The Demonstration of Gallstones by the Roentgen Ray

Arial W. George, Isaac Gerber
1914 Boston Medical and Surgical Journal  
Up to Avithin the past year, the demonstration of gall-stones upon plates by the Roentgen method has been regarded generally as a rare curiosity. Of late, however, Koentgenologists are learning more and more how to demonstrate these stones, so that the examination may be of definite diagnostic and prognostic value to the practitioner. We believe that this advance has been peculiarly an American one. Carl Beck showed the first plates of gall-stones at a meeting in New York in 1899.1 Since then
more » ... 1899.1 Since then he has devoted considerable energy to a development of the technique of gall-stone Roentgenography. More recently Case2 and Cole3 have both published numerous cases of gall-stones. The practical application of the Roentgen method to gall-stone diagnosis has apparently not spread so rapidly on the other side of the Atlantic. Ewald, in his very recently published monograph on diseases of the liver,4 states that-"unfortunately radioscopy has, up to the present, given us no reliable data for the recognition of gall-stones. The few cases that have been demonstrated were all rare exceptions of pure calcium stones." This statement is by no means true as regards the present status of gall-stone diagnosis in this country. In our own experience we began to find the shadows of gall-stones by accident during the course of the bismuth examinations of the alimentary tract. Gradually the accidental find-ings became so frequent that we found it advisable to look for gall-stones in every case. At present we have adopted the routine method of examining the gall-bladder region in every patient, before giving the bismuth meal. Pure cholesterin stones, as is Avell known, do not have a density differing much from that of the general ahdominal contents; therefore they will not interrupt the Roentgen Rays to any appreciable degree, so that their shadows cannot be differentiated. Fortunately however, these pure cholesterin stones are not common,5 or at least do not cause many chronic disturbances. When the gall-bladder is chronically inflamed with repeated infections, the stones that are deposited have the characteristic lamellae of calcium and bile salts encrusted on the cholesterin core. It is only the calcium admixtures that we can show by the Roentgen Ray. Therefore, the clearness of demonstration of gall-stones upon the plates will be in proportion to the amount of calcium present. As a rule nearly every case which has symptoms referable to gall-stones will have some calcium.5 Of course the Roentgen demonstration of gall-stones has not yet reached the position that has already been attained with regard to renal and uretéral calculi. However, at present avc believe that Avith care, and with attention especially directed to ¿he gall-bladder region, gall-stones can be demonstrated in nearly every case where the symptoms have been of long duration, and gall-stones are really present. In the near future avc hope that the certainty of diagnosis will approach that which already has been reached Avith renal calculi. At any rate, before long it will be possible to state definitely whether there are gall-stones present containing calcium or not. The technique for the demonstration of gallstones is very simple. The complicated methods which have been devised for projecting away the liver shadoAV, etc. are entirely unnecessary. The patient lies upon the table with his face down. The plate is placed under the right hypochondriac region. The maximum of sharp definition is obtained with a very small diaphragm, 1% inches in diameter, and a very small cylinder placed close down upon the back. It is preferable to use a fairly soft tubo with a rapid exposure. It is better not to use intensifying screens, but to use the simple plates as in kidney work. The gall-stone shadows will vary according to their calcium content. Often there will be a central light area due to the cholesterin core, with a peripheral calcium shadow. (Pig. 1.) Occasionally there may be made out the irregular deposits of calcium corresponding to the lamellated structure. (Pig. 1, stone 2.) At times the shadow will be dense and almost uniform, when there is considerable calcium salt present. (Pig. 2.) As a rule the faceted outlines will
doi:10.1056/nejm191404301701803 fatcat:vzdpbqhvareg7fqanibsot2eru