256 ILLINOIS STATE ACADEMY OF SCIENCE 



This shows a shadow of the liver and kidney, and re- 

 peatedly a shadow of the gall bladder can be demonstrated. 

 An accurate knowledge of the different types of gall blad- 

 der that are to be met with is essential. It is not neces- 

 sary to show the presence of stones to outline a patho- 

 logical gall bladder. 



Pathological bile, thickening of the gall bladder wall, and 

 adhesions combine to give a shadow so dense that it will 

 be cast upon the film if the proper technique is employed. 

 If the stones are present they may cast a shadow if of suf- 

 ficient density. On the other hand, some cholesterin stones 

 have given lighter areas than the surrounding medium; in 

 either case the result is apt to be a mottling or tessilation 

 of the area within the gall bladder shadow. A normal gall 

 bladder does not differ in density from the surrounding 

 structure sufficiently to throw any shadow. 



In addition to these findings others are of value, such as 

 local tenderness under the fluoroscope with accurate locali- 

 zation; immobility of the duodenum, where the bulbus is 

 perfect in outline, and not of the physical type where the 

 bulbus is normally immobile; at times a high help hepatic 

 flixure in addition to other findings; in other cases, a 

 gall bladder seat shown in the shadow of an other- 

 wise normal duodenum ; again a number of cases have been 

 noted in which the duodenum has taken an unusually wide 

 outward curve to the right, as though due to encroachment 

 of the head of the pancreas. While simulating carcinoma 

 of the head of the pancreas, which must always be con- 

 sidered, we have never seen a carcinoma of this type but 

 rather have found a pathological gall bladder adherent to 

 the head of the pancreas. 



Lastly complete the diagnosis, not as to fact, but as 

 to origin or contributing cause, when the patient goes to 

 operation. 



Here I want to emphasize the point that facts are fre- 

 quently overlooked which, while of no import to the sur- 

 geon at the time, may yield a wealth of information to the 

 internist who scrubs up, and examines carefully the patho- 

 logy before any of the relations are disturbed, then follows 

 every step of the operation. 



