Seminars VOL.
XI,
in Roentgenology JULY
NO. 3
----
Letter
N THE LAND of bile and money, every radiologist is an expert. Except me. As a teacher and consultant in a busy radiology department, 1 find that the radiology residents and young staff radiologists seldom seek my help in interpreting a cholecystogram, so I hardly ever see any. When one of them does show me a case, if we disagree he takes it to another staff member. No respect! I am reminded of the teacher who sent a note home, “Please give Johnny a bath.” Johnny’s mom sent a note back: “Learn him, don’t smell him.” So, whom can an unconsulted consultant consult? The answer is easy: other consultants. I have therefore gathered a group of leading bilious radiologists so that we can turn to the appropriate bilophile to resolve our bitter biliary arguments. An experienced physician is one who has made many mistakes and remembers them. I qualify as an experienced choleradiologist because I’ve made just about every mistake that can be made in performing and interpreting cholegrams and have seen almost every complication that can complicate. Furthermore, my memory for past events seems to be improving. I wasn’t a radiologist when Evarts Graham first performed cholecystography (Leo Rigler was*), but I do remember the earliest contrast medium, sodium tetraiodophthalein. What a miserable substance it was! Bad enough orally, for a time it was recommended for intravenous administration. We switched to this route, but the reactions were severe and gallbladder visualization was not enhanced, so we stopped doing it. Speaking of reactions, many of you must remember when Orabilex@ had to be withdrawn from the market because it occasionally caused Vol.
11, No.
1, January
1976.
Seminars
in Roentgmology,
Vol.
Xi,
No.
3 (July),
_. -__
From the Editor
I
*Seminars in Roentgenology,
1976
lg76
renal shutdown. I was close to the problem, since the medical director of the drug company that manufactured it was a tennis crony who once gave me an engraved silver trophy for beating him. 1 misshim. John, the morgue attendant in our pathology department, had the world’s greatest collection of gallstones,all cataloguedand sorted by color, size, and configuration. I too am a collector of biliary trivia and have accumulated a fascinating array of cases,including a gallstonein the stomach,a triple gallbladder, and examples of the Philomena sign. Yes, the Philomena sign. Within the spaceof 6 months, I encountered three women with this first name, each of whom had gasin the common duct. In two, a carcinomatous fistula of the pancreaticoampullary region was responsible; in the third, the gas was attributable to reflux through a normal ampulla, confirmed at operation. It is important to determine by one method or another whether the cystic duct is obstructed becauseof the nature and severity of the complications related thereto. Hydrops, empyema,perforation, “porcelain gallbladder,” and “limy bile” are found only in the presenceof cystic duct obstruction. Internal biliary fistula, gallstone ileus, and emphysematous cholecystitis are also often associatedwith cystic duct obstruction. Because of the scope of the subject, we have devoted two issuesof Seminarsto the biliary tract. However, much of this information may soon become obsolete. The following “Letter for the Editor” will explain what I mean. The subject index for this issuewill appear in a combined index with Part II of this Seminar in the October issue. Benjamin Felson, M.D. Editor
141
XI,
in Roentgenology JULY
NO. 3
----
Letter
N THE LAND of bile and money, every radiologist is an expert. Except me. As a teacher and consultant in a busy radiology department, 1 find that the radiology residents and young staff radiologists seldom seek my help in interpreting a cholecystogram, so I hardly ever see any. When one of them does show me a case, if we disagree he takes it to another staff member. No respect! I am reminded of the teacher who sent a note home, “Please give Johnny a bath.” Johnny’s mom sent a note back: “Learn him, don’t smell him.” So, whom can an unconsulted consultant consult? The answer is easy: other consultants. I have therefore gathered a group of leading bilious radiologists so that we can turn to the appropriate bilophile to resolve our bitter biliary arguments. An experienced physician is one who has made many mistakes and remembers them. I qualify as an experienced choleradiologist because I’ve made just about every mistake that can be made in performing and interpreting cholegrams and have seen almost every complication that can complicate. Furthermore, my memory for past events seems to be improving. I wasn’t a radiologist when Evarts Graham first performed cholecystography (Leo Rigler was*), but I do remember the earliest contrast medium, sodium tetraiodophthalein. What a miserable substance it was! Bad enough orally, for a time it was recommended for intravenous administration. We switched to this route, but the reactions were severe and gallbladder visualization was not enhanced, so we stopped doing it. Speaking of reactions, many of you must remember when Orabilex@ had to be withdrawn from the market because it occasionally caused Vol.
11, No.
1, January
1976.
Seminars
in Roentgmology,
Vol.
Xi,
No.
3 (July),
_. -__
From the Editor
I
*Seminars in Roentgenology,
1976
lg76
renal shutdown. I was close to the problem, since the medical director of the drug company that manufactured it was a tennis crony who once gave me an engraved silver trophy for beating him. 1 misshim. John, the morgue attendant in our pathology department, had the world’s greatest collection of gallstones,all cataloguedand sorted by color, size, and configuration. I too am a collector of biliary trivia and have accumulated a fascinating array of cases,including a gallstonein the stomach,a triple gallbladder, and examples of the Philomena sign. Yes, the Philomena sign. Within the spaceof 6 months, I encountered three women with this first name, each of whom had gasin the common duct. In two, a carcinomatous fistula of the pancreaticoampullary region was responsible; in the third, the gas was attributable to reflux through a normal ampulla, confirmed at operation. It is important to determine by one method or another whether the cystic duct is obstructed becauseof the nature and severity of the complications related thereto. Hydrops, empyema,perforation, “porcelain gallbladder,” and “limy bile” are found only in the presenceof cystic duct obstruction. Internal biliary fistula, gallstone ileus, and emphysematous cholecystitis are also often associatedwith cystic duct obstruction. Because of the scope of the subject, we have devoted two issuesof Seminarsto the biliary tract. However, much of this information may soon become obsolete. The following “Letter for the Editor” will explain what I mean. The subject index for this issuewill appear in a combined index with Part II of this Seminar in the October issue. Benjamin Felson, M.D. Editor
141
