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Roentgenoscopic diagnosis of gastrointestinal perforations: spontaneous pneumoperitoneum
New Series VOL.
II. No. I
Progress
upper part of the wire had broken off and risen in the aorta, where it curved with the arch. It is hard to say whether the improvement in this case was due to the introduction of the wire into the aneurysm or to the antisyphiIitic treatment, but as it began immediateIy after the operation the author thinks it was due partIy at Ieast to that. The presence of the broken wire in the aorta is a cause for serious anxiety. A recent articIe in the Britisb Journal of Surgery reviews 3 simiIar operations; one of the patients died eight and a haIf months after the the others within a few days. operation, The authors advise gastroenterostomy after the insertion of the wire into an aneurysm for fear of acute diIatation of the stomach from pressure on the pyIoric or prepyIoric region. But in this case the operation not onIy did not cause any stomach symptoms but reIieved those which already existed. It is hard to say whether this reIief was due to the decreased expansion of the aneurysma sac or to the section of sympathetic fibers in exposing the sac above the Iesser curvature. GUILLEMIN, A. Roentgenoscopic diagnosis of gastrointestina1 perforations: spontaneous pneumoperitoneum. Arch. franco-be&es de cbir., August, 1925, xxviii, 684-702. Sometimes the symptoms of a gastrointestina1 perforation are so indefinite that diagnosis is d&uIt. Even as expert a gastrointestina1 surgeon as Moynihan made an incision in the right iliac fossa in 18 out of 4g cases on a mistaken diagnosis of appendicitis. GuiIIemin describes 2 cases, one of vioIent abdomina1 pain in pneumonia and one of ruptured tubal pregnancy in which the symptoms were those of perforated gastroduodena1 uIcer, and on the other hand, one in which the symptoms of a rea1 perforation were so slight that the diagnosis was not made and the patient died. In IgIG Lenk first used roentgen examination to diagnose perforations of the intestina1 tract by bullets. He demonstrated a spontaneous pneumoperitoneum; the intestina1 gas had accumuIated between the Iiver and diaphragm which were pushed apart. A number of other authors have since used it in perforation of gastroduodena1 uIcers and typhoid perforations of the intestine. Vaughan and Brams demonstrated free air in the peritonea1 cavity in 13 out of 14, or 86.7 per cent of cases of typhoid perforation. The author has made a systematic examination of a11 the patients who entered his hospita1 with signs of gastrointestina1 perforation during the past year. He was abIe to make a diagnosis of perforation in 7 cases, 4 of perforation
in Surgery
American Journal of Surgery
87
of gastroduodena1 uIcer, 2 of perforated appendicitis and one of buIIet wound. The tendency of the gas is to rise to the highest point so that if the perforation is above the mesocoIon the gas wiI1 rise and collect between the Iiver and the right side of the diaphragm; the diaphragm wiI1 be immobile. But if the perforation is beIow the mesocoIon the gas will strike the barrier of the omentum and transverse mesocolon and push them up. In Iow or appendicuIar perforation the gas may pass along the colon and accumuIate under the diaphragm. If there are adhesions the gas may be encysted IocaIIv. The method is a vaIuabIe aid in cases which are doubtfu1 cIinicaIIy. Its vaIue is not absoIute for a smaI1 accumulation of gas in a case with earIy adhesions may not be seen; but in that case, the perforation being covered, there is no great danger to the patient. In perforated gangrenous appendicitis there may be a question as to whether the gas is from a perforation or has been produced by anaerobic bacteria. The objection has been urged that it deIays operation and that the patient may be injured by the change of position necessary for the examination. But an enrIy diagnosis is ;I necessary preIiminary to earIy operation and the makmg of an exact diagnosis 11~ means of roentgenoscopy may hasten, rather than deIay operation. The patient can be examined in ;I semi-recIining position and there is very Iittle danger of breaking adhesions or of disseminnting the infection. HEUSER, CARLOS. Air in the bladder. Roentgenographic expIanation of how it may cause death. Semana med., Buenos Aires, Jan. 28, 1926, xxxiii, 2 14-2 I 7. So far the author has not had a case of death from insulation of air into the bIadder but he has had a case which espIains how it ma> occur. He injected air in a case of suspected tumor of the bIadder in which cystoscopy couId not be performed on account of stricture. Some of the air escapec1 between the sound and the urethra and none couIc1 be seen in the bladder. A second insuflation was made and 30 C.C. Iipiodol aIso injected. The latter couIt1 be seen in the bladder but no air. Another roentgenogram was taken including the kidney region and the ureters and kidney pelves were found distended with air to such an extent that the ureters Iooked Iike small intestine but were recognized as ureter3 from their position. If a IittIe more air had been injectecl they would have ruptured. In a case like this if the waIIs of urinary canaIs were fragiIe air wouId infiItrate into the circulation and death resuIt from emboIism of the heart. Not more than 80 C.C. of air should IX insuf%tetl into
II. No. I
Progress
upper part of the wire had broken off and risen in the aorta, where it curved with the arch. It is hard to say whether the improvement in this case was due to the introduction of the wire into the aneurysm or to the antisyphiIitic treatment, but as it began immediateIy after the operation the author thinks it was due partIy at Ieast to that. The presence of the broken wire in the aorta is a cause for serious anxiety. A recent articIe in the Britisb Journal of Surgery reviews 3 simiIar operations; one of the patients died eight and a haIf months after the the others within a few days. operation, The authors advise gastroenterostomy after the insertion of the wire into an aneurysm for fear of acute diIatation of the stomach from pressure on the pyIoric or prepyIoric region. But in this case the operation not onIy did not cause any stomach symptoms but reIieved those which already existed. It is hard to say whether this reIief was due to the decreased expansion of the aneurysma sac or to the section of sympathetic fibers in exposing the sac above the Iesser curvature. GUILLEMIN, A. Roentgenoscopic diagnosis of gastrointestina1 perforations: spontaneous pneumoperitoneum. Arch. franco-be&es de cbir., August, 1925, xxviii, 684-702. Sometimes the symptoms of a gastrointestina1 perforation are so indefinite that diagnosis is d&uIt. Even as expert a gastrointestina1 surgeon as Moynihan made an incision in the right iliac fossa in 18 out of 4g cases on a mistaken diagnosis of appendicitis. GuiIIemin describes 2 cases, one of vioIent abdomina1 pain in pneumonia and one of ruptured tubal pregnancy in which the symptoms were those of perforated gastroduodena1 uIcer, and on the other hand, one in which the symptoms of a rea1 perforation were so slight that the diagnosis was not made and the patient died. In IgIG Lenk first used roentgen examination to diagnose perforations of the intestina1 tract by bullets. He demonstrated a spontaneous pneumoperitoneum; the intestina1 gas had accumuIated between the Iiver and diaphragm which were pushed apart. A number of other authors have since used it in perforation of gastroduodena1 uIcers and typhoid perforations of the intestine. Vaughan and Brams demonstrated free air in the peritonea1 cavity in 13 out of 14, or 86.7 per cent of cases of typhoid perforation. The author has made a systematic examination of a11 the patients who entered his hospita1 with signs of gastrointestina1 perforation during the past year. He was abIe to make a diagnosis of perforation in 7 cases, 4 of perforation
in Surgery
American Journal of Surgery
87
of gastroduodena1 uIcer, 2 of perforated appendicitis and one of buIIet wound. The tendency of the gas is to rise to the highest point so that if the perforation is above the mesocoIon the gas wiI1 rise and collect between the Iiver and the right side of the diaphragm; the diaphragm wiI1 be immobile. But if the perforation is beIow the mesocoIon the gas will strike the barrier of the omentum and transverse mesocolon and push them up. In Iow or appendicuIar perforation the gas may pass along the colon and accumuIate under the diaphragm. If there are adhesions the gas may be encysted IocaIIv. The method is a vaIuabIe aid in cases which are doubtfu1 cIinicaIIy. Its vaIue is not absoIute for a smaI1 accumulation of gas in a case with earIy adhesions may not be seen; but in that case, the perforation being covered, there is no great danger to the patient. In perforated gangrenous appendicitis there may be a question as to whether the gas is from a perforation or has been produced by anaerobic bacteria. The objection has been urged that it deIays operation and that the patient may be injured by the change of position necessary for the examination. But an enrIy diagnosis is ;I necessary preIiminary to earIy operation and the makmg of an exact diagnosis 11~ means of roentgenoscopy may hasten, rather than deIay operation. The patient can be examined in ;I semi-recIining position and there is very Iittle danger of breaking adhesions or of disseminnting the infection. HEUSER, CARLOS. Air in the bladder. Roentgenographic expIanation of how it may cause death. Semana med., Buenos Aires, Jan. 28, 1926, xxxiii, 2 14-2 I 7. So far the author has not had a case of death from insulation of air into the bIadder but he has had a case which espIains how it ma> occur. He injected air in a case of suspected tumor of the bIadder in which cystoscopy couId not be performed on account of stricture. Some of the air escapec1 between the sound and the urethra and none couIc1 be seen in the bladder. A second insuflation was made and 30 C.C. Iipiodol aIso injected. The latter couIt1 be seen in the bladder but no air. Another roentgenogram was taken including the kidney region and the ureters and kidney pelves were found distended with air to such an extent that the ureters Iooked Iike small intestine but were recognized as ureter3 from their position. If a IittIe more air had been injectecl they would have ruptured. In a case like this if the waIIs of urinary canaIs were fragiIe air wouId infiItrate into the circulation and death resuIt from emboIism of the heart. Not more than 80 C.C. of air should IX insuf%tetl into