GASTRO-PHOTOGRAPHY.

174

GASTRO-PHOTOGRAPHY. BY CHARLES A.

PANNETT, M.D. LOND., F.R.C.S. ENG.,

SURGEON TO ST. MARY’S HOSPITAL ; PROFESSOR OF SURGERY IN THE UNIVERSITY OF LONDON ;

AND

of which individual cameras face directions at right angles to each other, whilst being in the same horizontal plane. The two components of each stereoscopic camera are placed one vertically above the other. The angle of vision of each camera is so wide that it is possible to obtain images comprising the whole 0In;Ul11lerelloe

DAVID LEVI, M.S. LOND., F.R.C.S. ENG., SURGEON TO THE INFANTS HOSPITAL, VINCENT-SQUARE DEMONSTRATOR OF ANATOMY, ST. MARY’S HOSPITAL MEDICAL SCHOOL.

;

DIRECT inspection of the interior of the stomach

by means of the gastroscope, as a generally applicable clinical method, would seem to be an unattainable ideal. With such instruments as we possess gastroscopy In many can never become a routine procedure. individuals it is associated with an unjustifiable risk. The difficulties to be overcome to make it safe are so apparently insuperable that it is no wonder that efforts have been diverted to the problem of obtaining a photographic image in substitute. Yet this itself has raised questions of extraordinary complexity, and only quite recently has a certain measure of success been achieved by the inventive genius of F. G. Back, an Austrian engineer, working in Prof. Wenckebach’s clinic in Vienna, with Prof. Otto Porges and Dr. J. Heilpern. An instrument has been made which will, under conditions, give images -of a large part of the stomach and the use of which is .as free from danger as the passage of an ordinary .stomach-tube. The gastro-photor, as the instrument is called, is a magnificent example of the application of the resources of science to a difficult and intricate problem. The object of this communication is to ,examine critically the possibilities of the device in clinical medicine. .Some Fundamental Properties of the Apparatus. To carry out any useful investigation with the ,-gastrophotor it is essential to have an understanding FIGs. 1

Photograph of the anterior wall of the stomach to show the definition which can be obtained with the gastric

.

m

an

container enveloping over a zone whose vertical width will depend upon the distance of its inner wall from the camera. The horizontal groups of cameras are placed with the nearest pinholes 30 mm. vertically apart, so that the two vertical zones also overlap unless the containing walls are very close to the pinholes. The images on the films are only 5 mm. To show the shape of the airin diameter, the distended stomach and how the antrum turns backwards enlarged prints from at an angle to the general them have a diameter direction of the rest of the of 7-5 cm. But so stomach. brilliant is the flash and so sensitive the fine grained emulsion of the film, that it is possible to obtain prints of the definition shown in Fig. 1. However, the definition of the image depends to some extent upon the distance It falls off with of the object from the pinhole. increasing distance. The angle of the vision of the camera being so wide it naturally follows that the image of any particular object shrinks very quickly as it recedes from the pinhole, a fact necessary to keep prominently in mind in the interpretation of photographs. The intensity of the flash has been arranged to give a good exposure at the average distance the stomach walls must be away from the

5

6.

Lower antral picture of the cast.

Lower ventral picture of

the-cast.

camera.

- of the essential

principles of the apparatus and its pinholes to give pictures of a size which can be read physical possibilities. Its description has already and deciphered easily. It can be readily discerned appeared in several publications. It suffices to say how unfavourably the law of inverse squares acts in

here that in its latest form it consists of two groups of four stereoscopic pinhole flashlight cameras, in each

the

of the

distant

of the stomach, comprise just those areas the clinician would wish to inspect. Not only 1 Heilpern, J., and Porges, O.: Klin. Woch., 1930, ix., 15; is definition poor and the image excessively small, THE LANCET, 1931, i., 1371; Presse Méd., 1931, No. 31, p. 577. case

more

which, unfortunately,

often

areas

175 but the illumination is nothing like the optimum to ductions of the actual photographs, of which two are shown in Figa. 5 and 6. They are the lower ventral give the correct photographic exposure. When the camera is placed properly in the stomach and the lower antral pictures. It is interesting to the sizes of the squares in the ventral the pinholes of each group of cameras look

forwards,compare

FIG

FIG. 3.

Photograph of the posterior half of the model of the stomach with the camera in position. to left and to right. The images obtained described as upper or lower ventral, upper or lower dorsal, upper or lower fundal, and upper or lower antral.

backwards, are

of the Camera for Photographing the Stomach. The shape of the stomach differs very considerably in different people, as shown by X ray examination after the ingestion of an opaque meal. But the shapes thus revealed do not correspond with the air-inflated viscus which is photographed. The stomach, distended with air, approximates more to the shape of the In organ described in the older anatomy books. general it is to be considered as consisting of a large reservoir lying vertically or diagonally in the coronal plane of the body with a smaller antral portion which, as a rule, tends to turn backwards towards the spinal column (Fig. 2). The oesophagus passing into the stomach bears a little to the left, but a tube entering the cardiac aperture tends to be rather close to the lesser curvature. This can be seen very clearly in X ray photographs of the inflated stomach taken with the tube in position. In the diagrams (Figs. 7 and 8) it is seen that the camera cannot possibly give an image of that part of the lesser curvature, near the pylorus, and that in such a case the pylorus itself is not visible. This is one of the drawbacks of the apparatus ; in but few cases can the pylorus and the whole of the lesser curvature be photographed. To get some idea of the general field of view covered a cast of an inflated stomach was taken. A mould prepared from this was split into anterior and posterior halves. The inner surface was then marked out into square inches, which were numbered. The camera was used to photograph the inside of the model. Fig. 3 is a photograph taken with the ordinary camera of the posterior half of the model with ’, the telescopic camera in position. Fig. 4 is a drawing the shaded areas of which are those parts of the stomach of which images could not be obtained. More interesting than this, however, are the repro-

Suitability

Depicts the

area

4.

of the cast (dotted) which camera was placed

in the films when the

was as

not shown Fig. 3.

in

where the camera was near the model of the squares in the antral region. They are all of the same dimensions. The photographs also show what definition we may expect when contrasts are as great as black print upon a whiteground. If we look at the lower antral photograph we see the brightly illuminated arch of the lessercurvature with the larger sized images contrasted

photograph,

wall, with

some

FIG. 7.

To show how the camera can be withdrawn from contact with the lesser curvature by bending the the patient to

right,

FIG. 8.

To show how the camera may be made to advance along the greater curvature and thereby photograph more of

pyloric region by bending the patient to the left.

with the more dimly lighted small imaged squares of the part of the antrum forming the greater curvature. The actual pylorus is invisible. It is unfortunate that we do not see any more of the lesser curvature, and that the definition of the pyloric region of the stomach fails from small size of the image and poor quality of the illumination. And although the whole area visualised is a large part of the stomach it is not all actually useful as far as practical medicine is

concerned.

176 at the same time as the gastro-photograph. On the Technique of Gastro-photography. X ray film the image of the camera of known dimen. Though the apparatus has reached such perfection,1, sions can be measured and calculations based upon the we have found many pitfalls in the clinical application. corrected distance of the object from the pinhole L.0 and Errors can creep in at every stage of the process, so the known distance of the film from the latter. 8 that we cannot yet ensure at will a successful series This can only be an approximation, because the film of prints in every case. The preparation of the distance varies somewhat, as the films themselves patient is important. His stomach must be empty’f are not all accurately cut. Nevertheless, it is a usefor the examination. If any liquid should find its ful approximation, and enables us to realise, as do Itst way into the camera the films will be spoilt. Figs. 5 and 6, that a gastric ulcer, for instance, may suffices when the photograph is taken in the earlyhave a very different aspect according as it is seen morning to withhold food from the previous evening. close to or from some distance. In patients with much retention or with hyperWe do not feel at this stage that we can be dogmatic secretion the stomach will have to be evacuated*1 about appearances seen through the eye of the through a tube. Ryle’s tube is not suitable for thisS camera. At first the photographs look like meaningpurpose, owing to the small size of the holes, whichless blotches. With increasing familiarity they are apt to be plugged by food remnants. To preventb undoubtedly take on significance. Sometimes, by liquid entering the apparatus during its passage3 a trick of vision, depressions have the appearance through the oesophagus, a white paraffin wax is; of projections and by not viewing the photograph plastered into the crevices between the shutter andl as a whole from a sufficient distance we may perhaps the camera itself. The introduction of the camera fail to appreciate the forward bulging of the posterior is made much simpler and easier for the patient ift wall of the stomach caused by the vertebral column the pharynx and larynx be first sprayed with 5 per or the round into obscurity of the lesser bending cent. novocain. This makes not the slightest curvature. Much may be learned from the prodifference, the prejudice against it being quite baseless. jection of shadows on the gastric mucosa, and the If novocain be used the whole procedure can be intensity of the illumination in the depths of hollows. carried out with very little discomfort, whereas The intense whiteness produced by light reflected from without it some individuals exhibit an impassable the surface of mucus is characteristic. It is helpful to spasm at the entrance to the oesophagus, the attempt make use of the knowledge of the appearances of the to overcome which will cause considerable pain. different parts of the stomach obtained by gastroscopy. The camera will pass more easily if its rigid extremity It enables us to recognise the difference between the be directed down the oesophagus with the finger. It folds of the greater and lesser curvatures and other may be lightly lubricated with the paraffin wax, aspects of the mucous membrane. The deviations from referred to above, while the connecting rubber tube this normal-for instance, the drawing together of may be moistened with water. The instrument can these folds by cicatrisation round an ulcer-are the usually be felt to pass through the cardiac opening, features by which abnormalities are recognised. after which it is pushed on until it comes to rest, Conclusions. held up by the resistance offered by the greater curvature. Air is then blown into the stomach, the It is difficult to assess this new method of gastric patient having been previously warned to signalexamination at present. It is certainly a great technical when he feels distended, at which moment theachievement. It is also certainly sometimes capable photograph is taken and the apparatus withdrawn.of revealing abnormalities which remain concealed A good result will not be obtained unless the inflation by any other method of investigation. Extended is sufficient. fsystematic study of gastric disorders is required. X ray photographs of the camera in position Light may be thereby thrown upon the different show how it lies in the inflated stomach. It is very varieties of dyspepsia, the recognition of carcinoma apt to lie close to the lesser curvature, so close, in may become possible in some instances at an early fact, that it is not uncommon for no recognisable stage, before it is possible to discern its presence image to be obtained from the upper cameras facing by other methods of examination. The drawbacks antralwards. By bending the patient’s shoulders to of the method are obvious. It is a highly complicated the right it is possible to increase the distance between procedure requiring the utmost care at every step, the lesser curvature and the apparatus (Fig. 7), but and in the present stage of development cannot this manoeuvre will also carry it away from the most inevitably be made to produce results. It is a timefavourable position for seeing round the lesser consuming examination. Only further study will show curvature into the prepyloric region of the stomach, whether the gain is worth the immense trouble for which purpose it is better to have the patient’s involved. As a means of research it is essential that shoulders bent to the left (Fig. 8). All things con- it should be exploited. Doubtless its field of usefulness sidered, it seems more convenient to have the patient will be defined and experience will suggest alterations sitting up, but his back must not be allowed to sag. and simplification of technique. Such a safe method of The lesser curvature may also be well seen in the gaining further knowledge of gastric pathology seems left lateral position, with the pelvis and shoulders to offer distinct possibilities in the gastric investigation slightly raised. In the elongated variety of stomach of digestive ailments. a prolongation is screwed on to the extremity of the We wish to thank Dr. H. C. Gage for his cooperation in apparatus, otherwise, resting on the greater curvature, the X ray work and Mr. W. J. Newly, who has been it would be too far below the lesser curve to get useful responsible for most of the photographic technical work, and to whose enthusiasm the success is in great measure pictures. due. Baron Andre de Veitschberger has throughout given of Interpretation Photographs. us his guidance and the fruits of his experience ; to him we The extreme variation in the size of images has wish to accord our grateful thanks. already been referred to. It is one of the great diffiIt seems, however, that THE DONORS OF FALMOUTH HOSPITAL.-The culties of interpretation. of freedom the of Falmouth has been bestowed borough tell and will in here, experience reading photographs Mr. William Mountstephen and Mr. Alfred Charles it is possible actually to measure the size of an image upon Collins, who between them bore the entire cost of the newif a radiogram with the apparatus in position be made hospital at Falmouth.

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