BODY SECTION RADIOGRAPHY IN SURGICAL CONDITIONS*

SHERWOOD MOORE, M.D.

Professor of RadioIogy, Washington University SchooI of Medicine

ST. LOUIS,

B ODY section radiography is an in&- sive term appIied to methods of radiographing a seIected Iayer in the

MISSOURI

body to the excIusion, in greater or Iesser degree, of other Iayers. This t.ype of radiog- raphy can be done in severa ways, a11 of which have specific terms,t stratigraphy, pIanigraphy, tomography, Iaminagraphy, and serioscopy. It seems desirabIe to re- strict these specific terms to the particuIar method empIoyed, or to the type of apparatus used, and to employ a genera1 term to cover a11 of them. For a description of these severa methods (except serio- scopy), the reader is referred to the articIes by Andrews, l Kieffer,2 and Moore.3 Because the principIe is compIex, a simpIe explanation of the fundamenta1 basis of a11 the methods empIoyed in body section radiography is in order.

The ruIes which appIy to visibIe Iight appIy with equa1 force, but with a qua&a- tion, to x-light. This quaIifidation will be referred to later. In radiography, the x-light records the sum of a11 structures capabIe of forming a shadow on the recording medium, the radiograph. Many maneuvers have been devised to separate superim- posed shadotis by changes of position of x-ray tube, fiIm and object. AI1 of them are of Iimited use. The first effort to eIiminate undesired shadows by means of a co- iirdinated movement of x-ray tube and medium, during exposure, was by Bocage in 1921. The investigations since that time can be found fuIIy described in the refer- ences aIready given.

If a source of visibIe Iight and a recording medium be revoIved about a fixed axis, the shadow of any object in this axis wiI1 maintain a constant reIationship to the Iight and the recording medium. Any object not directIy in the axis, about which revoIu- tion takes pIace, wiI1 have a constantIy shifting reIationship which is dependent on its distance from the axis and its reIation- ship to either the Iight or the recording medium. This is seen in the diagram. (Fig. I .) The diagram iIIustrates the sim- pIest form of movement whereby shadows of objects in aIignment can be separated from each other. With combined move- ments, the separation of shadows can be made more effective.

With visibIe Iight, the Iimitation, in the separation of shadows has been referred to above. It is to be remembered, in shifting superimposed shadows with x-Iight, that a proportion of the shadows which are shifted is distributed throughout the path of trave1 of the beam of x-rays because of their penetrabiIity. In consequence, the cocrdinated movement of x-ray tube and its recording medium, in addition to shifting shadows above and below the axis of movement, must aIso distribute them wideIy and evenIy. The more mathe- maticaIIy harmonious and compIete the movement of the x-ray tube and fiim, the better the distribution of the undesired shadows. The merits of the different movements empIoyed in body section radiography need not otherwise be dis- cussed here.

t Stratigraphy, Vallebona; planigraphy Ziedses des PIantes; tomography, ChaouI and Grossmann; Iami- nagraphy,‘_Moore; serioscopy, Ziedses des PIantes and Cottenot.

A seIected IeveI or Iayer in the body can be radiographed, to the greater or Iess excIusion of Iayers above and beIow, in three ways : through coardinated, synchro-

* From the Edward MaIIinckrodt Institute of RadioIogy, Washington University SchooI of Medicine, St. Louis.

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nized movement in different directions of x-ray tube and fdm during exposure; by keeping the tube and fiIm stationary and revoIving the body-in VaIIebona’s strati- graphy the tube and film remain stationary and the object (the patient) is moved, which is the opposite principIe to that in the other methods of body section radiog- raphy; and by making multipIe radio- graphs at different angIes, the tube, fiIm and body being stationary. In the last case, the radiographs are moved over each other in a specia1 apparatus devised for that purpose, the serioscope. The fiIms are pIaced in the serioscope in the order in which they have been made. The move- ment imparted to them is in reIation- ship to the angIe at which they were exposed.

In a11 methods of body section radiog- raphy there are definite thicknesses of Iayer which can be recorded cIearIy. The thickness varies with the apparatus and the type and extent of excursion of tube and film. The Iaminagraph has most of the possible practical movements of tube and fiIm, with the means of varying the thick- ness of the Iayer to be investigated, the Iower limit being about 5 mm. Increasing this decreases clearness. The Iaminagraph can be used for serioscopy.

It is a genera1 principIe that body section radiography has its chief vaIue where there is a maximum number of superimposed structures (Fig. 2) and, converseIy, it is of Iess vaIue where the opposite is the case. Unwanted shadows are dispIaced and dispersed by this means, but there is aIso great vaIue in the fact that the shaIIow depth of Iayer permits minima1 contrasts in density to be recorded on the fiIm. (Fig. 3.) Finer changes in tissue, therefore, that otherwise wouId be undiscoverable, can be visuaIized; for example, smaI1 areas of caIcification in soft tissues or smaI1 frag- ments of fractured bone, or foreign bodies of IittIe density. Body section radiography, therefore, has its chief use in regions or conditions where standard x-ray practice is inappIicabIe.

It is to be borne in mind, however, that the Iimitations which appIy to radiography, because of great size or massiveness of the

FIG. z. Laminagraph of lateral view of normaI hip joint through opposite hip joint.

part to be studied, cannot be overcome by any method of body section radiography and, as a corollary to this, it must be stated that, so far as experience has gone, Iaminag- raphy is an adjunct to, and not a super- cession of, conventiona methods.

RESPIRATORY SYSTEM

Body section radiography is of the utmost vaIue throughout the respiratory tract. This method has more appIications in the Iower part of the tract than in the upper air passages, for the Iower part is subject to more pathoIogic states which can be investigated advantageousIy by any type of x-ray procedure. It does not promise ever to be very useful in acute or earIy chronic puImonary disease. It may demonstrate, however, that the disease is more advanced than was thought to be the case by other methods of examination.

But this is not true in earIy tracheo- bronchia disease, as there is great promise

3’2 American Journal of Surgery Moore-Body Section Radiography NOVEMBER. 1939

of v raluabIe aid from this method in early bronchia branches and Iikewise their dise ase, especiaIIy of an occIusa1 type. In narrowing and occIusion. In the case of a the norma respiratory tract, the larger puImonary cavity, its depth is accurateIy

A

FIG. 3. Tumor of thigh. A, conventiona radiograph. B, Iaminairaph.

divisions of the tracheobronchia1 tree can be deIineated through a Iarge part of their extent by the use of properIy exposed seria1 Iaminagraphs.

OccasionaIIy the vascuIar tree can be shown equaIIy weI1. The presence of cavities (Fig. 4) and, to a Iesser extent, of tumors, is discoverabIe. These cannot be found by any other means. There is every reason to beIieve that the absence of cavita- tion can be shown with equa1 faciIity, but it must be remembered that there is a certain minimum of contrast in density which must be present. For exampIe, if a cavity is compIeteIy fiIIed with fluid con- tents, it wouId not be demonstrated in an opaque area of the Iung. The thinness of the Iayer radiographed frequentIy permits, because of the Iow density differentia1, the dispIacement and distortion of very fine

estimated and its third dimension very cIoseIy approximated through seria1 Iamin- agraphs. This fact is invaIuabIe in the surgica1 therapy of such Iesions.

DispIacements, distortions and compres- sions of the tracheobronchia1 tree are dis- covered readiIy. The degree of obIiteration of puImonary cavitation through coIIapse therapy of any type can be estimated accurateIy onIy by this method. Recurrent cavitation in the Iung foIIowing therapeutic measures can be detected where its pres- ence wouId be undiscovered by standard methods.

OSSEOUS SYSTEM

The osseous system comes next in this fieId of usefuIness, body section radiog- raphy being of particuIar vaIue about the foIIowing portions of the axia1 skeIeton: the

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FIG. 4. Pdmonary tubercdosis. A, conventiona firm. B, Iaminagraph reveals large activity.

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skuh, particularIy its base, the cervicaI radiography they wouId not be observed. spine, the dorsaI spine, sternum and ribs, This is equahy true of the remainder of the in the order given. In the remainder of the skeIeton. In the appendictdar skeleton,

A B

FIG. 5. TorticoIlis. A, conventional film through open mouth. B, laminagraph reveaIs rotary dislocation of atlas.

axia1 skeIeton, the Iumbar spine and body section radiography has been of great sacrum, this method has yet to prove its vaIue in a Iimited number of instances. superiority over conventional radiography. About the base of the skuI1 the greatest

FIG. 6. OId trauia of dorsal vertebrae. A, conventional firm! B, Iaminagraph.

However, shah foci of destruction in bone, usefuIness has been in examination of the either of infectious or neopIastic origin, can tempora1 bone, particuIarIy in the case of be detected readiIy,aIthough with standard the mandibuIar articuIation. PathoIogic

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conditions affecting the interna and ex- terna auditory meati the existence of which is unsuspected otherwise, can be discovered. Disease and trauma of the occipito-atIanta1 junction and at the axis (Fig. 5) have been found with the greatest facility, and correct treatment instituted. Laminagraphic examination of the remain- ing cervica1 vertebrae has been of Iess help.

The upper dorsa1 vertebrae are visuaI- ized cIearIy in the IateraI view through both shouIder girdIes. At a Iower IeveI they are seen free from the shadows of the over- Iying ribs and Iung markings. (Fig. 6.)

Shadows of structures Iying posterior to the sternum can be so bIurred that this bone is delineated cIearIy throughout its extent, but in practice separate fiIms usu- aIIy are required for the manubrium and gIadioIus. The presence or absence of trauma or disease of the sternum can be estabIished readily. This is true also of obscure conditibns invoIving the ribs.

In the appendicuIar skeIeton, smaI1 defects in bone have been found, as has been mentioned above, after standard methods have faiIed. In a patient who was thought to have a primary maIignant tumor of the bone, the zone of caIcification which Ied to that beIief was shown, through Iaminagraphic examination, to be entireIy independent of the bone. Very smaI1 avuIsion fractures about the joints have been discovered when their presence was not suspected.

NERVOUS SYSTEM AND

NEUROVENTRICULOGRAPHY

Except where disease of the nervous system resuIts in bone changes, the Iamina- graphic examination of the nervous system has not been of vaIue, but the possibiIities which lie in the smaI1 density differentia1 of the thin Iayer may be usefu1 in the future. In investigation of intracrania1 caIcifications and in examination of the seIIa turcica, no superiority over standard methods has been found.

This method has not been empIoyed in either neuroventriculography or encepha-

Iography. However, its employment in this type of examination has its advocates.

DIGESTIVE AND URINARY SYSTEMS

Body section radiography has not been used, except experimentaIIy, in the diges- tive and urinary systems. However, in both systems there is the possibility of materia1 aid in cases in which the recording of slight contrasts in density wouId be heIpfu1, or in which elimination of the shadows of un- usua1 objects is desired.

VASCULAR SYSTEM

In the vascuIar system, caIcifications in aneurysms have been found and the sac outIined.

There is a possibiIity that the smaIIest intracardiac caIcifications, since their exact depth in the body is known, can be found, and it is probabIe that there wiI1 be important deveIopments in this fieId of investigation.

In this connection it may be said that Iike possibiIity exists in the other sdft tissues. ExactlocaIization of foreign bodies is possibIe in seria1 Iaminagraphs.

TECHNIQUE

It is to be repeated that body section radiography is not to be substituted for standard x-ray methods. The Iatter shouId precede always, and they are a vaIuabIe guide in determining the extent of the area to be examined and the IeveI at which examination shouId begin.

OnIy genera1 statements can be made as to the technique. KnowIedge as to type and ampIitude of movement, and thickness of Iayer to be radiographed, has to be gained by experience. The genera1 ruIes of radiog- raphy, in regard to the position of the patient, voItage, current, and time of expo- sure, appIy in body section radiography approximateIy the same as in standard methods. The technique is not difficuIt, but stiII requires a considerabIe amount of tria1 and error.

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SUMMARY AND CONCLUSIONS It is concIuded that this method of

Body section radiography has been de- radiographic examinationth~oI~~Iu~re$ fined, and a simpIe exposition of the funda- profnrse for extending

mental DrinciDIe of a11 methods of bodv radlograPhy*

section iadioiraphy has been made. Thi severa methods of carrying out this pro- cedure have been brieffy defined and I’ described. The possiI$e clinica appIications 2. of body section radiography in the several anatomica systems have been briefly 3. discussed.

REFERENCES

ANDREWS, J. R. Planigraphy. I. Introduction and history. Am. J. Roentgenol., 36: 575-587, 1936.

KIEFFER, J. The Laminagraph and its variations. Am. J. Roentgenol., 39: 497-513, 1938.

MOORE, S. Body section roentgenography with the Iaminagraph. Am. J. Roentgenol., 39: 514-522.

1938.

PHYSICAL pain is certainIy inffuenced by a mental jactor, by energy,

by freewiI1. But how do these factors take effect? Do they act onIy as a

brake on the expression, the representation of pain? Or are they able

actuaIIy to diminish the acuteness of our painfu1 perception?

From-“ Surgery of Pain ” by Ren& Leriche (WiIIiams & Wilkins).