The information obtained will govern the exact type of surgery to be undertaken. Another method is that...