Non-Secretion of Tetraiodo-Phenolphthalein

Abstract

Since the introduction of cholecystography by the method of Graham and Cole, a very great deal has been written on physiology of the gall bladder, chemistry of the drug, technic of administration and biliary circulation, and more lately on the various findings of many roentgenologists — of course, the greatest emphasis is laid on the negative result, that is, in the case where a gall-bladder shadow fails to appear. This result has been held to be positive evidence that there is disease in relation to the gall bladder or ducts. I have read of and also observed cases of acute jaundice where the gall bladder failed to show a shadow — several of these later did fill and these we were forced to believe were cases of catarrhal jaundice. All our patients are given the dye intravenously, as our early experiences with capsules orally were dismal failures. In the last six months two cases have been referred to the X-ray Department for cholecystography which did not show any shadow in the suspected region. Both of these cases were clinically suffering from gall-bladder disease. In both, the gastrointestinal examination was negative. On both cases laparotomy was performed and in both cases the gall bladder was found to be normal in the gross —the wall not thickened, the color good, and the viscus emptied freely on gentle massage, but there was a large amount of disease in the neighborhood. The liver in both cases was very largely replaced by carcinoma. In one case there had been a carcinoma removed from the pelvis a few years previously; in the other, no primary growth was discovered. Neither of these patients showed jaundice. Both died within a couple of months of the laparotomy. I am reporting these cases, with short case histories, as I found them most interesting, and as I have not, to date, seen reports of similar cases in the journals. In one of Dr. Evarts Graham's early articles, he stated that the production of the cholecystogram depended on four things, the first of which was the secretion of the dye by the liver. These cases point out one way in which this part in the process may be interfered with, and thereby lead to faulty diagnosis of gallbladder disease. Case 1. Mrs. T. McA., aged 61. Beyond influenza and pregnancies, history was uneventful until three years ago, when she was operated upon for uterine cancer. Ten days ago she had pain in the right upper quadrant which required morphia. Vomiting and distention; W.B.C., 9,600. Gastrointestinal examination negative. Cholecystography showed no shadow. Operation showed the liver to be studded with large hard masses over its upper and lower surfaces. The gall bladder was free, soft, and emptied readily. Case considered hopeless, abdomen closed in layers. Pre-operative diagnosis, cholecystitis, cholelithiasis; postoperative diagnosis, carcinoma of the liver. Case 2. Mrs. A. L., aged 52. Ill for four weeks. Pain in right upper quadrant, vomiting, loss of weight.