jIjMiljMXM^I^^^^
Presented in honor of
Alfons I. Wray, D.O., F.O.C.O.
COLLEGE OF OSTEOPATHIC PHYSICIANS
\\l) M K(,l (>\S • LOS ANGELES, CALIFORNIA
DR. L. A
L.ONQ BEACH, OAL..
LIPPINCOTTS NEW MEDICAL SERIES
Edited by FRANCIS R. PACKARD, M.D.
RONTGEN RAYS
AND
ELECTRO-THERAPEUTICS v
• — 1
WITH CHAPTERS ON RADIUM
AND PHOTOTHERAPY
BY/
MIHRAN KRIKOR KASSABIAN, M.D.
Director of the Rontgen Ray Laboratory of Philadelphia Hospital ; Formerly in charge of the
Rontgen Ray Laboratory and Instructor in Electro-Therapeutics in Medico-Chirurgical
Hospital and College ; Member of the Philadelphia County Medical Society ; Penn-
sylvania State Medical Society ; American Medical Association ; American
Rontgen Ray Society ; Vice-President of the American Physico-Electro-
Therapeutic Association ; New York Medico-Legal Society ; etc., etc.
PHILADELPHIA & LONDON
J. B. LIPPINCOTT COMPANY
M^/oo
r
Copyright, 1907, by J. B. Lipplncott Company
TO
MY MOTHER AND MY' BROTHERS
I DEDICATE THIS VOLUME
AS A TOKEN OF RESPECT AND AFFECTION.
THE AUTHOR.
" You go not till I set you up a glass,
Where you may see the inmost parts of you."
HAMLET, Act III. Scene IV.
" In wonder all philosophy began, in wonder
it ends, and admiration fills up the interspace ; but
the first wonder is the offspring of ignorance, the
last is the parent of adoration."
COLERIDGE.
VJ
1 107
PREFACE
THE object of this book, as indicated by its title, is to present,
clearly and concisely, the more important facts pertaining to electro-
therapeutics and the Routgeu rays. Notwithstanding the many valuable
and important treatises extant on both these subjects, the author has
keenly felt the need of something more, and he has endeavored to offer,
in a condensed but comprehensive manner, the theories and applications
of electrical energy, in its various forms, to the domain of medicine.
The initial portion of the work is devoted to the subject of electro-
therapeutics, whose compendious character, it is believed, will appeal
to the practical physician. Beginning with the definition of electrical
terms, this division of the work gradually leads the reader to an elaborate
description of high-frequency currents, which have recently opened up so
fertile and promising a field. As in other portions of the volume, the
introduction of debatable questions and mathematical formulas has been
studiously avoided, and no space has been encumbered with the recital
of fanciful theories or those of a controversial nature.
An exhaustive study of the Eontgen rays follows. The author has
bestowed much care to a description of the apparatus employed, believing
that its thorough mastery is essential to a complete understanding of the
subject. The technic of radio -photography is treated of at length, be-
cause an intimate knowledge of this department is indispensable for the
production of successful skiagraphs, and if the chapter on stereo-skia-
graphy seems extensive, it is due to the fact that the author regards the
subject as one of constantly growing importance. A word regarding
X-ray dosage. Lack of a standard unit of measurement in X-ray therapy
has compelled the lengthy discussion of the various methods in vogue. It
is believed, however, that this is a valuable addition to the work, and
may perhaps prove a convenience to many, who find the literature on
this subject to be widely scattered. Much thought has been bestowed on
the techuic of dental skiagraphy, and the same may be said of the chapter
on the localization of foreign bodies. "With an experience of more than
eight thousand cases under his immediate study and care, the author has
preferred, wherever possible, to introduce and quote the views of his
confreres, rather than to obtrude his own opinions as the only ones accept-
able. Because of the importance of the subject, much space has been
assigned to a study of the cathode rays, and to the terse and elegant
description of the Eontgen rays, so simply told by Eontgen and so faith-
fully translated by Professor Barker for Harper and Brothers.
^3416
iv PREFACE.
The therapeutic value ami tin- limitations of radium are being thor-
oughly investigated, and it is still too early to assign any definite place to
this remarkable agent in the practice of medicine. A space, all too
brief, is allotted to the study of phototherapy, and to the memorable
discoveries which the genius of Finsen bequeathed to science.
A striking feature, which will materially add to whatever merit the
work may possess, is the introduction, in its final pages, of a study of the
technic employed and the remarks made by many of the leading expo-
nents of Rontgen therapy both in this country and in Europe.
In the department of electro-therapeutics the author has freely con-
sulted the works of Rockwell, H. Lewis Jones, Erb, Hedley, and Snow.
In the portion devoted to the Rontgeu rays he has referred to the
treatises of Caldwell and Pusey, F. Williams, Freuud, Bouchard, Isen-
tlial and Ward, and Hyudinan.
I wish gratefully to acknowledge my indebtedness to Dr. Samuel
Lewald, of this city, who, by his literary skill and unceasing interest in
the preparation of the present volume, has greatly lightened the labor of
it. A word of thanks is due my colleagues Drs. Charles L. Leonard and
William M. Sweet; the former for many suggestions, the latter for
valuable advice in regard to the chapter on localization. Mr. H. C.
Snook very kindly offered several practical hints on the X-ray apparatus.
I am only too conscious of the courtesies shown me by Dr. Francis R.
Packard, the editor of Lippiucott's Xew Medical Series.
In conclusion, it seems fitting to remark that to his friends and to the
many friends of science, who have urged him on, and encouraged him to
the consummation of the present volume, the author feels profoundly
grateful.
MIHEAN K. KASSABIAN.
PROFESSIONAL BUILDING,
Philadelphia, Pa., June, 1907.
CONTENTS
PART I.
ELECTRO-THERAPEUTICS.
INTRODUCTION.
PAGE
HISTORICAL SKETCH OF THE RISE OF ELECTRICITY xxix-xxxi
ELECTRICITY AS A PART OF THE MEDICAL CURRICULUM xxxi, xxxii
CHAPTER I.
ELEMENTARY PRINCIPLES OF ELECTRICITY AND MAGNETISM.
I. Nature and Properties of Magnetism 33
A. NATURAL 33
B. ELECTRO-MAGNETS 33
II. Nature and Properties of Electricity 34
A. THEORY OF POTENTIAL 34
(a) Hydraulic Analogy 34
B. UNITS OF ELECTRICAL MEASUREMENT, C. G. S. SYSTEM 36
(a) Electro-static Units 36
(b) Magnetic Units 36
(c) Electro-magnetic or " Absolute " C. G. S. Units 37
(d) Practical Units and Standards 37
C. DEFINITIONS AND EQUATIONS 38
Conductivity 38
Resistance : Ohm's Law 39
Ampere ; Farad ; Watt ; Equations 39
III. Sources of Electrical Energy 39
A. STATIC 39
B. GALVANIC 39, 40
(a) Primary Batteries : Construction and Connection 40
1. Series 40
2. Parallel 40
3. Group 41
(b) Accumulators, Storage or Secondary Batteries 41
Principles ; Varieties 41, 42
Capacity 42
Charging from
1. Primary Cells 43
2. 110-Volt 44
3. Alternating Current 44
4. Bicycle 45
5. Thermopiles 45
v
CONTENTS.
PAGE
C. DYNAMIC OR ELECTRIC MAINS
(a) Direct ^
(b) Alternating 45
D. THERMOPILES
45
CHAPTER II.
THE STATIC, FRANKLINIC, OR FRICTIONAL CURRENT.
I. The Static or Influence Machines 46
Principles of Construction 46
A. TYPES OF INFLUENCE MACHINES 47
Theory of Action (Wimshurst)
Theory of Action (Holtz) 49
Theory of Action ( Voss or Toepler) 50
B. CARE AND MANIPULATION OF STATIC MACHINES 51
C. ACCESSORIES 52
The Leyden Jar 52
Electrodes 52
Chain-Holder 63
Muffler 54
Preparation of the Patient 54
Polarity • 54
Idiosyncrasy 55
Dosage 56
II. The Modes of Application 57
A. CONVECTIVE CURRENTS 57
Brush Discharge ; Breeze and Spray 57
Static Bath ; Interrupted Insulation 57
B. DISRUPTIVE CURRENTS 58
Direct ; Indirect ; Frictional 58
C. CONDUCTIVE CURRENTS 58
Static Induced Current 58
Wave Current (Morton) 58, 59
STATIC MODALITIES (CHART) 60, 61
CHAPTER III.
GALVANIC, CONTINUOUS, OR DIRECT CURRENT.
Galvanic Battery ; Connections 62
Types of Cells 63
Care of Battery ; Charging the Cells ; Polarity 64
Wall Cabinet 64
Rheostat ; Electrodes ; Galvanometer ; Milliampereineter 66
Galvano-Faradic Box 67
Definition of Terms 67
Methods of Application 68
Central Galvanization ; Gal vano- Faradization 69
Cautery Batteries 69, 70
Sinusoidal Current . . 70
CONTENTS. vii
CHAPTER IV.
FARADIC, INTERRUPTED, OR INDUCED CURRENTS.
PAGE
Principles of Induction 71
Faradic Battery 71
Medical Induction Coil 71, 72
Interrupter or Rheotome 73
Method of Application 73
Localized Faradization 74
As a Diagnostic Agent 74
As a Therapeutic Agent 74
CHAPTER V.
I. Cataphoric Method 75
II. Hydro-Electric Baths 77
CHAPTER VI.
ELECTRO-DIAGNOSIS.
The Motor Points 81
Upper Limb 82
Lower Limb 85
Face ; Neck 85
Segments 88
Usual Nerve Supply 88
Hints for Practical Testing 89
Reaction of Degeneration 90
Degeneration of Muscles 90
Partial Reaction of Degeneration 91
Sensory System ; Nerves of Special Sense 91
CHAPTER VH.
ELECTRO-PHYSIOLOGY.
Influence of Electricity upon Motor Nerves and Muscles 92
Pfliiger's Laws of Contraction 92
Upon Voluntary Muscles 94
Electrotonus t . . 94
Sensory Cutaneous Nerves 95
Sensory Nerves of Muscles 95
Upon the Special Senses 95, 96
Upon the Sympathetic System 96
Upon the Skin 97
Upon the Head 97
Upon the Spinal Cord 97
Upon the Abdominal Organs 97, 98
Electrical Currents in Disease 98
viii CONTENTS.
CHAPTER VIII.
PRACTICAL APPLICATIONS IN DISEASED CONDITIONS.
PAGE
I. Cutaneous System 99
Acne ; Eczema ; Pruritus ; Alopecia ; Sycosis 99
Hypertrichosis 10^-
Psoriasis and 1'ityriasis ; Ringworm and Scleroderina ; Prurigo 101
Cutaneous Anaesthesia, Herpes Zoster 101
vus ; Port-wine Mark ; Moles and Warts ; Furuncles and Carbuncles, 102
II. Muscular System 103
Myaliria : Writer's Cramp 103
Torticollis ; Muscular Contractions 104
M y asthenia Gravis 105
III. Articular System 105
Synovitis ; Hydro-arthritis ; Rheumatoid Arthritis 105
Chronic Articular Rheumatism ; Gout ; Tuberculous Arthritis 106
Fibrous Ankylosis 106
IV. Digestive System 107
Vomiting ; Dilatation of Stomach 107
Nervous Dyspepsia 108
Constipation— Method of Application 108
Enteritis 109
Fissure of the Anus 110
Prolapse of the Rectum 110
Hemorrhoids Ill
Stricture of the Rectum Ill
V. Genito-Urinary System Ill
Stricture of the Male Urethra 111-113
Proetatitis 113, 114
Paralysis of the Urinary Bladder 114, 115
Incontinence of Urine ; Nocturnal Incontinence 115
Spennatorrho2a and Seminal Emission 115
Impotence 1 16
Orchitis 116
Nephritis 116
VI. Nervous System 116
Neuralgias : Cephalalgia, Tic Douloureux, Peripheral Neuralgia, Sci-
atica 117, 118
Paralyses : Rheumatic Paralysis, Syphilitic Paralysis, Lead, Arsenic,
Opium, etc 118
Hemiplegia ; Paraplegia 118
Facial Paralysis ; Poliomyelitis ; Locomotor Ataxia 119
Chronic Spinal Muscular Atrophy 119
Epilepsy 119
Insomnia ; Hysteria ; Hypochondriasis and Melancholia 120
Insanity ; Neurasthenia 120
Exophthalmic Goitre 121
CONTENTS. ix
PAGE
VII. Gynaecology ll>^
Ltmtfotioni ami I'ossitiilities in the Treatment of Diseases of Women.... 122, 123
A menorrhrea 1 :M
Dysmenorrhcea 124
Fibroid Tumors 124
Ovarian Tumors 125
Chronic Metritis 125
Periuterine Htematocele 125
Stenosis of the Cervical Canal 125
Subin volution and Atrophy 125
Urethral Caruncle 125
Post-partum Hemorrhage 125
Vomiting of Pregnancy 126
Slow Labor 126
VIII. Aneurism '. 127-129
CHAPTER IX.
APPLICATIONS IN THE SPECIALTIES.
I. Rhinology and Laryngology 129
Atrophic Rhinitis ; Pharyngitis ; Ozaena , 129
Anaesthesia of the Pharynx ; Laryngeal Fatigue 130
Atrophic Pharyngitis ; Anosmia 130
Asthma 131
II. Otology 131
Auditory- Nerve Deafness 131
Chronic Suppuration of the Middle Ear 131
Tinnitus Aurium 132
Electricity in Otology (Richardson) 132-134
III. Ophthalmology 134
Paralysis of the Muscles of the Eye 134
Blepharoepasm 134
Cataract 135
Electrolysis in Diseases of the Lacrymal Canal 135
Retinal Anaesthesia and its Treatment by Voltaic Alternatives 135
Miscellaneous Ophthalmic Affections : 136
CHAPTER X.
HIGH-FREQUENCY CURRENTS.
I. Historical Introduction 138
II. Principles and Apparatus 139
Morton's " Static Induced Current" High-Frequency Apparatus 140
D' Arsonval High-Frequency Apparatus 141
Tesla's High-Frequency Apparatus 142
The Oudin Resonator 143
Glass Vacuum Electrodes 143
Cataphoresis Electrodes 144, 145
x CONTEXTS.
PAGE
III. Physical Properties 145
A. IxnrcrioN EFFECTS 145
B. ELECTRO-STATIC EFFECTS 145
C. DYNAMIC PROPERTIES 145
D. RESONANCE 146
IV. Methods of Application 146
1. Direct Application 146
2. Indirect Application or Auto-conduction by the Solenoid 147
3. Auto-condensation 148
4. By Local Application 148
V. Physiological Properties 148
VI. Applications in Various Diseases 149-155
Tuberculosis 149
Gout ; Rheumatism ; Obesity 150
Hysteria 151
Lupus Vulgaris 151
Rodent Ulcer and Malignant Diseases 151
Piles, Rectal Fissures, and Pruritus Ani 151
Colitis 152
Ozaena 152
Epilepsy 153
Skin Diseases 153
Trachoma 154
Dulness of Hearing and Subjective Noises 154
Gonorrhoea . 155
PART II.
THE RONTGEN RAYS IN DIAGNOSIS.
Historical Introduction 156
1650, Otto von Guericke 156
1740, Abbe" Nollet 156
1834, Sir W. Snow Harris 156
1838, Michael Faraday 156
1838, Heinrich Geissler 156
1840, Clerk Maxwell 156
1860, Sir Wm. Thomson (now Lord Kelvin) 156
1865, Gassiot and Sprengel 156, 157
1869, Hittorf 157
1876, Goldstein 157
1877, Warren de la Rue, Hugo Miiller, and W. Spottiswoode 157
1879, Sir Wm. Crookes 157
1883, Wiedemann and J. J. Thomson 157
1883-1894, Hertz 157
1895, Lenard, Perrin, Elster and Geitel, Rontgen 157
CONTENTS. xi
PAGE
Comparative Study of the Properties of the Cathode and the Rontgen Rays. . . . 158
CATHODE RAYS 158
Production ; Radiability 158
Fluorescence and Phosphorescence 159
Reflection, Refraction, and Polarization 159
Chemical Effects ; Physiological Effects 159
Various Theories 159
RONTGEN KAYS 160
Production 160
Radiability and Penetrative Power 160
Fluorescence and Phosphorescence 161
Reflection, Refraction, Polarization, and Interference 162-166
Chemical Effects 166
Physiological Effects ; Various Theories 167
Visibility of the Rontgen Rays 167
Velocity of Propagation of the X-Rays 167
Velocity of the Rontgen Rays 168
Charging Action of the Rontgen Rays 168
CHAPTER I.
THE RONTGEN-RAY APPARATUS AND ITS MANIPULATION.
I. The Induction Coil 169
A. FARADAY ON THE ELEMENTARY LAWS OF INDUCTION 169
B. THE CONSTRUCTION OF THE INDUCTION COIL 171
Primary and Secondary Coil 171
Condenser and Commutator 171, 172
C. INTERRUPTERS 172
(a) Mechanical 172
Platinum 172
Vibrating Hammer 172
Independent 172
Self-Starting 173
Vril 173
Mercury 173
Dipper 173
Rotary 173
Disk 174
Johnston 174
Jet 175
(b) Electrolytic 175
AVehnelt 175
Caldwell and Simon 178
D. VARIETIES OF INDUCTION COILS 178
(a) Variable Primary Induction Coil (" Jumbo " ) 178, 179
(b) Tesla Coil 180
(c) Kinraide 181-183
(d) Gaiffe 184
(e) Coil without Interrupter ; Max Levy ; Grisson 184
xii CONTENTS.
PAGE
II. Discharges in Partial Vacua and the Crookes Vacuum Tube 185
A. VARIETIES TYPES, CONSTRUCTION, AND PRINCIPLES 189
(a) Stationary Vacuum 189
(b) Self-Regulating and Regenerative , 189
Heat 190
Method by Osmosis 194
Mechanical Regeneration l'-'4
Electro-static Regeneration 195
Water-cooling 195
B. THE QUALITY OF THE X-RAYS 195
Kind of Electrical Energy Employed 195
Condition of the Tubes 195
Soft, Medium, and Hard Tubes 195
Xrray8, X2-rays, X3-rays, Porter 195
Hani, Medium, Soft, Very Soft, Albere-Schonberg 195
Fifth Grade, Kienbock 196
Osteoscope of Carl Beck ; Spintermeter 196
C. CARE OF THE TUBE 196
Connecting Leading Wires 197
Blackening of the Tube 197
Puncture and Explosion of Tube 198
III. Fluoroscope and Accessories 199
A. CONSTRUCTION OF THE FLUOROSCOPE 199
B. SKIAGRAPHIC TABLE 200
C. HOFFMAN'S MEASURING STAND AND FRAME 200
D. TUBE-HOLDERS 201
E. BOX-COVER FOR TUBE 202
F. DIAPHRAGM AND COMPRESSION DIAPHRAGM 202
IV. Selection and Installation of the X-Ray Apparatus 203
A. SELECTION. Hospital, City, Country, Portable Outfits 203, 204
B. INSTALLATION. Connections (Diagrams) 204-i'07
C. POLARITY AND CONNECTION OF TUBE 207
Advantages of Static Machine 208
Disadvantages of Static Machine 208, 209
CHAPTER II.
THE PRINCIPLES OF TECHNIC.
I. Fluoroscopy 210
A. METHODS OP EXAMINATION 210
(a) Screen and Fluoroscopic Examinations 210
(b) Preparation of the Patient 211
(c) Position of Tube 212
(d) Position of the Patient 213
(e). Size, Shape, and Intensity of Image on the Screen 213
B. ADVANTAGES OF FLUOROSCOPY 213
C. DISADVANTAGES OF FLX-OROSCOPY . . 214
CONTENTS. xiii
PAGE
II. Skiagraphy 214
A. SYNONYMS, DEFINITION, AND NOMENCLATURE 214
B. THE PATIENT 216
History Taking 216
Preparation of the Patient 216
Position of Patient 216
Immobilization of Part 217
C. PLATES, THEIR PREPARATION, SIZE, AND PROTECTION 217
Data on the Negative 218
D. SELECTION AND USE OF THE CROOKES TUBE 218
Position of the Tube 218
Form of the Ray-emitting Area of the Anti-cathode 219
Direction of the Rays , 219
Anodal Distance of the Tube from the Plate 219
E. FACTORS VARYING THE TIME OF EXPOSURE 220
The Capacity of the Apparatus 220
The Peculiarity of the Part to be Examined 220
Quality of the Rays 220
Intensifying Screens 220
F. PREVENTION OF SECONDARY OR SAGNAC RAYS 220
Lead Iris Diaphragm 221
III. Photography 221
Dark Room ; Light 221
Sensitive Plates and Films 222
Care of the Plates 222
A. DEVELOPERS ; FORMULAS ; VARIETY 222
(a) Reducing 222
(b) Preservative 223
(c) Accelerating 223
(d) Restraining 224
Tropical Developer 224
B. MODUS OPERAND! OF DEVELOPMENT 224
Developing : Rapid ; Slow Process (Tank) ». 226
Fixing, Washing, Drying, and Hardening 227-229
C. IMPROVEMENT OF THE NEGATIVE 229
Intensification 229
General and Local Reduction 230
Causes and Prevention of Faulty Negatives : Fogging, Stains,
Spots 231
D. PRINTING (POSITIVE) ; TONING AND MOUNTING 231
Dodging 232
Ground-Glass Substitute 232
Developing Papers 232
Toning Process and Formula 233
Printing and Mounting ; Positives 233
Transparencies and Lantern Slides 234
XIV
CONTENTS.
PAGE
IV. The Interpretation of X-Ray Negatives 234
What Constitute Satisfactory Negatives 234
How to View the Negative 234, 235
The Proper Light ; Author's Examining Box 235, 236
A. FOREIGN BODIES 236
B. FRACTURES AND DISLOCATIONS 237
C. DISEASES AND TUMORS OF THE BONES 238
D. DISEASES OF THE SOFT STRUCTURES 238
E. DISEASES OF THE THORACIC ORGANS 238-240
F. ALIMENTARY SYSTEM 240
• ;. GENITO-URINARY SYSTEM 240-242
V. Stereo-Fluoroscopy and Skiagraphy 242
A. HISTORY AND PRINCIPLES 242, 243
B. STEREO-FLUOROSCOPY 243
C. TECHNIC OF STEREO-SKIAGRAPHY 244-249
D. METHODS OF VIEWING STEREO-SKIAGRAMS 24!»
Wheatstone 249
Brewster 249
Plastography 250
E. ADVANTAGES OF STEREO-SKIAGRAPHY 250
Anatomy ; Surgery 251
CHAPTER III.
THE CLINICAL APPLICATIONS OF THE RONTGEN RAYS.
I. The Uses of X-Rays in Anatomy and Physiology 252
A. BLOOD-VESSELS AND RESPIRATORY TRACT 252
B. BONES AND JOINTS 253, 254
C. PHYSIOLOGY OF PHONATION 255, 256
II. Diagnostic Value in Fractures and Dislocations and Callus Formation. . . . L'5i>
A. THE ADVANTAGES OF THE RONTGEN RAY METHOD IN THE DIFFERENTIA-
TION OF COMPLICATED FRACTURES 257
B. DISEASES AND TUMORS OF THE BONES AND JOINTS 258
C. VALUE IN THE TREATMENT OF FRACTURES 259
D. STUDY OF CALLUS FORMATION 259
Duration and Varieties 259
Perfect Apposition of Fragments 260
Slight Overlapping 260
False Joint 260
Fractures with Extensive Displacements 260
Structure of the Callus 260
III. Fractures and Dislocations of the Upper Extremity 260
1 I AND. Fluoroscopic Examination 260
Skiagraphic Examination 261
WRIST-JOINT. Fluoroscopic and Skiagraphic Examinations 261
LOWER END OF RADIUS AND ULNA 261
FOREARM 262
ELBOW-JOINT. Fluoroscopic and Skiagraphic Examinations 263
CONTENTS. xv
PAGE
MIDDLE THIRD OF THE HUMERUS 264
SHOULD ER-.IOI XT. Fluoroscopic and Skiagraphic Examinations 264
Dislocations 264, 265
CLAVICLE. Skiagraphic Examination 265
SCAPULA. Skiagraphic Examination 265
FRACTURES OF THE SKULL. Skiagraphic Examination 265
IV. Fractures and Dislocations of the Lower Extremity 266
FOOT 266
ANKLE 267
LEG (MIDDLE THIRD) 268
KXEE-JOIXT ; PATELLA 268
FEMUR (MIDDLE AXD LOWER THIRDS) 269
HIP-JOINT 269
THE Os IXNOMIXATA, SACRUM, AND COCCYX 270, 271
THE SPINAL COLUMN 271
RIBS AND STERNUM 272
V. Diseases of the Osseous System 272
A. PATHOLOGICAL CONDITIONS 273
Acute and Chronic Periostitis and Osteomyelitis 273
Tuberculosis of Bone 273
Syphilis of Bone 273
Hypertrophic Deforming Osteitis (Paget's Disease) 273
Leprosy 273
Acromegaly 274
Rickets 274
Cretinism 274
Osteomalacia 274
Necrosis and Caries 274
B. TUMORS OF THE BONES 274
Sarcoma, Carcinoma, and Cysts 275
C. DEFORMITIES OF BONES 275
Congenital 275
Exostoses 275
Deformities of Intra-uterine Origin 275, 276
Diseases and Deformities of the Spinal Column 276
Torticollis 276
Pott's Disease 276
Amputation Stumps 276
Resection of Joints 277
Regeneration of Bone 277
VI. Diseases and Tumors of the Soft Tissues 277
Hjematomata 277
Abscesses 277
Myomata and Fibromata 278
Enchondromata ; Lipomata ; Sarcomata ; Carcinomata 278
Tumors of the Brain 278
Reports of Cases 279-282
Calcareous Deposits in Glands 282
xvi CONTENTS.
PAGE
VII. The Articular System :>-
A. DISEASES OK THE JOINTS 2S2
Acute Arthritis 282
Acute and Chronic Articular Rheumatism 282
Gout 282
Tuberculous Arthritis 283
Coxalgia 288
Coxa Vara 283
Genu Valgum 284
Genu Varum 94
B. AHTHROPATHIES ....'. 284
Tabes ; Syringomyelia 284
VIII. Foreign Bodies and their Localization 285
A. MILITARY SURGERY 285
Greece-Turkish War 285
Chitral Campaign 285
Soudan 285
Spanish-American War 285
South Africa 286
Russo-Japanese War 286
B. VARIETIES OF FOREIGN BODIES 286
Transparent ; Translucent ; Opaque 286
Table of Permeability of Rontgen Rays 287
C. FOREIGN BODIES IN THE DIGESTIVE, RESPIRATORY, AND GENITO-URINARY
TRACTS 287
(Esophagus 287
Stomach 288
Intestines 288
Larynx, Trachea, and Bronchi 288
Genito-Urinary Tract 288
Foreign Bodies entering from Without 289
D. THE X-RAYS IN OPHTHALMOLOOICAL SURGERY 289
Foreign Bodies in the Eye 289
Sweet's Method of Localization 290-295
Davidson's Method L".'-V297
Grossman's Method l>97; 20S
Fox's Method j<(s
K. VARIOUS METHODS OF LOCATING FOREIGN BODIES 299
Screen Method 299
Punctograph 299
R^my's Method 300
Barrel's Method 300
Shenton's Method 301
Harrison's Method 302
Leonard's Double Focus Stereoscopic Method 002
Triangulation Method 303
Grashey's Method 3037 304) 305
CONTENTS. xvii
CHAPTER IV.
PAGE
APPLICATION OF THE X-RAYS IN DISEASES OF THE THORACIC ORGANS.
I. Fluoroscopic Examinations 306
Anterior and Posterior Views 306
Lateral and Oblique Views 307
Methods of Examination of the Lungs 307
Normal Heart and Diaphragm 308
Measurement of the Diaphragmatic Incursion 308
Measurement of the Costal Angle 309
Causes of Restriction of the Diaphragm 310
Diseases of the Diaphragm 310
Average Normal Excursion of Diaphragm ; Width of Normal
Heart 311
II. Skiagraphic Examinations 311
Various Positions of Patient 311
Time of Exposure 312
III. Clinical Applications 313
A. DISEASES OF THE BRONCHI AND LUNGS 313
Bronchitis ; Bronchiectasis 313
Asthma 314
Emphysema 315
Broncho-Pneumonia 315
Pulmonary Tuberculosis 315-318
Cavitation 318, 319
Acute Miliary Tuberculosis 319
Pneumonia 320
Atelectasis 320
Abscess and Gangrene 321
B. DISEASES OF THE PLEURA 321
Pleurisy with Effusion 321
Empyema 322
Pneumothorax ; Hydro-pneumothorax and Pyo-pneumothorax, 323
Subphrenic Abscess ; Tumors of the Thorax 323
Enlarged Glands 324
IV. Applications of the X-Rays to the Circulatory System 324
A. FLUOROSCOPIC EXAMINATION OF THE NORMAL HEART 324
The Orthodiagraph 325-328
B. SKIAGRAPHIC EXAMINATION OF THE HEART 328
Size and Measurement of the Heart ; Cardiac Mobility 329
Displacement 330
Cardiac Atrophy, Hypertrophy, and Dilatation 331
Examination of the Heart 332
Pericarditis (Pericardial Effusion) 332
Aortic Aneurism 333
Dilatation of the Aorta ; Displaced Aorta ; Enlarged Glands . . . 335
Neoplasms ; Pulsating Empyema ; Atheroma 335
B
CONTENTS.
CHAPTER V.
APPLICATION OF THE X-RAYS IN .DISEASES OF THE ABDOMINAL ORGANS.
PAGE
I. Alimentary System 336
A. (ESOPHAGUS 336
Stricture ; Stenosis 336
Diverticulum ; Tumors 337
B. STOMACH : SIZE, SHAPE, AND POSITION 337
Examination by the Aid of Gaseous Distention 337
Mechanical Method 337
Bismuth Subnitrate Method 338
Fluoroscopic and Skiagraphic Examinations of Stomach 338
Time of Exposure 339. 340
Transillumination 341
C. THE CLINICAL APPLICATION OF THE RAYS 342
Behavior of the Stomach during Digestion 342
Position of the Stomach 342
Gastroptosis 343
Stenosis of the Pyloric End 344
D. INTESTINES 344
Sounding and Radiography of the Large Intestine 344
Obstruction 345
Rectal Imperforation 345
Abdominal New Growths 346
E. LIVER 346
Size and Location ' 346
Biliary Calculi 346, 347
F. PANCREAS 348
G. SPLEEN 348
II. The Genito-Urinary System 349
A. ORDINARY METHODS ; DIFFICULTIES 349, 350
B. CALCULI : their Specific Gravity, Penetrability, and Density 350
Hypertrophy ; Atrophy 351
Hydronephrosis and Pyonephrosis 351
C. TECHNIC OF RENAL SKIAGRAPHY 352
Preparation of Patient 352
Literature of Renal Calculi 352-354
Advantages and Defects of this Method 355
D. URETERAL CALCULI 355
Reports of Cases 355-359
E. THE BLADDER 359
Examination for Calculi 359
Closure of the Bladder, as shown by X-Rays 360
F. PROSTATIC CALCULI 360, 361
CONTEXTS. xix
CHAPTER VI.
APPLICATION IN THE SPECIALTIES.
PAGE
I. Obstetrics and Gynaecology 362
Pelvimetry 362
Skiagraph of Foetus 365
Skiagram of Gravid Uterus ; 366
Neoplasms 367
II. Rhinology, Laryngology, and Otology 367
Abscess of the Antrum and of the Frontal Sinuses 368
Foreign Bodies in the Larynx 369
Ossification of the Laryngeal Cartilages 369
Foreign Bodies in the Ear 369
Abscess of the Mastoid Process 369
CHAPTER VII.
APPLICATION IN DENTISTRY.
I. Apparatus Used 370
II. Technic 370
Intra-Oral 370
Extra-Oral or Buccal ; Tousey's Method 371
III. Clinical Applications 372
Unerupted Teeth 372
Necrosis of the Maxilla 372
Ankylosis of the Inferior Maxillary Articulation 373
Fracture of the Inferior Maxillary Bone 373
Broken Instruments ; Root-Canal Fillings ; Abscess of the Antrum 373
Alveolar Abscess ; Orthodontia 374
CHAPTER VIII.
THE RONTGEN RAYS IN FORENSIC MEDICINE.
I. Legal Status of the X-Rays 375
A. ADMISSIBILITY IN VARIOUS STATES 375-377
B. TECHNIC OF MEDICO-LEGAL SKIAGRAPHY 377, 378
C. How THE SKIAGRAPHER SHOULD PREPARE FOR COURT 378-382
II. The Physician's Responsibility in Cases of X-Ray Burn 382-387
Medico- Legal Aspect of Sterility 387, 388
PART III.
RADIOTHERAPY, RADIUM, AND PHOTOTHERAPY.
CHAPTER I.
ACTION OF THE X-RAYS ON BACTERIA.
Experiments of Numerous Operators 389-395
x CONTENTS.
CHAPTER II.
HlSTOLOGICAL CHANGES INDUCED BY THE ACTION OF THE X-RAYS.
PAGE
I. X-Ray Dermatitis - 395, 398
A. CAUSES OF X-RAY DERMATITIS 398, 399
B. CLASSIFICATION OF X-RAY DERMATITIS 399
C. LATENT STAGE; FREQUENCY AND SUSCEPTIBILITY IN X-RAY DERMA-
TITIS 401-104
D. PATHOLOGICAL PHYSIOLOGY 404-401 >
E. DURATION OF CHRONIC DERMATITIS 406
F. PREVENTIVE MEASURES AGAINST X-RAY DERMATITIS 407, 40S
G. TREATMENT OF X-RAY DERMATITIS 408-4 1 2
II. Remote and Indirect Action of X-Rays 412
. STERILITY 41 2-414
CHAPTER III.
CHANCES INDUCED IN VARIOUS DISEASED TISSUES BY THE RONTGEN RAYS. 415-420
CHAPTER IV.
TECHNIC OF RONTGEN RAY THERAPY.
I. Apparatus and Method of Treatment 420-422
CROOKES TUBE 422
PROTECTION OF HEALTHY PARTS 422—123
POSITION OF THE TUBE ; DISTANCE OF THE TUBE 424
DURATION OF EACH EXPOSURE; FREQUENCY OF THE EXPOSURE 425
FILTERS ; THE DOSAGE 426
II. Methods of Measuring X-Ray Dosage 427
A. MEASUREMENT OF THE ELECTRIC CURRENTS 427
The Current going to the Primary Coil 427
Milliamperage of the Secondary Induced Current 427, 428
Spintermeter 429
B. THE PENETRATION METHOD 429
The Radiochromometer of Benoist 429-431
Skiameters and Penetrometers ; Cryptoradiometer of Wehnelt. . 431
C. THE PHYSICO-CHEMICAL METHOD 431
Chromoradiometer of Holzknecht 432
Radiometer of Sabouraud and Noir6 432, 433
Chromoradiometer of Bordier 433, 434
Quantimeter of Kienbock 434
New Radiometer of Freund 435
Precipitation Test 436
D. THK IONIZATION METHOD 436
lonization of Confined Gases 436
The Radio-active Standard of Phillips 437
CONTENTS. xxi
PAGE
E. THE PHOTOMETRIC METHODS 438
The Kadiometer, of Courtade 438
The Guilleminot-Courtade Method 438
The Fluorometer 438
The Method of Contrernoulins 439
Selenium Photometer 439, 440
Fluorescence of the Tube and the Appearance of the Electrodes. 440
The Thermometric Method 441
III. Natural Fluorescence in the Human Organism and its Artificial Produc-
tion 441
APPLICATION IN DISEASE 442, 443
Influence of Photodynamic Substances on the Action of X-Rays, 443
CHAPTER V.
THERAPEUTIC VALUE IN DISEASE.
I . Cutaneous Affections 444
LUPUS ERYTHEMATOSUS 444
LUPUS VULGARIS 444, 445
N.EVUS 446
ALOPECIA AREATA ; Parasitic Alopecia 447
HVPERTRICHOSIS 447-449
FAVUS AXD TIXEA TOXSUHANS 449-451
ECZEMA 451, 452
ACXE 452
Acne Vulgaris 453
Acne Rosacea 453, 454
SYCOSIS 454, 455
PRURITUS ANI AXD PRURITUS VULV^: 455
XERODERMA PIGMEXTOSUM 455
PSORIASIS 456, 457
SEXILE LEG LTLCERS ; VARICOSE VEINS 457
HYPERIDROSIS 458
KRAUROSIS VULV.E 458
LEPROSY 459
II. Malignant Growths 460
A. EPITHELIOMA 460-464
B. CARCINOMA 464, 465
Cancer of the Breast 465-469
Cancer of the Sternum ; Cancer of the (Esophagus 469
Cancer of the Larynx * 470
Cancer of the Stomach and Bowels 470
Cancer of the Uterus 470, 471
Therapeutic Action of the X-Rays in Cancer 471— i 73
C. SARCOMA 473-477
III. Constitutional Diseases 477
A. TUBERCULOSIS 477-482
B. LEUKEMIA . . 482-487
xxii CONTENTS.
PAGH
IV. Miscellaneous Affections 487-497
A. TRACHOMA 487-489
B. KELOID 489, 490
C. EXOPHTHALMIC GOITRE 490-492
D. HYPERTROPHIED PROSTATE 492
E. ANALGESIC ACTION OF THE RAYS 493-495
NEURALGIA 493
F. EPILEPSY 495-497
CHAPTER VI.
RADIUM AND OTHER RADIO-ACTIVE SUBSTANCES.
OCCUURREXCE 498
CHEMICAL AND PHOTOGRAPHIC EFFECTS 498-500
PHYSICAL PROPERTIES OF RADIUM 500
Penetration ; Fluorescence and Luminosity 500
THEORETICAL CONSIDERATIONS : CLASSIFICATION 501
BIOLOGICAL EFFECTS 501
Bactericidal Action 501
Influence of Radium on Agglutination ; Physiological Action. . . 502
Effects on the Nervous System ; Effects on the Eye 502
RADIUM AND THORIUM AS THERAPEUTIC AGENTS 503
Diseases of the Skin 503
Mode of Retrogression of Cancer Metastases under Radium Rays, 504
Reports of Various Radium Therapeutists 605-507
Exophthalmic Goitre ; Rabies ; Nsevus 507
Radio-active Treatment with Thorium 508
Rheumatism 509
CHAPTER VII.
PHOTOTHERAPY.
COMPOUND NATURE OF LIGHT 510, 511
ACTION OF LIGHT ON PLANTS 511
ACTION OF LIGHT ON BACTERIA 511, 512
EFFECT OF LIGHT ON ANIMALS AND MAN 512
THERAPEUTIC ACTION OF LIGHT; ITS USE AMONG THE ANCIENTS 513
TREATMENT WITH SUNLIGHT 514
TREATMENT WITH THE INCANDESCENT ELECTRIC LIGHT 514, 515
TREATMENT WITH THE CONCENTRATED ARC LIGHT 515, 516
THE DERMO OR IRON ELECTRODE LAMP 516
THE COOPER-HEWITT MERCURY-VAPOR LAMP 516, 517
THE FINSEN OR RED-LIGHT TREATMENT OF SMALLPOX 517-520
Conditions for Success by Finsen's Method 520
BLUE LIGHT 520
Blue Light as an Anaesthetic 520, 521
APPENDI X :
TECHNIC OF RONTGKN RAY TREATMENT. . . 522
ILLUSTRATIONS
1 . Electric units illustrated by means of the hydraulic analogy (Hedley) 35
2. Connection of battery cells in " series " 40
3. Connection of the cells in " parallel " 40
4. Connection of the cells in "groups " 41
5. Diagrammatic view of the inner construction of a storage cell (American
Battery Co.) 41
6. Diagrammatic view illustrating the charging of a battery by the ammeter
and volt-meter 43
7. Diagrammatic view illustrating the charging of a battery by a bank of lamps 44
8. Diagrammatic view illustrating the principles of influence and accumulation
of static or influence machines 47
9. Diagrammatic illustration of the theory of action of a Wimshurst influence
machine 48
10. Wimshurst influence machine 49
11. Toepler-Holtz influence machine 50
12. Static-disk electrode with insulated points 53
13. Static massage electrodes for wet applications 53
14. Universal hard-rubber handle for holding electrodes 53
15. Insulated hook for holding conducting cord 53
16. Pole changer of Betz 56
17. Static breeze, concentrated brush discharge, or spray facing 56
18. Static negative insulation or static bath facing 56
19. Direct spark facing 56
20. Indirect spark facing 57
21. Friction-spark treatment facing 58
22. Static induced current facing 59
23. Galvanic cell 62
24. Bunsen cell (double fluid) 63
25. Wall cabinet for galvanic, faradic, and sinusoidal currents 65
26. Deprez-D'Arsonval galvanometer (milliamperemeter) 67
27. Galvanic, faradic, cautery, and diagnostic lamp battery 69
28. Medical induction coil 72
29. Galvanic and faradic lamp controller 73
30. Peterson's cataphoric electrode 76
31. Sectional view of the same 76
32. Three varieties of cataphoric electrodes 76
33. Martin's cataphoric electrode 76
34. The four-celled battery of Schnee 78
35. Diagrammatic view of the direction of current as is illustrated in Schnee's
four-celled battery 79
36. Motor points of the arm 82
37. Motor points of the forearm and hand 82
38. Motor points of the arm (front view) 83
xziii
xxiv ILLUSTRATIONS.
FIG. PAGE
39. Motor points of the forearm and hand (front view) 83
40. Motor points of the thigh 84
1 1 . Motor points of the leg and foot 84
42. Motor points of the thigh and leg (posterior view) 86
43. Motor points of the leg and foot (inner side) 86
44. Motor points of the head and neck 87
45. Motor points of the chest and abdomen 87
46. Interrupting needle-holder for electrolysis 100
47. Roller electrode with insulated points for muscular faradization 103
48. Double rectal bulb electrode Ill
49. Shoemaker's prostatic electrolyzer 114
50. Vesical electrode for hydro-electric application to the female bladder 123
51. Goelet's intra-uterine electrode 123
52. Ozone inhalation facing 128
53. Curved sponge electrode for application to throat 129
54. Electrode for hydro-electric application, post-nasal and pharyngeal 129
55. Double sponge-tipped ear electrode 131
56. Adjustable eye electrode, for one or both eyes 136
57. Oscillatory nature of the Leyden-jar discharge 139
58. Morton's "static-induced current " high-frequency apparatus 140
59. D'Arsonval high-frequency apparatus 141
60. The Tesla transformer 142
61 . Diagram of the Oudin resonator facing 142
62. The Oudin resonator and Tesla coil, with electrode facing 142
63. Glass electrodes facing 143
64. Piffard's glass electrode 144
65. Morton's cataphoric electrode 144
66. Treatment by auto-conduction facing 148
67. Treatment by the effluviation method facing 149
68. Diagram illustrating the principles of induction (after Donath) 170
69. Self-starting interrupter facing 172
70. Diagrammatic view of self -starting interrupter (Rontgen Manufacturing
Co.) facing 172
71 . Mercury interrupter 173
72. Davidson's interrupter facing 174
73. Johnston's mercury interrupter facing 174
74. Wehnelt interrupter 175
75. Simon interrupter 176
76. Friedlander electrolytic interrupter 177
77. The Tesla oscillator 18O
78. Outer view of the same 180
79. Lines of force in the older coils 182
80. Lines of force in Kinraide's coil 182
81 . Kinraide's diagram of two coils side by side 183
82. 83. Discharge passing through low-vacuum tubes (Bouchard) 186
84. Cathode rays (Bouchard) 186
85. Deflection of the cathode rays (Bouchard) 186
86. Illustration of the effect of one cathode and several anodes under different
degrees of vacuum (Bouchard) 187
87. Illustration of one of the phenomena in high vacua, — the rectilinear propaga-
tion of the cathode rays (Bouchard) 187
I LLTJSTR ATICXN S. x x f
FIG. PAGE
88. Essential features of an X-ray tube 188
89. Queen's self-regulating tube 191
90. Midler's regulation tube 192
91. Monopol tube ; 193
92. Osmosis regulating tube of Gundelach 194
93. Self-regulating X-ray tube, operating properly facing 194
94. Self-regulating X-ray tube, current running in wrong direction facing 196
95. Villard's venjril tube 198
96. Self-regulating X-ray tube, low vacuum facing 198
97. Self-regulating X-ray tube, punctured or cracked, bulb partially filled with
air facing 200
98. Ordinary diaphragm 203
99. Tubular or compression diaphragm (Donath) 203
100. Author's table and tube-holder 205
101 . Diagrammatic view of the installation of the " jumbo " coil and its connections
with the variable primary coil, as used by the author at the Philadelphia
Hospital 206
102. Author's office outfit 207
103. Polarity as determined by the appearance of the spark 208
104. Detachable fluoroscope and screen 21 1
105. A study in shadow distortions (fluoroscopic or skiagraphic) with correspond-
ing density difference 212
106. Envelo developer (Lyon Camera Co.) facing 226
107. Automatic tray-rocker (Rontgen Manufacturing Co.) facing 226
108. Author's washing tank 228
109. Author's negative-viewing box 236
110. Principles of Brewster's refracting stereoscope 243
111. Principles of Wheatstone's reflecting stereoscope 243
112. Technic of stereo-skiagraphy, and viewing by reflection and refraction 245
113. Author's plate-changing box 246
114. Wheatstone's reflecting stereoscope, as modified by Weigel facing 250
115. Prism stereoscope of Walter 250
116. Stereo-skiagrams of Colles's fracture facing 250
117. Inward dislocation of the first phalanx of the thumb facing 262
118. The normal hand, taken with high-vacuum tube facing 262
119. Fracture of the scaphoid facing 262
120. Colles's fracture (antero-posterior view) facing 262
121 . Colles's fracture (lateral view) facing 262
122. Fracture of the styloid process of the ulna (supine position) facing 263
123. The same (prone position) facing 263
1 24. Typical Colles's fracture facing 263
125. Green-stick fracture of the ulna facing 266
126. Fracture of the neck of the radius facing 266
127. Epiphyseal separation and displacement of the lower end of the humerus
facing 266
128. Fracture of the ulna and displacement of the head of the radius facing 266
129. Supracondyloid fracture of the humerus facing 266
130. Fracture of part of inner epicondyle, after forcible reduction facing 266
131. Detachment of a portion of the external condyle of the humerus (antero-
posterior view) facing 266
132. The same, in the lateral view facing 266
xxvi ILLUSTRATIONS.
KG. PAGE
133. Detachment of the supinator longus muscle facing 266
134. Epiphysitis of the humeral head facing 266
135. The corresponding normal side facing 266
136. Subluxation of the shoulder-joint facing '266
137. Fracture of the acromion process facing 266
138. Fracture of the acromial end of the clavicle facing 266
139. Fracture of the metatarsal bones facing 267
140. Fracture of the middle of the fourth metatarsal bone facing 270
141. Pott's fracture * facing 270
142. Fracture of tibia and fibula, taken at an angle between the antero-posterior
and lateral positions facing 270
143. The same, in the lateral view facing 270
144. Fracture of the anterior portion of the patella facing 270
145. Detachment of the tubercle of the tibia facing 270
146. Incomplete inter-trochanteric fracture facing 270
147. Congenital dislocation of the head of the left femur facing 270
148. Congenital dislocation of both hips facing 270
149. Pathological dislocation of left hip in a child facing 270
150. A case of probable infantile palsy facing 271
151. Chronic osteitis with eburnation facing 274
152. Osteitis of the index finger facing 274
153. Tuberculous osteitis facing 274
154. Syphilitic osteitis of the radius facing 274
155. Necrosis of the os calcis facing 274
156. Supernumerary thumb facing 274
157. Congenital absence of the ulna and two fingers facing 275
158. Congenital multiple exostoses facing 275
159. Delayed ossification of the epiphyses facing 276
160. Author's head rest 278
161. Tuberculous arthritis of the knee-joint facing 284
162. Coxa vara facing 284
163. Arthropathies in the knee-joint facing 284
164. Penny in the oesophagus facing 285
165. Principles of the method of localization (Sweet) 291
166. Indicating apparatus secured to the side of the head (Sweet) 292
167. Outline drawing of radiograph, tube above the plane of indicators 293
168. Outline drawing of radiograph, tube below the plane of indicators 293
169. Sweet's chart for plotting location of foreign bodies in the eye 294
170. Mackenzie Davidson's localizer 295
171 . Fox's localizer facing 298
172. The right-angle method of localization 299
173. "T" scale used in the triangulation method 304
174. Scheme of application of the "T " scale 304
175. Orthodiagraphic localizer of Grashey 305
176. Diagrammatic view of the same 305
177. Tuberculosis of the right lung (posterior view) facing 318
178. Tuberculosis of the right lung (anterior view) facing 319
179. Moritz' ort hodiagraph (horizontal position) facing 324
180. Moritz' orthodiagraph (vertical position) facing 324
181. Levy-Dorn's orthodiagraph for the standing position 327
182. Levy-Dorn's orthodiagraph for use in the recumbent posture 328
ILLUSTRATIONS. xxvii
FIG. PAGE
183. Author's table for skiagraphing the heart and lungs facing 328
184. The same when used in the sitting position facing 329
185. Aneurism of the descending aorta facing 334
186. Tracing of the same facing 334
187. Dilatation of the heart, with aneurism of the aorta facing 335
188. Atheroma of the femoral artery facing 335
189. A case of gastroptosis (bismuth emulsion method) facing 344
190. Reid's apparatus for renal skiagraphy 356
191. Clock arrangement and break of the same 357
192. Compression diaphragm of Albers-Schonberg (Kny-Scheerer Co.) 358
193. The same, postero-anterior view (Kny-Scheerer Co.) 359
194. Calculus in the pelvis of the right kidney facing 360
195. Vesical calculus facing 361
196. Varnier's arrangement for radiography 364
197. Author's head rest for stereoscopic work 366
198. Author's head rest for skiagraphing diseases of the frontal sinuses 368
199. Tumor in the trachea facing 368
200. Extra-oral method in dental skiagraphy facing 372
201. Unerupted teeth facing 372
202. Unerupted upper cuspid tooth facing 372
203. Delayed eruption of the upper cuspid tooth facing 372
204. Delayed eruption of the upper cuspid tooth with the temporary teeth in situ
facing 372
205. Delayed second bicuspid, right side of lower jaw facing 372
206. Delayed second bicuspid, left side of lower jaw facing 372
207. Phosphorous necrosis of the inferior maxilla facing 373
208. Chronic alveolar abscess of the right central incisor tooth facing 373
209. Author's hands, showing result of chronic X-ray dermatitis facing 400
210. Author's scheme for the operator's protection 408
211. Piffard treatment tube 421
212. The bi-cathode tube of Koch of Dresden 421
213. The Kny-Scheerer tube 421
214. Rosenthal's tube for therapeusis 422
215. Connection of the tube and Villard valve with the oscilloscope 423
216. Benoist's radiochromometer 430
217. The improved Benoist radiochromometer as modified by Pfahler (Rontgen
Manufacturing Co.) facing 430
218. The same, with its parts connected (Rontgen Manufacturing Co.) facing 430
219. The skiameter facing 430
220. Crypto-radiometer of Wehnelt 431
221. Kienbock's quantimeter 435
222. Profile and full view of a patient with acne rosacea facing 456
223. The same, after fifty irradiations facing 456
224. Epithelioma of the nose, before irradiation facing 456
22.5. The same, after irradiation facing 456
226. Epithelioma of fifteen years' standing, treated by irradiation, and in which
radium therapy was employed as a control test facing 456
227. Epithelioma of the dorsum of the hand, before irradiation facing 457
228. The same, after irradiation facing 457
229. Tubes and rubber tube shields for therapy of the body cavities (R. V. Wag-
ner Co.) 471
xxviii I LLfST RATIONS.
FIG. PAGE
230. Pennington's treatment [cavity] tube (R. V. Wagner Co.) 472
231. Cavity tube applied (R. V. Wagner Co.) 472
!'.;_'. Sarcoma of the leg facing 476
233. Skiagraph of the same facing 476
•_•:;} . Tuberculosis of the skin facing 488
235. The same, after irradiation facing 488
236, 237, 238. Groups of patients irradiated for epilepsy facing 489
239. Hartigan's radium applicator 508
240. Shober's radiode 509
241. Solar spectrum, showing the scheme of wave lengths of different radiations. . 510
242. Cabinet for the treatment of disease by the employment of incandescent
lights (Kny-Scheerer Co.) facing 514
243. The ^insen method of treatment facing 515
244. The dermo or iron electrode lamp.' 516
J45. Photograph of the late Professsor Niels R. Finsen facing 518
Rontgen ray treatment chart facing 526
INTRODUCTION
HISTORICAL SKETCH OF THE RISE OF ELECTRICITY
IN the remotest periods of the world's history, when legend, myth,
and fact were inseparably connected, the phenomena of electricity were
regarded as symbolic of some special deity and formed the basis of a na-
tional faith. The philosophers of Greece would bow in veneration at the
sound of the thunderbolt, and in Rome the ominous herald of the storm
would silence the orator in the Forum. Indeed, to enumerate the mean-
ings and the attributes ascribed to the lightning flash and to the reverber-
ating thunder would be to rewrite a lengthy and absorbing chapter from
the pages of mythology.
But in the midst of all this myth and superstition, — this era of the
legendary period, — arose Thales of Miletus, whose profound knowledge
of science and metaphysics had challenged the admiration of the famous
Phoenician voyagers. These intrepid navigators were accustomed to
sailing the straits of Hercules in order to reach the Baltic Sea, and from
its desolate waters they would seize a delicate substance, fair in color,
and beautiful in transparency. To Thales this strange creation of nature
had mysterious properties. He named this precious find electron or am-
ber, and he blazed the way for future knowledge in discovering that when
electron was rubbed it possessed the property of attracting to itself vari-
ous light articles. Three hundred years later Theophrastus enlarged
upon the teaching of Thales and conferred the name of "animated gem"
upon this beautiful product of the northern seas. Pliny followed with
other learned dissertations ; and thus through ages the mysterious electron
confounded the minds of philosophers, never once intimating that the
secrets hidden in its delicate transparent substance were the secrets of
Indra, the Jupiter of the Hindoos, or the terrible weapon of Jupiter
Tonans defiantly passing over suppliant Rome. Centuries passed. King-
doms arose and nations disappeared, but the studies of Thales were never
forgotten. Not till the dawn of the sixteenth century was the subject
again brought forward upon a scientific basis. In 1590 Gilbert's work
"De Maguete," having for its keynote the words: "Magnus magues
ipse est globus terrestris, ' ? appeared in England, and the discoveries
made by this new champion confused and terrified its readers. The super-
natural seemed to envelop its pages ; the printed words breathed of the
spiritual. Sparks and flames, shocks and strange sensations, pranced and
xxx INTRODUCTION.
teased the hands and bodies of hundreds of experimenters, and the masses
of the people were almost unanimous in declaring that electron was in-
vested with a soul. Although Physician in Ordinary to Queen Eliza-
beth, Gilbert did not attempt to apply the knowledge thus gained to
medicine. His friend, the poet Dryden, immortalized him in the follow-
ing lines :
"Gilbert shall live till lodestones cease to draw
Or British fleets the boundless ocean awe."
Such was the birth of the science of electricity.
But the magnificent generalization made by Gilbert was but the
initial step ; the scientifically inquisitive Otto von Guericke of Magde-
burg quite promptly gave to the world a machine for generating elec-
tricity, as useful at that period as was his indispensable air-pump. It
remained, however, for Stephen Gray, in 1730, to disclose the secrets so
deeply hidden in this mysterious substance, and it was he who ex-
pounded the leading principles of the science of electricity. Amazed at
the wondrous achievements attained by these later philosophers, Du Fay
and Kollet in France assiduously applied themselves to a study of elec-
trical phenomena. Du Fay suspended himself by a silken cord, and was
then filled with electricity by Nollet ; he presented his hand to his com-
panion, when a brilliant spark shot from hand to hand, a phenomenon
that completely baffled the minds of both these scientists.
Shortly after this the whole of Europe was awe-struck by the inven-
tion of the Ley den jar. Professor Musschenbroek received its first full
discharge, and he wrote to Reaumur that he would not suffer a second
such shock for the whole kingdom of France. Seizing upon this famous
discovery, Franklin in America invented a battery of jars capable of
giving shocks quite analogous to the terrifying powers of the thunder-
bolt. It was Franklin's contention that the electricity of the earth and air
was one, and it was this positive conviction that awakened the derision
and evoked most painful sarcasm from the Royal Society of London. Not
dismayed by this adverse criticism, the persistent American philosopher
constructed a silken kite containing an iron point. Attached to the kite
was a hemp string ending in a silken cord ; to the latter was hung an iron
key. He selected a rainy day in June, 1752, for the experiment. Sta-
tioning himself on what is now known as Ridge Avenue and Green
Street, in Philadelphia, Franklin flew his curious apparatus to the
breeze. Suddenly the falling rain made the hemp string an excellent
conductor, the fibres were stirred as by a strange impulse ; he applied his
hand to the key and at once drew sparks from its sides. He felt that he
had triumphed : he had seized the vagrant lightning of the storm ! The
Royal Society of London realized that a mighty scientific achievement
had Ix'en wrought, and made him a member and awarded him their
INTRODUCTION', xxxi
greatest prize, and he was signally honored in Germany, France, and
Russia.
During the eighteenth century, the science of electricity became one
of the most important and interesting branches of knowledge. In 1790
Galvaui, through the convulsive movements of a dead frog, hanging from
an iron balcony, brought forward his great discovery of galvanism. The
immortal Yolta improved upon Galvauf s teachings. With the intro-
duction of the voltaic pile, in 1800, his fame spread world- wide, by later
modifications he formed the beautiful uLa Couronne de Tasses," the
model by which to-day we flash our messages through the fathomless
oceans. It was more than one hundred years after Gilbert's time, that
electricity was lirst brought into use as a curative agent. De Haen
(1745), Jallabert (1748), and Abbe Xollet (1749) were the first to employ
static electricity in medicine. In 1758 Benjamin Franklin tried the
action of the electric current on a number of paralytics. In 1759 the
Keverend John Wesley, the famous divine, published a treatise entitled
The Desideratum, or Electricity made Plain and Useful, by a Lover of Man-
kin<l and Common Sense. The first records of electrical treatment at a
London hospital are found in the year 1767, when a static machine was
installed at the Middlesex Hospital, and in 1777 another was placed in
St. Bartholomew's Hospital. At St. Thomas's Hospital the subject was
systematically pursued by Mr. John Birch, the surgeon ; and in 1799
he contributed an essay of fifty pages on medical electricity to John
Adams's book, An Essay on Electricity. The nineteenth century has
seen the fruits of these great labors practically applied. To enumerate
even a tithe of the marvellous discoveries and inventions that form
part of our conveniences, of our necessities, of integral parts of our every-
day lives, would be merely to repeat an oft-told story — a story of the
great triumphs of human achievement.
ELECTRICITY AS A PART OF THE MEDICAL CURRICULUM:
It has been estimated that about 12,000 physicians are constantly
using some form of electricity in their daily practice. The question
nat u rally arises, Why doesn't the subject of medical electricity form part
of the college curriculum? Without some theoretical and practical
knowledge of the science, how can the physician hope to apply a current
intelligently or know when its application is advantageous I Is not this
ignorance of its principles and practical workings responsible for its being
classed in the charlatan's armamentarium and its administrator desig-
nated a quack? To understand medical electricity the tyro must begin
in the laboratory. He must there study the physics of electricity and
magnetism ; he must study electrical appliances for creating energy.
xxx ii 1NTRO1MVTION.
IJesides these tiling he should diligently inquire as to the resistances
encountered in the human body, the electrolysis resulting in living tissues,
the range of voltage, etc. He needs to be trained especially in what may
be termed the physiological action of the various currents and their
therapeutic values. Indeed, if but one hour daily for a single term be
devoted to the study of the mechanism of the apparatus, to the connection
of the wires, the nature of the current, etc., and a corresponding limited
number of hours be devoted in a succeeding term to the therapeutic
application of the science, it is more than likely that a correct apprecia-
tion of the study will be meted out to it, and the professed specialists
who are now duping the unwary would be forced to retire ignomiuiously
from the field.
PRACTICAL
ELECTRO-THERAPEUTICS
PART I
ELECTRO-THERAPEUTICS
CHAPTER I
THE ELEMENT A EY PRINCIPLES OF ELECTRICITY AND
MAGNETISM.
IN the following paragraphs an effort has been made to present, in a
space succinct yet commensurate with the importance of the subject, the
underlying principles of electricity and magnetism, embracing the more
usual terms, tables of units, sources of energy, and the fundamentals of
the science necessary to an understanding of its application to medicine
and surgery. Clearness of expression has been aimed at rather than a
detailed scientific and mathematical exposition of every term employed.
Those interested in a more elaborate study of these principles are referred
to the standard works on natural philosophy and electricity.
I. Nature and Properties of Magnetism.
The nature of magnetism is more or less closely allied to that of elec-
tricity. The term u magnet" is supposed to originate from the Greek
word il Magnesia,"1 a principality of ancient Greece, where deposits of
magnetite were first discovered. Chemically this is known as magnetic
iron ore (Fe3O4).
Magnets are of two kinds :
(a) Natural.
(b) Artificial.
Experiments have demonstrated that, when steel bars are applied to
lodestoues or other magnets, they become magnetized, and the original
magnet suffers no loss of magnetic property. Magnets made in this
manlier are called i • artificial magnets." The original lodestoues, from
their inherent magnetic properties, an- designated ''natural magnets."
Chemically the substance is known as "magnetite."
3 33
34 ELECTRO-THERAPEUTICS.
Magnetism may be temporary or permanent. Temporary magnetism
is magnetism remaining only tor a short time, as in soft iron.
Permanent magnetism, as the name indicates, permanently resides
in the magnet, as in steel.
ELECTRO-MAGNETS.
When a bar of soft iron has wound around it a coil of wire for the
purpose of establishing a magnetic field, we obtain an electro-magnet.
Soft iron is almost universally employed in the manufacture of electro-
magnets. The use of hard steel with a similar strength of current yields
far less magnetic force.
II. Nature and Properties of Electricity.
Electricity (derived from the Greek rj^xrpo-^ amber) is the term
applied to a certain invisible agent known to us only through its peculiar
behavior. The early scientists held that electricity was a fluid ; later ex-
periments tended to show that it beLaved like an incompressible liquid,
and in other ways resembled a gas highly attenuated and without weight.
In the light of present knowledge, the fluid theories have been abandoned,
and it is now generally accepted that the peculiar phenomena are the re-
sult of some strain or other action in the ether, the latter being supposedly
a fluid medium that exists in all parts of the universe — in gases, solids,
and liquids.
A. THEORY OF POTENTIAL.
The laws which concern the magnitude and measurement of electrical
quantities are very difficult to explain. That branch of electrical science
dealing with the measurements of electrical charges is called electro-statics.
Many of the less complicated electrical phenomena may be conveniently
illustrated by the action of fluids, though it must be remembered that
such comparisons are only relative, and introduced to facilitate the easy
mastering of electricity. Electrical potential, or electro-motive force ( writ-
ten thus — E. M. F. ), is that property possessed by a body by means of
which an electric current is enabled to pass from it, through some
other medium, into another body. In order to simplify the theory of
potential, it is essential to notice the elementary laws governing electrical
force.
Hydraulic Analogy. — In order to simplify the term "potential."
let us assume the following analogy between electricity and water.
L<-t us suppose two reservoirs (both partly tilled with water at different
levels and connected with each other by means of tubing. Evidently the
water in the reservoir placed at the higher level will flow through the
pipe into the lower reservoir. The flow is due to difference in levels
ELECTRICITY AND M A< iNKTISM. 35
producing pressure (or motive force . measured by the difference in alti-
tude (or potential) between the water contained in the two reservoirs.
When the two reservoirs are placed at the same level, no difference in
pressure will exist; hence, no water will llo\\- from the one reservoir to
the other. If we substitute the word "potential" for "level," we then
employ the common electrical term.
Imagine two charged bodies to be connected with each other by wire r
a flow of current takes place from the positive to the negative charged
body : this is possible because of a difference in the potential in* the two
bodies. Allowing that the positive charged body is at a higher potential
(or level ) than the one charged negatively, we must state that the flow of
IVOLT
HATE. OF FLOW —curvrvEHT i AMR
WOI\K DONE. 1 JOULE
I\ATE AT WHICH WORK
Fi> DONE. 1 WM1
FIG. 1.— Electrical units illustrated by means of the hydraulic analogy. (Hedley.i
current results from the difference in the potentials, thus creating an elec-
trical pressure or electro-motive force. The fact that there is a flow of
current from a higher to a lower potential must not be overlooked. From,
the foregoing remarks it may be assumed that no flow of current takes
place between the bodies when they are at equal potentials. Whenever
a stream of water falls from a higher to a lower level, it will perform a
certain amount of work in its course downward, — i. e., it has acquired a
certain amount of potential force, and, besides, the difference of level can-
not be restored without expending a certain amount of work. For every
pound of water that is lifted through a difference of level equal to a foot,
one foot-pound of work is done, no matter what the shape of the path
may be by which the elevation of the water to a higher level is accom-
plished. Likewise, electricity cannot be transferred from one body to
36 ELECTKO-THKkAPFJ'TK s.
another at a higher potential without requiring a certain amount of work
to be accomplished. The term potential, tin nigh relative, must be
considered as meaning a force or power to do work. For instance, if we
lift a one-pound body five feet high against the force of gravity, the
weight of the pound-body in turn can accomplish five toot pounds of
work in falling to the ground. In the strictest sense of the term, poten-
tials are relative ; hence it is always the difference of potential with
which we are dealing.
-
B. UNITS OF ELECTRICAL MEASUREMENT.
C. G. S. System. — Electricians have universally agreed to adopt a
system of measurement based upon three fundamental units : namely,
the centimeter, — the unit of length ; the gramme, — the unit of weight or
mass ; and the second, — the unit of time. All other units are derived
from these three, and are known as derived units, one of the most impor-
tant of these being the unit of force, called the dyne. The dyne is that
force which when acting for one second of time on a mass of one gramme
conveys to it a velocity of one centimeter per second.
(a) Electro-static Units. — (1) The unit of electro -static quantity is
that quantity of electricity which, when placed at a distance of one centi-
meter (in the air) from a similar and equal quantity, repels it with a
force equal to one dyne.
(2) The unit of electro-static potential is equal to the unit of work
done in moving a unit of positive electricity against the electric forces.
(3) The electro -static unit of difference of potential is that difference
existing between two points when it requires the expenditure of one erg
of work to bring a positive unit of electricity from one point to the other
against the electric force.
(4) The electro-static unit of capacity is that conductor which requires
a charge of one unit of electricity to bring it up to unit potential.
(5) By electro-motive intensity is meant the electric force of intensity
of an electric fluid at any point, being measured by the force which it
exerts on a unit charge placed at that point.
(b) Magnetic Units. — (1) The unit magnetic pole is one of such a
strength that when placed at a distance of one centimeter (in the air)
from a similar pole of equal strength, repels it with a force of one dyne.
(2) Magnetic pnti'iitialis measured by the amount of work done in
moving a unit magnetic pole against the magnetic forces.
(3) Unit difference of magnetic potential exists between two points
when it requires the expenditure of one erg of work to bring a unit mag-
netic pole from one point to the other against the magnetic forces —
magneto- motive force being measured in the same units as difference of
magnetic potential.
ELECTRICITY AND MAGNETISM. 37
(4) The intensity of magnetic field is measured by the force it exerts
upon a unit magnetic pole ; hence,
(5) Unit intensity of field is that intensity of a field which acts on a
unit pole with a force of one dyne, the term gauss having been proposed
for this unit.
(6) Magnetic flux, or total induction of magnetic lines, is equal to the
intensity of field multiplied by area — its unit being equal to one magnetic
line.
(7) Magnetic reluctance is the ratio of magneto-motive force to mag-
netic flux.
(c) Electro-magnetic or " Absolute " C. G. S. Units. — The pre-
ceding magnetic units give rise to the following set of electrical units, in
which the strength of currents, etc., is expressed in magnetic measure,
according to the ceutimeter-gramme-second system :
(a') A current has a unit of strength when one centimeter length of
its circuit bent into an arc of one centimeter radius exerts a force of one
dyne of a unit magnet- pole placed at the centre.
(&') Unit of difference of potential exists between two points when it
requires the expenditure of one erg of work to bring a unit of positive
electricity from one point to the other against the electric force.
(c') A conductor is said to possess a unit resistance when unit differ-
ence of potential between its ends causes a current of unit strength to
flow through it.
(<f ) Unit of quantity of electricity is that quantity which is conveyed
by unit current in one second.
(e1) Unit of capacity requires one unit quantity to charge it to unit
potential.
(/') f'1^ °f induction is such that unit electro-motive force is
induced by the variation of the current at the rate of one unit of current
per second.
(d) " Practical Units and Standards.1 — Several of the above
' absolute ' units in the C. G. S. system would be inconveniently large
and others inconveniently small for practical use. The following are
therefore chosen as practical units :
" (1) Resistance. — The Ohm, = 109 absolute units of resistance (and
theoretically the resistance represented by the velocity of one earth-quad-
rant per second) but actually represented by the resistance of a uniform
column of mercury 106.3 centimeters long and 14.4521 grammes in mass
at 0° C. Such a column of mercury is represented by a l standard' ohm.
1 An International Congress of Electricians met at the Columbian Exposition, at
Chicago, in 1893 for the purpose of adopting practical and standard electrical units.
These commissioned delegates of many countries agreed upon the following eight
definitions of terms.
38 ELECTRO-THERAPEUTICS.
11 (2) Current. — The Ampere < formerly called the 'weber'),
= 10 — ' absolute units; practically represented liy the current which
deposits silver at the rate of 0.001118 gramme per second.
11 (3) Electro- mot ire Force.— The Volt, == 10s absolute units, is that
E.M.F. which applied to 1 ohm will produce in it a current of 1 ampere :
being »« of the E.M.F. of a (Mark standard cell at 15° C.
" (4) Quantity. — The Coulomb, = 10' absolute units of quantity ;
being the quantity of electricity conveyed by 1 ampere in one second.
"(5) CajHieifi/. — The Farad, =- 10 — 9 (or one one-thousand- mill-
ionth) of absolute unit of capacity : being the capacity of a condenser such
as to be chauged to a potential of 1 volt by 1 coulomb. The micro-fa rod
or millionth part of 1 farad = 1015 absolute units.
" (6) Work. — The Joule, == 107 absolute uuits of work (ergs), is
represented by energy expeuded in one second by 1 ampere in 1 ohm.
" (7) Power. — The Watt, = 107 absolute uuits of power (ergs per
second), is power of a current of 1 ampere flowing under a pressure of 1
volt. It is equal to one joule per second, aud is approximately ^^ of
cue horse-power.
u (8) Induction. — The Henry, — 109 absolute units of induction, is
the induction in a circuit wheu the electro -motive force induced in this
circuit is 1 volt, while the inducing current varies at the rate of one
ampere per second.
"Seeing, however, that quantities a million times as great as some
of these, and a million times as small as some, have to be measured l>y
electricians, the prefixes mega- aud micro- are sometimes used to signify
respectively 'one million' and 'one millionth part.' Thus, a megohm is
a resistance of one million ohms, a micro-farad a capacity of y^nr^innr °f a
farad, etc. The prefix kilo- is used for ' one thousand ' and milli- for ' one
thousandth part ' ; thus, a kilowatt is 1000 watts, and milliampere is the
thousandth part of 1 ampere.
" The 'practical' system may be regarded as a system of units
derived not from the fundamental units of centimeter, yrammc, andsm»wf,
but from a system in which, while the unit of time remains the second,
the units of length and mass are respectively the earth-quadrant aud
10" grammes." '
C. DEFINITIONS AND EQUATIONS.
We are now prepared to follow our analogy in the comparison be-
tween the flow of \\ater in a tube and the How of the electric current.
Tin- lirst principle to demand attention is that of conductivity.
Conduct! rill/. — I'pon the si/e and construction of a pipe depends the
amount of energy required to propel water through it. A pipe that has
'Elementary Lessons in KU-ctririty and Magnetism. — Sylvanus Thompson.
ELECTRICITY A XI) MAGNETISM. 39
•a smooth inner surface conducts water more readily and with less loss of
energy than one whose size is the same but has a rough inner surface.
Similarly does the flow of electricity depend upon the size and material
of which the conducting medium is composed. Au electric current Hows
through the entire cross-section of a conductor, so that the resistance
offered is uniform throughout the material. Different materials conduct
electricity differently, so that we speak of their relative powers as their
conductivities.
Resistance: Ohm's Laic. — When forcing water through a pipe by
means of pump pressure, the flowing stream is proportional to the pres-
sure divided by the resistance. The resistance is the result of friction.
This applies to an electric current, the current strength being equal to the
electro-motive force divided by the resistance and inversely as the resist-
ance of the circuit ; in other words, anything that makes the E. M. F.
acting in the circuit greater will increase the current, while anything
that increases the resistance (either the internal resistance in the source of
E.M.F. itself, or the resistance of the external wires of the circuit) will
diminish the current. This is Ohm1 s law, and is frequently expressed thus :
Volt E. M. F. Electro-motive Force
Ampere = C = = Current =
Ohm R Resistance.
True electrical resistance depends upou the nature of the metal of which
the conductor is composed, the area or diameter of its cross-section, its
length, and lastly upou its temperature. "The greater the cross-section
of a conductor the greater is its electrical conducting power, and there-
fore the less is its resistance ; and the longer the wire the less is its
conducting power, and therefore the greater is its resistance."
The relations of the above units may be expressed as follows :
1 volt x 1 ampere = 1 watt
1 volt -i- 1 ohm = 1 ampere
1 ampere x 1 ohm = 1 volt
1 ampere x 1 second x 1 ohm = 1 joule
1 ampere x 1 second = 1 coulomb
III. Sources of Electrical Energy.
The energy required for producing the electric current may be
derived from
A. Static 1
B. Galvanic
r, -n t electricity.
C. Dynamic
D. Thermal j
A. STATIC ELECTRICITY will be discussed in the chapter on the Routgen-
ray apparatus.
40
ELECTRO-THERAPEUTICS.
B. THE G ALT AX ic CURREXT.
(a) Primary batteries consist of n series of cells containing a cor-
rosive fluid, called the electrolyte, in which are two immersed dissimilar
metals. The employment of the galvanic current, however, is not prac-
tical in X-ray work, owing to the necessity of employing large numbers
of cells and the tedious and unpleasant labor occasioned by their use.
The most reliable of these cells are the Bunsen and the Daniell. The
latter cell is recognized as a standard, the pressure of one of the cells
being equivalent to one volt (approximately). These cells may be con-
nected in one of three ways :
1. In series.
2. In parallel.
3. In groups.
(1) Series. — In order to obtain the highest E. M. F. (voltage) it is
necessary to connect the cells in ''series:" in other words, the negative
pole of the first cell is connected with the positive pole of the second
cell, the negative pole of the second cell with the positive pole of the
third cell (and so on), and the free negative and free positive poles of the
first and last cells form the ends or terminals of the "battery." In
such an arrangement the E. M. F. resulting is equal to the sum of the
E. M. F. of the individual cells. (Fig. 2.)
FIG. 2. — Connection of the cells in "series.'1
(2) Parallel. — In order to obtain increased current strength
(amperage) the cells are connected in a manner known as the " parallel "
plan (Fig. 3), thus : The positive poles of the individual cells, as well
AMP*.
VOUT*.
FIG. 3.— Connection of the cells in "parallel."
as the negative, are connected in such a manner as to form one pole of
the battery, positive — and the other pole, negative. In other words,
by the union of the several cells in this manner one large cell has been
produced. The resulting electro- motive force is the electro-motive force
of one cell only, while the resistance equals that of one cell divided by
ELECTRICITY AXD MAGNETISM.
41
the total number of cells. The amperage is equal to the product of the
uuinber of cells by the amperage of each individual cell.
(3) Group. — In the u group •• method some (Fig. 4) cells are joined
in series and some are in parallel. Thus, — place two cells in one series,
and the other two in another series ; connect the positive poles of the
two groups to form a positive pole, and the negative poles of the two
FIG. 4. — Connection of the cells in "groups."
groups to form a negative pole, — the result of this arrangement being to
halve the number of cells and thus double their size.
(b) Accumulators, Storage or Secondary Batteries. — In 1802
Gautherot, after laborious experiments, invented the storage battery.
This was improved upon by
Hitter in 1803, but the great-
est improvements were intro-
duced in 1859 by the elabo-
rate investigations of Gaston
Plaute.
Briefly, the principle in-
volved in the accumulator is
as follows : We pass an elec-
tric current into a primary
cell, containing two plates of
similar metals. For this pur-
pose, lead is almost univer-
sally employed, the chemical
action from the current result-
ing in the production of the
peroxide of lead (PbO2) on
that sheet of lead to which
the positive pole is attached,
whilst the negative plate shows
the formation of spongy me-
tallic lead i Pb). The charging current is now removed, the two plates
of lead are united, and a current having the opposite direction is pro-
duced. So long as this condition is maintained a new phenomenon is
observed : the peroxide of lead suffers a change, being reduced to plumbic
oxide (PbOj, and the spongy lead is changed to the oxide of lead through
FIG. 5.— Diagrammatic view of the inner construc-
tion of a storage cell. (American Battery Company.)
1, positive binding post; 2, negative binding post ; 3 rub-
ber cap ; 4, hard-rubber vent-tube ; 5, oak case; 6, com-
pound between rubber jar and oak case ; 7, hard-rubber
jar; 8, leaden lug attached to positive plates ; 9, leaden
lug attached to negative plates ; 10, positive plate : 11,
negative plate ; 12, sulphuric-acid solution ; 13, soft-rub-
ber bands ; 14, hard-rubber insulators.
42 ELECTRO-THERAPEUTICS.
the process of oxidation, until the two plates are again chemically
identical : when this condition is arrived at, the current ceases. A very
ingenious construction of this principle is shown in Fig. .">.
A marked improvement over Plant e's accumulator is the ingenious
invention of Faure. In 1881 the latter scientist perfected his invention
that is now so largely employed. lu the Faure system, the active
material is previously prepared and spread on a suitable support or
grid— mostly of lead — in such a manner that it is well retained, which
offers little electrical resistance. For the positive plates, use is made of
red lead (Pb3O4) and sulphuric acid (50# ); for the negative plates, either
litharge (PbO) and sulphuric acid or porous lead.
Other advantages to be gained in the employment of the accumulator
are :
1. Its high E.M.F. (2 volts for each cell).
2. Its compactness, portability, and durability.
The capacity of an accumulator is usually expressed in "ampere-
hours," implying the product of maximum discharging current together
with the length of time in hours it discharges. The capacity will be
slightly reduced when an accumulator discharges for a very short length
of time at a higher rate than the maximum discharge current; the capac-
ity depending upon the size, the number of plates and their formation.
For illustration, if we assume that a certain accumulator has a capacity
of forty-eight ampere-hours at the maximum discharge of eight hours,
then we may use the battery normally at one charge as follows :
With one ampere for 48 hours
With two amperes for 24 hours
With four amperes for 12 hours
With eight amperes for 6 hours
The utmost precautions must be taken in caring for accumulators ;
this is of paramount importance, because they are very sensitive to
shocks and over-exertion, and any bending of the plates is liable to give
rise* to short circuits. There is likewise danger of leakage of acid, break-
ing of glass cells, etc. Another point to be remembered is that the cells
must be frequently charged and discharged ; if this is neglected the plates
will rapidly become impaired.
It must not be forgotten that the cells must be arranged in a
"series."
Sulphuric acid of the best quality must always be used in diluted
form and free from all impurities. The strong acid should be diluted with
absolutely pure water to a specific gravity of 1200 or 25 Beaum6 as shown
by the hydro meter at a temperature of 60° F. In mixing the electrolyte
the acid must always be poured into the water. The electrolyte should
never be added to the cells until cold.
ELECTRICITY AND M A< INK TISM.
43
In subsequent charges and in general use, it is only necessary to
charge until the voltage is 2.5 per cell while charging. It is advisable to
charge the cells once a week until the voltage per cell is 2.5 volts or
about one-third the normal charging rate.
When discharging, the electro-motive force of each cell, as measured
by the voltmeter, must not be allowed to sink below 1.85 volts ; thus, in
the case of a 6-cell battery 11 volts is the lowest limit for the discharge.
Cells should never be permitted to stand idle if more than 75 per
cent, of their capacity has been used.
If a battery is to remain idle for a long time, it should first be fully
charged and then given a recharge enough to bring it to a boil, and
left charged.
T\MEOST«T
~F \
1 \
1 \
J \
FIG. C.— Diagrammatic view, illustrating the charging of a battery by the ammeter and volt-meter.
Always see that the cells are well covered with the electrolyte. If the
latter has been spilt or become partly evaporated, it must be replaced
with distilled water, and during the charging the top should be open so
as to allow the escape of the hydrogen bubbles. Avoid unnecessary
vibration and shaking of the cells. With proper care the accumulator
should render good service for five to eight years.
Accumulators may be charged in any of the following five ways :
1. Primary cell.
2. 110-volt (direct) current.
3. Alternating current.
4. Bicycle dynamo.
5. Thermopile.
(1) The method by the primary cell is not practical, because the labor
involved is unpleasant and tedious, and the process is a most lengthy one.
44
ELECTBO- T II I •: R A I 'EUTICS.
(2) The second method, or the use of the 110- volt (direct) current, is
the most practical and most easily available method in use. It is neces-
sary in this method to find the correct polarity of both the 110-volt and
also of the accumulator. The manner of determining- the polarity will
be discussed in a subsequent chapter. It is necessary by this method to
offer a resistance to the current, owing to the circumstance that the
degree of voltage is too great fpr the accumulator. The means employed
to effect resistance to this excess of current are either a group of lamps or
the rheostat. In the latter method the ammeter is placed in the path of
the current, and the rheostat is so regulated that the exact voltage sent
to the accumulator can be determined by the amperage recorded by the
ammeter. (Fig. 6.)
The simpler and cheaper method is that obtained by the group of
lamps, mounted on a base and connected in parallel. Each lamp (16
candle-power) is equivalent to one-half an ampere ; therefore, by this
method we can accurately estimate the resistance required, by introduc-
ing that number of lamps which will be necessary to produce the proper
amperage for charging the accumulator. When the accumulator is not
properly connected, the lamps burn more brightly than usual. (Fig. 7.)
o-
3 4
S.B.
1 / i / \ r \
FIG. 7.— Diagrammatic view, illustrating the charging of a battery by a bank of lamps.
(3) The alternating current presents the disadvantage that, not
being unidirectional in character, it requires the employment of a
lt converter" in order to produce a unidirectional current, and also to
provide a low voltage that may be suitable for charging an accumulator.
ELECTRICITY AND MACNKTISM. i.->
(4) Where it is impossible to obtain a current, as on the battle-field,
ingenious use has been made of the bicycle, by employing it as a motor
and attaching it to a dynamo, which generates the current for charging
the accumulator. This clever thought originated with Major Battersby
in his memorable Soudan campaign, and the method has been success-
fully imitated in South Africa. Other means, but not so practical, are
by water-power, windmill, or by horse- or man-power.
(5) The fifth and last method is by the use of the thermopile for
charging purposes, which has found but little favor, and is rarely, if
ever, employed in this country.
C. DYNAMIC OR ELECTRIC MAINS are of two kinds :
(a) Direct.
(b) Alternating.
(a) Continuous or Direct. — In places where a current from the
continuous commercial main is available and voltage ranges from 100 to
250, advantage is often taken of this source of energy, owing to the fact
that it presents few difficulties and demands but little attention ; the
rheostat alone being necessary to regulate both the voltage and amperage.
(b) Alternating or Street Current. — When it is necessary to em-
ploy an alternating current, there will be required a motor-transformer.
D. THERMOPILES.
In 1822 Professor Seebeck, of Berlin, accidentally discovered that
when heat is applied to a circuit-junction, a current of electricity is pro-
duced ; also, that when two junctions are of different temperatures, the
current produced is directed from the warmer to the colder junction.
Thermopiles are very seldom employed for working an induction coil.
Their use is extremely limited in this country.
CHAPTER II
THE STATIC, FRANKLLNTC, OR FRICTION AL CURRENTS.
THERE are three chief forms of electricity used iu medicine and
surgery :
Static, Frankliuic, or frictional.
Galvanic, continuous, or direct.
Faradic, interrupted, or indirect.
The other so-called varieties, such as the sinusoidal current, high-
frequency currents, etc., are modifications of the above forms.
I. The Static or Influence Machines.
Ever since static electricity was discovered and the first static
machine was invented by Otto von Guericke, a burgomaster of Magde-
burg, Germany, in 1647, the subject has received the closest study from
scientific minds. Sir Isaac Newton eagerly seized and improved upon
von Guericke' s discoveries, and these early researches were continued
through the centuries by English, German, French, and Italian phi-
losophers, not the least conspicuous among whom may be cited Ramsden,
Plant4, and De la Fond. While the friction or static machines of these
searching inquirers are now obsolete, their persistent study laid the
foundation for the present-day influence machines.
In the construction of influence machines two important principles
are carried out : (1) the principle of influence, whereby a conductor
touched acquires a charge of the opposite kind, and (2) the principle of
reciprocal accumulation.
"In Fig. 8 let us, for instance, employ two insulated conductors, A
and B, electrified ever so little, one positively and the other negatively.
Let a third insulated conductor C, which we shall call a carrier, be
arranged to move so that it first approaches A and then B, etc.
"If touched while under the influence of the small, positive charge
on A, it will acquire a small IK -gative charge ; suppose that it then moves
on. and gives this negative charge to B, and it then be touched while
under the influence of B, so acquiring a small positive charge. When
it returns toward A, let it give up this positive charge to A, thereby
increasing its positive charge. Then A will act more powerfully, and
on repeating the former operations both B and A will become more
highly charged. Kach accumulates the charges derived by the inilu-
ence from the other. This is the fundamental action of all the modern
46
FRICTIOXAL CURRENTS.
47
influence machines, dating from 1860, the first having been constructed
i»y ('. F. Varley, consisting of six carriers mounted on a rotating disk of
glass."1
A. TYPES OF INFLUE.M i: MACHINES.
(a) The Wimshurst influence machine (Fig. 10) consists of two
circular disks of glass, so mounted as to be rotated in opposite directions,
at a distance of one-eighth of an inch apart. Each disk is attached to
the end of a boss of ebonite, upon which is turned a small pulley. Both
disks are well varnished and cemented. To the outer surface of each are
twelve or more sectors, made of thin brass and at equal angular distances
apart. Twice in each revolution, the two sectors situated on the same
FIG. 8.— Diagrammatically illustrates the principle of influence and accumulation of static or
influence machines.
diameter of each, disk are momentarily placed in metallic connection with
one another by a pair of fine wire brushes, supported at the middle of its
length, by one of the projecting ends of the fixed spindle upon which the
disks rotate, the sector plates just grazing the tips of the brushes as they
rotate. The position of the two pairs of brushes with respect to the fixed
collecting combs and to one another is variable.
The fixed conductors consist of two forks, furnished with collecting
combs directed toward one another and toward the two disks which rotate
between them, the position of the two forks, which are supported on
ebonite pillars, being along the horizontal diameter of the disk. To these
fixed conductors are attached the terminal electrodes, whose distance
apart can be varied. This form of machine is very efficient and self-
excitiiig, provided that a sufficient number of sectors be present, for it is
56, 57.
1 Sylvan us Thompson, Elementary Lessons in Electricity and Magnetism, pp.
4S
ELECTKO-THERAPEUTICS.
found that the machine works at full power after the second or third
revolution of the handle. The "NVimshurst machine works best when the
resistance of the discharging circuit is high, and it has been proposed to
enclose the apparatus in a strong metal case, and to work it under a pres-
sure of several atmospheres, thus avoiding leakage through brushing.
The theory of action of these machines is perhaps best explained by
the aid of the accompanying illustration (Fig. 9), in which, for the sake
of greater clearness, "two rotating plates are represented as though they
were two cylinders of glass, rotating in opposite directions, one within the
other. The smaller inside cylinder, in the figure, represents the front
plate, and the larger outer, the back plate : the front plate rotates right-
handedly, and the back plate left-haudedly. The neutralizing brushes,
FIG. 9.— Illustrates diagrammatically the theory of action of a Wimshurst influence machine.
Wx, »2, touch the front metallic sectors, represented near the top of the
diagram, to receive a slight positive charge. As it is moved onward
toward the left it will come opposite the place where one of the front
sectors is moving past the brush wt. The result will be that the sector
touched while under influence by nl will acquire a slight negative charge,
which it will carry onward toward the right. When this negatively
charged front sector arrives at a point opposite n3, it acts inductively on
the back sector which is being touched by n3 ; hence this back sector will
in turn acquire a positive charge, which it will carry over to the left. In
this way all the sectors become more and more highly charged ; the front
sectors carrying over negative charges from left to right, and the, back
sectors carrying over positive charges from right to left. At the lower
FRICTIONAL CUEEENTS.
49
half of the diagram a similar but inverse set of operations take place.
For when % touches a front sector under the influence of a positive back
sector, a repelled charge will travel along the diagonal conductor to n%,
helping to charge positively the sector which it touches. The front
sectors, as they pass from right to left, in the lower half, will carry posi-
tive charges ; while the back sectors after touching n4 will carry negative
charges from left to right.
"The metal sectors then act both as carriers and inductors. It is
clear that there w7ill be a continual carrying of positive charges to the
FIG. 10.— Wimshurst influence machine.
right, and of negative charges to the left. At these points, toward which
the opposite kinds of charges travel, are placed the collecting combs com-
municating with the discharging knob."1
(&) Holtz of Berlin invented a very powerful" influence machine.
(Fig. 11.) In brief, it consists of two glass plates, the diameter of one
plate being slightly larger than the other. The plates, though in close
relationship, do not touch. The fixed plate contains two " windows"
1 Sylvanus Thompson, Elementary Lessons in Electricity and Magnetism, p. 63.
50
1 : 1 , 1 ;<JTKO-THERAPEUT 1 ( S.
directly opposite one another. Two bits of paper (field plates) are glued
to the stationary plate, oue above the window on the left side, and one
below the window on the right. From each of these pieces of paper a
tongue protrudes through each aperture, almost, but not quite touching
the revolving plate. The plate is rotated in a direction opposite to that
in which the tongue projects. The prime conductor consists of two
metallic combs, supported by brass rods with knobs, and mounted on
glass supports. Two other brass knobs with ebonite handles and knobs
form the discharging electrodes, through whose agency the spark length
can be varied. A neutralizing rod to minimize the reversal of polarity
FIG. 11.— Toepler-Holtz influence machine.
is also provided. Before working the machine, one of the field plates
must l>e charged from an outside source and the knobs of the discharging
rods must be brought together.
(c) The Voss or ToepJfr is more self-exciting than the Holtz, but is
less si i re in its action than the WimahniBt The Voss resembles the Jlolt/
machine in many details, but the moving plates carry a lew sectors, and
these in their rotation touch a pair of brushes carried by two bent arms
which connect with the Held plates, and so convey charges from the mov-
ing plate to the armature of the fixed field plates. In this country there
are practically no Wimshurst machines used. They are nearly all
Toepler-Holtz machines, that is to say, Holtz machines modified so as to
FKKTIOXAL CURRENTS. 51
be self-exciting, as invented by Toepler. The Eastern manufacturers are
largely using the Holt/ machines which are excited by a smaller genera-
tor of the Wimshurst or Toepler type, while mostly all the Western
manufacturers use the Toepler- Holtz type machine.
B. CAKE AND MANIPULATION <>F STATIC MACHINK.
In the use of influence machines certain requisites are necessary to
insure satisfactory results. Chief among these are dry ness and cleauli-
!ie>». The accumulation of dust or moisture upon the insulating surfaces
interferes with the high voltage that must be obtained. The machine
may be freed from dust and moisture by the use of a dry silk fabric;
the oxidation of the metallic sectors can be effectively obviated by cleans-
ing them with a cloth previously immersed in benzine or gasoline. Alco-
hol should never be used on any varnished part, as it acts as a solvent
thereof. During the summer months when the air is often surcharged
with moisture, it becomes necessary to place in the case a deep tray
containing fused calcium chloride ; this must be free from impurity, else
there will result oxidation of the metallic parts. Likewise during the
torrid season it is found that the current acting on the air in the case of
the machine, develops a nitrous oxide, and that the nitrogen combining
with hydrogen forms nitrous acid accumulations, which are detrimental
to the working of the machine. Wagner uses ventilators in his machine,
which carry off the nitrous oxides, and recommends that during the sum-
mer months a dish containing oil, such as boiled linseed oil, be placed.
inside of the case. The oil takes up the active nitrogen because it has
more affinity for the nitrogen than for the hydrogen. Sulphuric acid is
also one of the Ix-st and most inexpensive driers that can be used in a
static machine. When it is used, it should be placed in a broad, open
dish, four or live inches deep, and the full-strength commercial sulphuric
acid should not more than half fill the dish, as the acid will take up the
moisture and increase until it has almost doubled its volume ; then it
loses its efficiency as a drier.
When used tor exciting an X-ray tube, this machine must be operated
by a power capable of giving a high and steady electro-motive force. In
cities an electric motor (of the required horse-power) should be em-
ployed ; in country places water motors or gasoline engines should
furnish the power ; hand power with this machine is inefficient for
skiagraphy.
The length of a spark of a properly working machine ought to
equal the radius of the revolving plates (approximately). Care should
be exercised that the neutralizing brushes are so bent as to bring
them in proper contact with the disks during the whole period of
revolution.
52 ELECTKO-THERAPEUTICS.
The electro-motive force of a static machine depends upon the
number of revolutions per minute, the size and number of the revolving
plates, aud the general construction and care of the same.
Glass plates have been in use for more than a century, but mica
plates possess certain advantages. They are not fragile and less hygro-
scopic than glass ones, and I have never kuowu them to warp. Because
of the non-breakable character of mica, a high speed can be obtained for
the generation of extremely high volume of tension of current.
Machines not self-exciting have a charge added. This is usually fur-
nished by a revolving plate to which are fastened several brass sectors.
On revolving, the latter are brought into contact with the brushes. The
stationary plate of this machine encloses a sheet of tin-foil or paper as
a collector.
A static machine in bad order is said to have "lost its charge"
when it fails to generate electricity. This may be caused by dampness,
by the humidity of the atmosphere, or by turning the crank attached to
the driving-wheel in the wrong direction.
C. ACCESSORIES.
THE LEYDEX JAR.
This is an electro-static condenser, so named from its invention by
Cuneus, in the town of Leydeii, in 1745. In its modern form, a Ley den jar
is a cylindrical glass bottle, lined inside and out with tin foil, to within
a short distance of the top. A brass knob inserted in the wooden cover
is connected with the inner coating \)y means of a wire or chain.
Thus we have essentially two conductors, the one almost completely
enclosed in the other and separated from it only by the thickness of the
dielectric. If either conductor is put to earth, and the other insulated
and charged, an opposite and nearly equal charge is induced in the former.
Leydeu jars are frequently connected in series (the cascade arrangement)
to secure a potential difference equal to the sum of those due to the elec-
trification of the individual jars, or in multiple, all outside coatings con-
nected together and inner coatings the same, when increased quantity is
desired.
ELECTRODES. (Figs. 12 and 13.)
These may be of metal or of wood. The metallic electrodes are
usually of brass, made in a variety of shapes and sizes, and may be
round, pointed, etc., each being mounted upon a holder of ebonite (vul-
canite), which acts as an insulator. Boilers are usually made of brass,
and mounted upon a base or stem of elxmite. The wooden electrodes are
usually described as discharge electrodes, but they are not so frequently
FRICTIOXAL CUKKEXTS.
53
employed as are the metallic variety. Lately glass vacuum electrodes
lmv<- come iuto vogue. A convenient handle for holding electrodes is
shown in Fig. 14.
CHAIN-HOLDER.
This is usually a brass ring or hook attached to an ebonite stem, and
is employed for holding the chain which conducts the current from one
54 ELK< T I {( )-T I \ ER APEUTICS.
pole of the machine to the electrode (Fig. l">i. It prevents bringing the
chain in contact with the patient, and thus avoids shock.
MUFFLER.
This is a cylindrical glass tube, into the ends of which are fastened
discharge rods. The tul>e in a horizontal position is held to the discharge
rods of the static machine by means of wire hooks. The rods of the
muffler can be readily adjusted by simply turning them in a screw-like
fashion. This is employed for the purpose of lessening the noise from
the discharge rods of the static machine.
PREPARATION OF THE PATIENT.
When a patient comes for treatment it is necessary to ascertain the
nature of the disease, before deciding upon the kind of treatment to be
instituted. If the method selected requires the removal of some of the
apparel, this should be arranged by the physician' s attendant or nurse
in a separate room. If much of the clothing is removed, a wrapper or
loose gown should be thrown over the patient. If the patient is nervous
it is advisable to instruct the attendant to remove as few of the garments
as practicable, so as not to offend modesty and in order to lessen the
fear so frequently induced by the careless therapeutist. Celluloid combs
and all hair-pins should be removed from the patient's head ; if hair-pins
be permitted to remain they may cause unpleasant pricking sensations in
the scalp.
The patient should be placed in a comfortable position and far
enough from the machine to prevent shocks from the emitted sparks. In
damp weather or when the current is not very strong the patient should
hold the metallic electrode. The cords leading from the discharge rods
should not touch the ground, the patient, or each other : if they rest
upon the floor or " ground" there will be a flow of current into the
earth, if they touch the patient, shock will occur, and if they touch one
another a short circuit will result. I prefer to treat the patient in the
sitting posture, as this permits the application of the current to all parts
of the body, especially if he be seated upon a revolving stool. Occasion-
ally it may l>c necessary to adjust his chair so that he cannot rotate it,
thus allowing a constant flow of current to the part needing treatment.
POLARITY.
The polarity of a static current is not of great moment. I have
heard some patients say that the current of the positive electrode is more
pleasant than the negative and others affirm the opposite. I am of the
opinion that there is little, if any, difference between the positive and
FRICTIOXAL CURRENTS. 55
negative electrodes, so far as the emanating current is concerned. Never-
theless, this is easily determined Itv starting tlie machine with tin- mils
slightly apart, and obserx in^ that the spark is whitest near the posi-
tive pole, due to incandescent oxygen 1 icing whiter than incandescent
nitrogen.
The positive electrode emits a sharp hissing noise when placed in a
horizontal position.
Xo current will flow when a non-conductor is applied to the negative
discharge, but it will flow from the positive.
The positive pole can be determined by the collecting combs showing
points of light, while a brush-like form is evidenced upon the negative
side. This is best observed in a darkened room while the sliding rods are
in contact.
If we separate the balls on the ends of the sliding rods for an interval
of two centimeters, the spark stream issuing between the rods displays a
distinct violet portion, which begins at the ball in a bright point. This
violet portion denotes the negative pole, while the positive pole is
reciignized by a bright area of white light lying near it.
To reverse the polarity of an influence machine, the usual procedure
is to ground both terminals, and give the machine a few turns in the
opposite direction, then remove the grounds and start the machine
normally. The effect of this operation is rather uncertain, and Herr J.
R. Janus/.kiewicz1 has devised a system which is more reliable. In this
one pole of the machine is connected electrically to the inducing plate for
the opposite pole. The machine is revolved in the normal direction,
and if the connection then be broken the polarity of the machine will be
found to be reversed. If the machine is running at a fair speed only a
momentary connection is needed, but if it is running slowly it may be
necessary to leave the connection for ten or fifteen seconds. Care should
be taken that good electrical contact is made. A new pole changer that
bids to become very popular is shown in Fig. 16, which illustrates the
wrou<r connection of the Crookes tube with the static machine, as is iudi-
0 '
cated by the heavy lines. By this arrangement we correct the polarity
without changing the position of the tube, by sliding the rod, H, from
C to C1. the rod carrying the positive pole, which becomes A' (anode).
The negative pole, D, touches the metal D1, which is carried, and becomes
B1 (cathode).
IDIOSYNCRASY.
By this term is meant the susceptibility of the patient to the ac-
tion of the static electric cm-rent. It has frequently been observed that
1 Physikalische Zeitschrift (Leipsic), abstracted in the Electrical Review, Oct
15, 1904.
56
ELECTKO-THERAPEUTICS.
certain patients are unusually susceptible to static electricity. I have
seen many cases where a static breeze applied to the head was sufficient
to cause fainting, or at least dizziness. For such patients it is necessary
to diminish the strength of the current, also to shorten the length and
lessen the number of applications.
THE DOSAGE.
By this term is meant the length of time required for administering
the current in the particular case, the intensity of each treatment, — /. c.,
the strength of static current produced and applied, — and the frequency
FIG. 16.— Pole changer of Betz.
of its use. The length of each application should be between ten :m<I
twenty-five minutes. The number of applications will naturally depend
upon the character of the disease treated, the suffering of the patient,
and also upon idiosyncrasy. Here is where good judgment and skill on
the part of the therapeutist are required. It is the general practice to
give from one to five treatments a week. Frequently the pat lent inquires
as to the number of applications requisite before a change in the disease
will be noted. Unfortunately, we are not able to answer such ques-
tions satisfactorily. I have seen cases where only three or five treat-
ments were necessary ; again I have seen cases of the same disease
where twenty treatments were necessary before a change for the better
could be observed.
FIG. 17.— Static breeze, concentrated brush discharge, or spray. If the crown is positive, it is a
contractor of blood-vessels and acts as an anaesthetic. If it is negative, it dilates and liquefies and is an
irritant. The indicator on the machine is turned to the printed word "breeze."
Fio. 18.— Static negative insulation or gtatic bath. Patient holds the negative electrode on an
insulated platform ; positive is grounded and the sliding electrodes are widely separated.
FIG. 19.— Direct spark.
Flo. 20.— Indirect spark.
FRICTIONAL CURRENTS. 57
II. Modes of Application.
The forms of application used in electro- therapy are :
CONYKCTIVE \
DlSlU'I'TIYK DIscHAKliKS.
CONDUCTIVE )
A « <>NYK(TiYi; discharge occurs when electricity of a high poten-
tial discharges itself at a pointed conductor by accumulating there
with a density sufficient to electrify the neighboring particles of air
(these particles then flying off by repulsion), and conveying away
with them part of the discharge. This form of application is illustrated
in the use of the static bath, the breeze, and the spray as given off
from metal electrodes, the high-frequency discharges from glass vacuum
tubes, etc.
The DISRUPTIVE discharges embrace the various sparks, — the long,
short, and frict ion.
The CONDUCTIVE discharge is derived from an electrified conductor.
This may be a continuous current flowing through a thin wire connecting
the knobs of an influence machine or joining the positive pole of a
battery to the negative pole.
A. CoN'VKCTIVi: CUKKKXTS.
In using the brush discharge (Fig. 17) the patient holds either elec-
trode while the other, which may be pointed, broom -shaped, or coronal in
outline, is applied to the area to be treated. This includes the breeze
and spray (all these terms being synonymous); the breeze is the concen-
trated brush disci large.
The static bath (Fig. 18), also called static insulation, is administered
by having the patient on an insulated platform in communication with
one of the poles of the machine ; after some turns of the handle, it is
found that he is charged with positive electricity of a high potential,
while there is a constant waste of electricity from all parts of his body
and clothing. The effect of the static bath is ultimately sedative and it
is the form usually employed. It may be greatly intensified by applying
to the affected part a tinsel rosette instead of a crown piece. Strong
revulsive effects, leading to actual blistering, may occur when the patient
is connected directly with the positive pole. Dr. G. Bettou Massey, who
has had a great deal of experience in electro-therapeutics, believes that
this intensified spray has a deep penetrating action and is of great value
in intractable chronic rheumatism.
In the interrupted insulation the negative electrode is held by the
patient and the positive is grounded. The sliding electrodes are moved
to and fro, so as to produce an interruption in the current.
58 ELECTKO-TIIEK APEUTI CS.
B. DISRUPTIVE CURRENTS.
These are subdivided into the direct, indirect, and friction.
In the direct <Iix/- a j>f ire current (Fig. ID) the patient is seated oil the
platform, holding either the positive or the negative electrode, the
remaining electrode l>eing applied to the affected part. The Leyden jar
may or may not be in the connection. When it is so connected, the cur-
rent, as a rule, is usually too severe. The spark-gap is wide open.
Direct sparks are very painful, and are to be used only in cases of
surface anaesthesia.
The indirect disruptive current differs from the above in that the pa-
tient sits on the platform, holding the negative electrode, the positive
being grounded. If the electrode chain is attached to the water-pipe
(the indifferent pole being attached to the gas-pipe), more capacity is
gained, the single sparks give good muscle responses with little pain.
(Fig. 20.)
The friction disruptive current differs from the indirect only in that the
roller electrode is rapidly applied against the affected part. (Fig. 21. )
C. CONDUCTIVE CURRENTS.
Conductive currents are subdivided into the static induced current
and the wave current.
The static induced current (Fig. 22) is in connection with both the
Leyden jars and the patient ; the electrodes must be of metal and applied
to the bare skin or mucous membrane. The spark-gap is closed at first,
and then gradually opened to the point of toleration.
In the wave current the positive electrode is grasped by the patient
and the negative is applied to the ground; the necessary electrode is
block-tin or metallic cloth placed on the hare skin or mucous membrane.
Begin the application with the discharge rods touching ; then gradually
separate them until the desired strength of charge is attained.
The electric souffle or wind is applied by directing the point of a me-
tallic uninsulated rod toward, but one foot away from the patient. The
point is electrified negatively, — L e., if we are using positive electricity.
The surrounding air particles, becoming electrified, are attracted to the
nearest part of the patient's body, the stream of molecules producing
a perceptible current of air. The action of the soutlle is sedative.
Dr. William J. Morton's "Wave Current and High-Frequency Ap-
paratus"1 is described as follows :
"One prime conductor of the static generator is grounded; the
other is connected with an electrode applied to the patient who is on an
1 Bulletin Officiel de la Soci6te Francaise d'Electrotherapie, Jan., 1899 ; Electrical
Engineer, vol. xxvii., March 2, 1899.
FIG. 21.— Friction spark treatment.
FIG. 22.— Static Induced current. In this form of static treatment the indicator is turned to the
word "induced," which connects the Lcyden jars. The cords are attached to the binding posts, and
the sliding electrodes are very gradually separated, as otherwise the shock would be too intense.
FEICTIOXAL (TKIiKXTS. .V.»
insulating stand. The current received by the patient is due to the
spark discharge between the knobs of the prime conductors. The patient
forms one coating of a Leydeu jar condenser, the other coating of which
is the earth and surrounding objects and walls connected electrically
therewith.
11 ' The greater part of the charge and resulting strain on the dielectric
(air) will be found at those parts of the patient and the floor or walls of
the room that are nearest together.
li If the spark-gap be long, the time of charging by the small con-
tinuous current will also be comparatively long, because the potential
must be raised to a high point in order to produce a long spark. The
duration of the discharge, which will probably be an oscillatory one of
relatively high frequency because of the small capacity of the condenser,
will be short. The small continuous charging current will flow through
the patient without causing appreciable sensation. The sudden oscilla-
tory discharge may flow over the surface of the patient because of its
high frequency, and therefore without disagreeable eifect. As the length
of the spark gap is diminished, the time and amount of charge become
less, with a resulting diminution of sensation."
The following chart illustrates static modalities in a convenient
form :
STATIC
Compiled and Arranged by
CLASS. NAME.
CONNECTIONS FOR POLES LEYDKN
AND ELECTRODES. JARS.
PatCnl *S»SSl
SPARK-
GAP.
Closed to
Static induced.
Both to Levden jars, and v
both to patient.
Metal, to bare
No skin or to mu-
cous membrane.
begin and
gradually
open to
tolerance
of patient.
Con-
ductive.
Block tin or rne-
The wave cur- Positive to patient,
rent. Negative to ground.
No
Yes
tallic cloth to A . .
bare skin or
mucous mem- Induced.
•
brane.
Disruptive.
Sparks :
Indirect and
friction.
Positive to patient or to
platform.
Negative to ground.
Electrode to ground.
Optional,
out as a
rule too
severe.
Yes
Brass
balls.
Wide
open.
connective. Brush discharge.
Positive to ground.
Negative to patient or to
platform.
Electrode to ground.
No
Yes
Made of wood of
various sizes
and shapes.
Wide
open.
Breeze and spray
Positive to patient or
platform.
Negative to ground.
Electrode to ground.
No
Yes
Usually brass
point, single or
multiple.crown
or broom.
Wide
open.
High - frequency.
Positive to ground.
Negative to electrode.
No
No
Special glass
vacuum.
Begin %"-
gradually
regulate to
capacity
of patient.
Both to series interrupter;
High - frequency
specially inter-
rupted.
and
negative current to elec-
trode.
Yes
No
As ordinary h. f.
Wide
open.
Positive to ground.
Water, block tin.
Wide
Con-
vectlve.
Potential
alternation.
Positive to patient.
Negative to ground.
No
Yes
wooden or brass,
depending upon
open
(see re-
work required.
inarksi.
Usuallv positive to pa-
tient or platform.
Negative to ground.
NOTE. — These are the
The static bath
or general
electrification.
usual connections. It
sometimes happens
that the reverse may
suit certain cases.
No
Yes
None.
Wide
open.
This does not apply to
the high- frequency
currents, where the
connections cannot
be changed.
MODALITIES
F. HOWARD HUMPHRIS, M.D.. F.R.C.P.
PHYSIOLOGY AND THERA-
PEUTICS—(after Sn<".\ .
SPECIAL INDICATIONS.
REMARKS.
SUBJECTIVE.
o Induces muscular contraction.
5. Physiological tetanus.
c. Local vibratory effect. Obstinate constipation.
CLINICAL. Painful neuroses.
a. Relieves local pain.
b. Relieves local congestion.
c. Increases secretion.
The constitutional effects of this
current are practically nil.
During the application of this cur-
rent to extra-sensitive areas, e.g.
forehead, eye, ear, nose, and
throat, it is advisable to do away
with the negative grounding.
The two formsof the intensification
of this current have been omit-
ted ; they are more local and less
constitutional in their effect
when this (the unmodified) can-
not be used, then the static in-
duced current is indicated.
SUBJECTIVE.
u. Local vibratory effect.
6. Induces muscular contraction.
e. Physiological tetanus.
CLINICAL.
«. Diminishes local swelling and
congestion.
6. Local pain relieved.
c. Acute muscular spasm relieved.
d. Increase of local metabolism.
Insomnia, facial neuralgia,
gout, sprains, asthma, rheu-
matism, pelvic congestion,
lumbago, dysmenorrhoja. ini-
potency, prostatitis. dys-
pepsia "i nervous), gleet, con-
stipation, goitre.
SUBJECTIVE.
a. stinging sensation.
b. Muscular contraction.
c. Blanching, followed by redness,
wheals, and even blisters, by
successive applications.
d. Increase of local secretion.
CLINICAL.
a. Relaxation of muscular spasm.
b. Relief of pain.
c. Hyperaemia and swelling less-
ened.
M u s c u 1 a r, subacute and
chronic rheumatism, loco-
motor ataxia, rheumatoid
arthritis, all deep-seated
nervous structural lesions,
and deep-seated pain, sci-
atica. Of all local currents
the spark is ihe best dia-
phoretic.
SUBJECTIVE.
a. Increases local secretion.
6. Rubefacient, if pushed.
c. Local antisepsis.
CLINICAL.
a. Relieves local congestion.
b. Lessens local swelling.
c. Diminishes local pain.
d. Promotes local metabolism.
e. Destroys superficial septic pro-
cesses.
The same as the brush discharge,
but more irritating and less effec-
tive.
Early acute rheumatism,
sprains, abscess, swelling in
fractures, early stages in any
ncute inflammation, lum-
bago, gout, otitis media,
lupus, tubercle, and any con-
gestion or stasis, with or
without germ life.
There is also the direct spark ; it is
very severe and only of use in
humid weather. In other re-
spects it resembles the ordinary
spark, but the positive connec-
tion is to the patient and the
negative to the electrode.
The currents in order of preference
for the relief of pain:
1. Wave. 5. Breeze.
2. Brush. 6. Spray.
3. High-fre- 7. Static bath.
quency. 8. Static induced.
4. Sparks.
The positive breeze is stimulating,
the negative is sedative. . . .
The negative breeze is where the
negative pole and the electrode
are both grounded and the posi-
tive pole is connected with the
patient.
Increase voice range. Piles,
rectal ulcer, fissure. Ton-
sillitis, catarrh, hay fever.
Lupus, acne, and other skin
affections.
Ozone evolved . . . Vacuum elec-
trodes without wire are preferable,
because they are less liable to
puncture, cheaper, and equally
efficient.
The same as for the ordinary
high-frequency current.
Even more ozone is evolved. Note
that the positive current comes
from thatLeyden jar attached to
the negative prime conductor,
and vice versa.
Painless, simple, and fairly
effective. The indications
are the same as for the spark.
Note that the interruption is effec-
ted w ith the stand ball electrode
and the prime cond uc tor to
which the patient is connected.
ALL STATIC MODALITIES :
Circulatory System.
a. Lesse'n arterial tension.
b. Lessen heart frequency.
c. Lengthen diastole.
d. Increase pulse volume.
Ri.<piratt>rii System.
a. Rapid and labored breathing Where a general sedative is
relieved. indicated. Congestive head-
6. Deepened breathing, with in- ache. As a prelude to, or in
crease in elimination of CO2. conjunction with, other
yfrwius System, static modalities.
o. Relieve irritability.
6. Induce soporific effect.
Vase-motor System,
a. Induce diaphoresis.
6. Induce diuresis, with increased
elimination of urea.
Increase general metabolism.
61
CHAPTER III.
GALVANIC, CONTINUOUS, OE DIEECT CUEEENT.
GALVANISM is named in honor of Galvani, a physician of Bologna,
who in 1790 observed that convulsive seizures could be produced in the
limbs of a dead frog, when certain metals were made to touch the nerve
and muscle simultaneously. The electrical theory of these motions, how-
ever, originated with Volta, and, deserving of the credit that his genius
gave to science, his name is inseparably linked with the subject of
galvanism.
BATTERY.
A galvanic battery is a collection of two or more galvanic cells ( Fig.
23) so connected that the electricity generated by all can be conducted
X. POS/T/ VE
POLE
FIG. 23.— Galvanic cell.
through a single wire. A cell consists of two dissimilar metals, one of
which is more readily acted upon by the electrolyte than the other.
The metals usually selected are zinc and copper. Such a cell is frequently
referred to as a galvanic couple.
CONNECTIONS.
Upon joining the two metals with a wire an electrical circuit is
formed. If a number of such simple cells are united in "series," the
zinc plate of one joined to the copper plate of the next, and so on, a
greater difference of potential will be produced between- the copper
"pole" at one end of the series and the zinc "pole" at the other,
62
DIKECT CURRENT.
Hence, when two or more poles are connected by a wire, there will be a
greater How of electricity than would be generated by a single cell. Such
is the principle of the galvanic battery. The connection of zinc to copper
throughout the cells makes the latter in " series." By this arrangement
the amperage is the same as for a single cell, but there is a great increase
of voltage.
The cells are said to be in ••parallel" when all the zincs are con-
necied with each other and all the coppers are united to each other. In
this instance the electro-motive force is not increased, but the strength of
the current is materially augmented.
TYPES OF CELLS.
The cells used in the formation of batteries may be either " dry " or
••\\et." By a "dry" cell is meant the combination of certain metallic
bodies in such a way as to produce a simple galvanic current without
making use of an electrolyte ; the latter, however, is employed in the
••wet " cell. Of these the best is the zinc-carbon type, of which there
are a variety on the market.
Grove's (\-U. — This consists of an outer cell of glazed ware con-
taining an amalgamated zinc plate and dilute sulphuric acid. In the
inner porous cell, a strip of platinum serves as a negative pole and dips
into the strongest nitric acid. The hydrogen generated bj~ the sulphuric
acid acts upon the zinc and transferred to the platinum element meets
the nitric acid and decomposes it. The platinum is not acted upon by
the acid. The advantage of the Grove cell is its lowest internal resist-
ance, and its high electro-motive force.
Lately the use of dry cells has come into vogue. These are port-
able, do not need attention as to refilling, etc., and they are in every
way equal to the best of the wet batter-
ies. Most of them are made of chloride
of silver, and are encased in a readily
portable box.
The Bioiscn cell (Fig. 24) differs from
the Grove's cell only in that it contains a
carbon cylinder in place of a platinum plate.
A common Bunseu cell will give a current
strength on short circuit of 12 amperes.
To avoid the annoyance and the dan-
ger occasioned by the liberation of nitrous
acid fumes derived from the nitric acid
employed, chromic acid or a combination of potassium bichromate and
sulphuric acid may be substituted. This constitutes the bichromate cell.
This cell is capable of generating a high electro-motive force.
FIG. 24.— Bunsen cell (double fluid).
64 ELECTRO-THERAPEUTICS.
The Leclanche cell consists of a porous cup and a carbon plate. The
positive element consists of a rod of zinc, having a copper win* attached.
The exciting fluid is a solution of sal ammoniac, in which the zinc dis-
solves, forming a double chloride of zinc and ammonia ; while ammonia
gas and hydrogen are liberated at the carbon pole.
CARE OF THE BATTERY.
When a battery is frequently and continuously used, it is essential
that the plates should be kept clean by washing, scraping, etc. The
solution must be renewed from time to time, and the zincs must also be
amalgamated.
When not in use, the metal plates should be withdrawn from the
solution. If they remain too long a time, a deposit of salt occurs on the
top of the zincs, which must be removed to insure the correct working
of the apparatus. The battery is working correctly when bubbles of
hydrogen are perceived to rise at the sides of the zinc.
CHARGING THE CELLS.
Dissolve one and one-half ounces of bichromate of potash in ten
ounces of cold water, and add one ounce of sulphuric acid. Allow the
solution to cool.
POLARITY.
When a battery has been disconnected and put together again, espe-
cially if it has many complex parts, there is danger that the positive pole
may be accidentally connected to the binding screw marked " negative,''
and vice versa. To obviate this error it is necessary to resort to sonic
method of testing the polarity of the electrodes. For this purpose the
use of wet litmus answers admirably. The ends of the wires resting on
the litmus for a few minutes will show the results of electrolysis, the
paper becoming reddened by the acid liberated at the positive pole, and
will turn blue at the cathode or negative pole. Other reagents proposed
include a solution of phenol-phthaleiu in dilute alcohol, which gives ;i
purple-red color at the cathode.
A quickly performed test, is to immerse the tips of the wires in a
saline solution, and it will be found that the negative pole will give off
double the volume of hydrogen gas in comparison with the oxygen gas
liberated at the anode.
WALL CABINET. (Fig. 25.)
This is of great utility! in that it allows of a wide range and varia-
tion of current. It is so constructed as to be readily adapted for use with
DIRECT riKRKXT. 65
the 110-volt current, with any commercial current, or with a series of
cells. It combines a galvanic, faradic, and sinusoidal out Hi.
Direct commercial currents are often used instead of cells, but when
a commercial current is used the means of regulating the voltage is of
FIG. 25.— Wall cabinet for galvanic, faradic, and sinusoidal currents.
the utmost importance, because when the current passes through the
tissues at low pressure or voltage, there is more diffusion, and the
action of the current is more completely confined to the surface of the
electrodes, and is thus less painful ; whereas, when the current passes
through the tissues at high pressure (as is the case when a rheostat
5
66 ELECTRO-THERAPEUTICS.
is used for regulating the strength), it does not spread out in passing
through the tissues, aud is thus more paiuful, but better adapted for
cataphoresis.
THE RHEOSTAT.
The rheostat or current controller is an appliance for the reduction
of the known electro- motive force. By its use we may also turn "on?5
or "off" the current-supply as gradually as desired. The various forms
of rheostats have been fully described.
ELECTRODES.
These are of various forms aud sizes, as the special part and purpose
may demand. Some of the most useful electrodes are those that are ad-
justable. The latter are used in central galvanization, galvanization of
the cervical sympathetic, etc. The adjustable electrode can be readily
passed under the clothing, thus obviating the necessity of the patient un-
dressing. Electrodes are made of various substances, sponge or absorbent
cotton being most commonly employed.
The part to which the electrodes are to be applied must be free of all
clothing. If the skin is harsh, dry, or hairy, it is well to moisten it
with a sponge dipped in an aqueous solution of bicarbonate of soda. In
beginning treatment, the strength of the current used should be regulated
by the sensations experienced by the patient. A safe rule is to begin
with a weak current and gradually increase it. It is necessary that the
sponge attached to the electrode be frequently washed in warm water.
and those that are much in use should be subjected to the disinfecting
action of chlorinated solutions.
GALVANOMETER.
This is an instrument employed for the purpose of indicating and
measuring the strength and the direction of a current. The principle
involved in its construction is that a current of electricity will deflect a
magnet from its normal position. An ingenious device is the Deprez-
D'Arsonval galvanometer. This electrode bears a inilliampereineter and
allows of application in any position. (Fig. 26. )
MlLLIAMPEREMETER.
This instrument is the standard for measurement of electrical units.
Under the principles of electricity we observed that the ampere was the
unit of current strength, but this is entirely too powerful for electro- thera-
peutic purposes. The resistance of the human body is approximately
3000 ohms, and the milliampere (the one-thousandth part of an ampere)
has been found a more convenient unit for that resistance.
DIRECT CURRENT.
67
Tin; GALVANO-FARADIC Box.
This is a combination of the galvanic and faradic battery. The cur-
rent from the battery is generated by tin- Leclanclie cell, which contains
dry sal ammoniac, the necessary water l»eing added when called into
use. It possesses a great variety of combinations of length of wire,
enabling the operator to regulate the
current strength at will. The apparatus
is provided with a rheostat, a rapid
interrupter, a pole changer, a slow auto-
matic interrupter, etc.
DEFINITIONS OF TERMS.
Although many of these terms have
been and will be defined at length, it
is thought l>est to tabulate them here,
so as to present in a compact form the
commoner expressions employed in
electro-therapeutics.
In stabile applications both elec-
trodes are kept in a fixed position.
In labile applications one of the elec-
trodes is moved over the surface, some-
times both are moved simultaneously.
A current is sometimes called con-
tinuous when it is allowed to flow in one
direction, without interruption.
A current is said to be interrupted
when it is broken by the removal of one of the electrodes, or by some
form of current-breaker in the electrode, or by any method of breaking
in the circuit.
Voltaic alternatives is the term applied to those applications in
which the current is reversed continually, while the electrodes are kept
firm.
The ascending current is one where the flow is from the periphery
toward the nerve centre.
In the descending current the flow is in the direction from the nerve
centre, toward the periphery of a part.
By the term dosage we mean the amperage of the current employed
either in treatment or for diagnostic purposes ; the duration of each ap-
plication of the electrodes, the amount of pressure exerted, and the size
of the surface of the electrode applied, are conditions which must be
taken into consideration when the dosage is to be accurately ascertained.
(Modified after Rockwell.)
FIG. 26.— Deprez-D'Arsonval galvanometer.
(Milliamperemeter.)
68 ELECTRO-THERAPEUTICS.
METHODS OF APPLICATION.
There are two methods of applying current to a part, — (1)
and (2) labile.
(1) By the stabile method we mean the keeping of the electrodes
on spots first ascertained, without moving them about in any direc-
tion,— i. «., the electrodes are retained in stationary positions. Alter
ascertaining the polarity, the sponges are carefully moistened, and
it is then decided which pole is to be applied. After this has been
done the electrode is gently applied to the part, bearing upon it with a
slight degree of pressure. The current is now turned on, beginning
with a minimum degree of current, and gradually increasing it by
turning the lever of the rheostat ; the amount of current applied de-
pending upon the susceptibility of the patient. The current should
not be turned off suddenly, as this is liable to shock and induce fear in
the mind of the patient.
The sudden reversal of the polarity in the circuit formed, is also
liable to produce an unpleasant sensation. Each and every apparatus
has certain appliances and methods of working them, and the directions
accompanying the instrument, as outlined by the manufacturer, should be
carefully followed.
(2) Labile. — This method consists in keeping one of the electrodes
at a certain indifferent part, while the other electrode is slowly moved or
stroked over the skin of the part to which the current is to be applied.
In this stroking, a certain, even, constant pressure should be exerted.
As in the former instance the current strength should be very gradually
increased, and at its completion the current intensity should again be re-
duced as much as possible before removing the electrode. This method
has a stimulating effect, especially upon the nervo-muscular tissue of
the part.
The positive electrode is preferably held stationary at some indif-
ferent part, as in the right hand when treating the lower extremity.
The cathode or negative electrode is applied and reapplied alternately.
When contact is made, a complete electrical circuit results; when with-
drawn, this circuit is broken, and no sensation of a current can be felt
by the patient.
A method which I prefer consists of an interrupting electrode
handle. By pressing a small lever and again releasing it, the circuit is
respectively made and broken. It is easy to manipulate, and the results
obtained are most satisfactory.
Another method used is called the il voltaic alternative," which con-
sists in alternately reversing the polarity of the circuit by working the
lever of the commutator or pole discharger. This current is employed
for diagnostic purposes, as in atrophy of muscles of a part, etc.
DIRECT CURRENT. 69
CENTRAL GALVANIZATION.
The object of central galvanization is to subject the whole central
nervous system to the influence of the galvanic current. One pole, prefer-
ably the cathode, is applied against the epigastrium, whilst the anode
is placed over the forehead for a period of time, depending upon the
purpose for which the current is employed. As a rule, an application
of five minutes duration may be accepted as a maximum. The positive
pole should then be moved to the vertex, and thence along the course of
the vagus and over the sympathetic area to the lowest extremity of the
vertebral column. There may be found on the market a variety of
portable batteries combining in one a galvanic, faradic, cautery, and
diagnostic lamp battery. (Fig. 27.)
FIG. 27.— Galvanic, faradic, cautery, and diagnostic lamp battery.
( ; \ LVANO-FARADIZATION.
By this term we mean the combination of both the galvanic and the
faradic currents. This may be applied by employing four separate elec-
trodes, or by connecting the secondary coil and the galvanic battery in
one circuit, the negative pole of the one with the positive of the other,
attaching the electrodes to the two extreme poles, and thus passing
simultaneously both currents through the body.
CAUTERY BATTER IKS.
These are somewhat different from the batteries above referred to.
They are subdivided into two classes, — the thermo- cautery and the light
70 ELECTRO-THERAPEUTICS.
battery. It is here our aim to increase the amperage and not the electro-
motive force, heuce it is necessai y that the cells be arranged in the form
of "parallels." For lighting a small incandescent lamp which requires
a voltage of 6 c. p., the cells must be connected iu a group of two,
whereby the electro-motive force is halved, and the size of the cells
doubled.
Accumulators seem to be more sensitive for this -work, especially
when there is a direct 110-current available for charging.
The use of the continuous current in diagnosis and as a therapeutic
agent, will be found fully discussed iu the chapters ou Electro-Diagnosis
and Electro-Therapeutics.
SINUSOIDAL CURRENT.
This current is alternating in type, and derives its name from the
fact that its relation to time follows the law of series. It bears a great
similarity to the ordinary, pure faradic current, in so far that its motor
effect also varies according to the rate of alternations. When the alter-
nations are 20 or less per second, — i.e., when they are very slow, — the
effect produced will be a contraction at each end of an alternation.
When the alternations are more rapid, — say, 200 or 2000, — the muscular
contraction becomes tetanic.
The sinusoidal current has a smooth and gradual variation. It is
typically adapted for muscular stimulation, and by a properly constructed
apparatus we may applj7 a slightly greater milliamperage than the pain-
producing properties of the primary induction current would perm it.
The ease with which a large number of complete alternations per second
of this smooth character can be obtained, renders the sinusoidal current
an excellent nerve sedative.
CHAPTER IV
FARADIC, INTERRUPTED, OR INDUCED CURRENTS.
Principles of Induction.
ACCORDING to a natural law it is observed that when two distinct
circuits are near each other, currents in the one will u induce" currents
— or, more exactly, electro-motive forces — in the other. These induced
currents are of momentary duration and appear only when the inducing
current is made to vary, as is instanced when the current is made or
broken. The current induced at the beginning of the inducing current
is opposite in direction to the inducing current itself ; and the current
induced at the break of the inducing current has the same direction as
the inducing current. The strength of a current so produced is propor-
tional to the strength of the producing current plus the length of the
wire subjected to the influence of the inducing current circuit. The
action of the inducing current in the first coil is augmented if there be
introduced within this coil a soft iron core, constituting the so-called
electro -magnet.
Based upon these principles, first studied by Faraday in 1832, is the
faradic or induction battery. This battery consists of one or more cells
placed in circuit with a primary insulated wire surrounding the core, and
with an automatic device for alternately breaking and making the cell
current. Over the primary coil is slipped a bobbin having another coil
of insulated wire wound around it. The secondary coil has no connec-
tion with the cell, deriving its current by induction, because of its being
placed over and close to the primary coil and wire.
MKDICAL INDUCTION COIL.
The principles of the induction coil are well illustrated in Fig. 28.
The current makes a circuit from the cell and passes through the
platinum point. A, to the interrupter, and thence through the primary
coil : the latter becomes an electro-magnet, which brings about the
interruptions, through the mechanism of the hammer.
The heavy line indicates the primary interrupted current. The
light line indicates the induced or secondary current.
The intensity of the induced current can be regulated by sliding the
metallic tube in or out. The arrow D •* >• I indicates that, when
the sliding tube passes in the direction Z>, there is a decrease of current,
because of a decrease in the area of the magnetic field, and vice vers&.
ELECTRO-THERAPEUTICS.
The operation of the coil is as follows : The cell current proceeding
from the carbon pole of the cell traverses the primary coil, and returns
to the cell through the interrupter, the platinum points of the latter
being in contact. In the act of traversing the coil, this current makes
the core magnetic, which in turn attracts the small armature on the in-
terrupter, breaking the cell current ; the magnetism of the core now
having disappeared, the spring returns to contact, when the process is
again repeated. On closure of the cell current a reverse induction
arises in the secondary coil, but this rises slowly on account of self-
induction between contiguous windings of the primary coil. At the
instant of opening the cell current, a direct current arises in the sec-
ondary coil of a much sharper curve of ascent because there is but little
Int.
1*1!
1
$8.
Jw
sr
£^&j£fc.rc^
1 i''i •'•'» •£ SJ i'i' ....,.„,,... ^
W^?^] ^ — -
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_g ..*««a6a»aaQtt»ft«ft^_njjm_nj
FIG. 28.— Medical induction coil.
self-induction to interfere with it. It is imperative that these coils shall
not touch each other at a single point. Upon opening or closing the
primary circuit, there will be established an induced current in the
secondary coil. This type of electric current is produced by the use of a
medical Ruhmkorff coil. The screw of the vibrating hammer should
always be most carefully regulated. Some of the coils have two kinds of
interrupters accompanying the outfit. One of these is slow, while the
other is more or less rapid. Occasionally the hammer requires a slight
touch of the finger in order to be started so as to form a circuit
between the coil and cell or battery. The current produced by a fa-
radic equipment is alternating in character, as may be readily demon-
strated when applied to the tissues. Instead of a current from a cell.
advantage is often taken of a direct 110-current, as is well illustrated in
Fig. 29.
INI )U( 'E I ) ( ' U RRENTS.
73
INTERRUPTER OR RHEOTOME.
The interrupter which forms an essential part of the battery is the
vibrating spring hammer of Xeef. Many authorities condemn this form
of rheotome, and recommend one which has double the ordinary spring
length, both ends being attached to posts, to one of which is connected a
tension-screw for regulating the rate of vibrations. The armature is
attached to the middle of the brass spring and platinum plate for contact
near t lie fixed post. Besides regulating the frequency and amplitude of
the vibrations by the tension-screw, we regulate them also with the set-
screw carrying the platinum contact point. This device gives easily the
FIG. 29. — Galvanic and faradic lamp controller.
rate of vibration suitable for muscular contraction, and this is from 1 to
about 3000 per minute. Vibrations above 3000 per minute are sedative.
The highest stimulation is from 3000 to 4000 interruptions per minute.
METHOD OF APPLICATION.
This method of electrization consists in placing one pole, generally
the negative, at the feet or coccyx, while the other is applied to any part
of the surface. The current may be applied (stabile) stationary or
(labile) moving ; it may be increased or decreased in intensity according
to the desire of the operator. The person applying it should have some
experience, so that the very best results may be obtained.
74 ELECTRO-THERAPEUTICS.
LOCALIZED FARADIZATION.
Localized farad i/at ion. as termed by Ducheime, or, more correctly,
polar faradization, in contradistinction to the polar and bipolar method
of galvanization, is applied in precisely the same manner as is the galvanic
current. This localized or polar method has eliminated the unscientific
terms "ascending" and "defending" currents. ^Nevertheless, we still
speak of labile and stabile currents, one of the electrodes being moved
over the surface or both being stationary, and of superficial and deep or
penetrating currents; the former with a dry metallic electrode to the
dry skin and superficial nerves, the latter with moist electrodes to the
deep-seated tissues.
As A DIAGNOSTIC AGENT.
As a diagnostic agent, the induction current is of value for de-
termining the increase or decrease of pathological excitability, and in
differentiating between central and peripheral lesions. The tension
current (fine coil) is sedative in character and is valuable in quieting
hysterical suffering, thus affording differentiation between pain and hys-
teria in gynecological practice. The irritability of muscle is tested by
determining the lowest power of the faradic current which will contract
it, and then comparing with the normal side. In hysterical paralysis, the
electro-contractility is usually normal, while electro- sensibility is low-
ered; in infantile paralysis voluntary contractility is increased, whilst
faradic contractility disappears. So also in the reaction of degeneration,
or where a nerve is cut in its continuity, and more or less atrophy or
degeneration is found in both muscle and nerve.
As A THERAPEUTIC AGENT.
As a therapeutic agent the induction current acts on nerves and
muscles, stimulating each into action or developing anaesthetic effects.
Its use therefore is demanded in instances of nerve or muscle pain. Bi-
polar electrodes are most efficient in producing contraction of relaxed
pelvic muscles, including the uterus itself : in other cavities and mucous
membranes its employment is becoming general, through the brilliant
results achieved by Apostoli.
CHAPTER V
< ATAPHORESIS. HYDRO-ELECTRIC BATH.
I. Cataphoresis.
CATAPHORESIS is the introduction into the human body of remedial
agents through the physical properties of the electrical current. Were
the procedure electrolytic, either pole could be applied.
In 1859 Dr. B. W. Richardson l produced local anaesthesia by apply
ing morphia to the anode. Since then various experimenters have
succeeded in introducing many different medicaments by this process.
Accurate doses are easily obtained. A piece of tissue paper or absorbent
cotton is patterned to fit the electrode, and the desired quantity of the
agent is placed upon it ; the current strength varies from 3 to 20 uiilli-
amperes. Cataphoresis is mainly used to impress the skin and mucous
membranes. Chloroform should only be employed as a counter-irritant, as
its application produces a dermatitis. Helleboriu and acouitin have been
successfully used. Figs. 30, 31, 32, 33 depict various forms of cataphoric
electrodes.
Rockwell believes that i ' the effects of the galvanic current upon
nutrition are in part due to the cataphoric transfer of molecules of
protoplasm and liquid from one cell to another, or from a cell to a capil-
lary vessel in the path of the auodal stream, and since the diffusion takes
place more rapidly and more quickly in direct proportion to the current
strength, it behooves us to employ as many millianiperes as feasible in our
galvanization of the atrophied and paralyzed extremities of poliomyelitis
and chronic neuritis and peripheral nerve trauma."
Dr. James C. Gill,2 in a paper read at the Thirteenth Annual Meeting
of the American Electro-Therapeutic Association, September 23, 1903,
entitled ' { Cataphoresis, ' ' said : " I believe that cocaine used with the aid of
cataphoric action of electricity is the ideal method. Its use requires no
great amount of skill and no expensive complicated outfit ; an ordinary
galvanic current with various sized electrodes is all that is necessary.
The strength of the current or the solution used matters but little, as the
stronger the solution the less time required to produce the desired effect,
and a high amperage is undesirable because of the unpleasant sensation
from the electric current. The advantages of cataphoric anaesthesia are
these: 1. Complete amesthesia without pain, which fact should not be
1 Medical Times and Gazette, February 12 and June 25, 1859.
2 Journal of Advanced Therapeutics, July, liX)4.
ELECTRO-THERAPEUTICS.
underestimated, especially wheii dealing with an acutely inflamed and
hypersensitive area, such as is frequently found in certain conditions
FIG. 30. — Peterson's cataphoric
electrode.
FIG. ul. — Sectional view of the same.
A is a disk, made of metal that will not oxidize. The stem which passes through the hard-
rubber cover Cis held in place by nut D. It also holds the tip for connecting with the battery. B is a
soft-rubber ring, which is held in place by A, and at the same time it insulates the skin from .4, allow-
ing the current to pass from A to the skin of the patient, through the medicated paper contained in the
cavity formed by A and B. (Courtesy of Waite and Bartlett Manufacturing Co.)
FIG. 32.— Three varieties of cataphoric electrodes.
The one furthest to the left consists of a glass jar, covered with a porous earthy material; the jar
is filled with the solution desired. The middle electrode is that of Eisenberg, made of ebonite and
covered with parchment. The right-hand one is the electrode of Dr. Strauss, which because of its
small size can be utilized in the treatment of acne, sycosis, etc. (From the catalogue of Reiniger-
Gebbert and Schall.)
FIG. 33.— Martin's cataphoric electrode.
It consist1) of a metallic plate over which is stretched a piece of parchment, which can be satu-
rated through the tube with the required medicament.
necessitating the use of the knife. 2. No danger from constitutional dis-
turbances, as the cataphoric action of the current brings the drug in
CATAPHORESIS. HYDRO-ELECTRIC BATH. 77
contact with the terminal filaments of the sensory nerves, and not into
the absorbents as does the hypodermic injection, a sufficient amount is
never token into the general circulation to produce any noticeable effect.
Personally, I have never seen any disagreeable symptom from its use in
this way. 3. Xo danger of formation of drug habit. Patients do not
know from any effect upon the nervous system that any drug has been
used. 4. A large area may be anaesthetized, if necessary, with the absence
of unfavorable symptoms.1'
Dr. G. Betton Massey.1 "The Apostoli Treatment; Final Results in
Some Cases of Fibroid Tumor of the Uterus," records the final results of
electrical treatment in 101 cases of fibroid tumor, so far as they could be
ascertained by personal inquiries, letters, and circulars. In some of the
cases the treatment had stood the test for a period of sixteen years, while
in none had less than three years elapsed. The tabulated results follow :
Cases in which the results are unknown 9
Cases resulting in anatomic and symptomatic cure 22
(Included in the list are 18 that disappeared by absorption,
while 3 were extruded through the cervix in whole or in part,
one was destroyed piecemeal by electrolysis.)
Cases resulting in symptomatic cure only 53
(These include 12 with great reduction in size, 26 with slight
reduction in size, and 15 permanently relieved of symptoms
without change in size. )
Total cases resulting in practical success 75
Cases resulting in partial or complete failure 26
Total cases treated 101
Excluding the 9 cases in which the results are unknown it will be
seen that the figures show 75 actual or practical cures, and 26 failures in
101 cases. In other words, 75 per cent, of the cases were successful and
25 per cent, were failures.
II. The Hydro-electric Bath.
The hydro-electric bath is useful in many diseases for its stimulating
and tonic effects as well as for its trophic influence. It is applicable in
anaemia, chlorosis, rickets, rheumatism, gout, sciatica, etc.
The bath itself should be made of porcelain or glazed ware. The
w;iior should have a temperature of 90°-98° F. (32° to 37° C.). Two
metal electrodes, that must always be kept clean and bright, are placed at
the head and foot of the bath. These plates are attached to the battery
by binding screws. The larger electrode is placed at the head of the
'Journal of the American Medical Association, May 21, 1904.
78 ELECTKO-THERAPEUTICS.
bath, and is usually 1-Sx 12 inches (45x30 cm.); the smaller electrode is
11x9 (28x23 cm.). In order to localize the current a movable paddle
connected to the foot-piece is often employed. A wooden rest prevents
the back and shoulders of the patient touching the head-plate. It is
immaterial if the feet, with their thickened epidermis, touch the foot-board
FIG. 04.— The four-celled battery of Schnee.
or not. A part of the current traverses the body, and the remainder
• s through the water. The resistance in the bath depends upon its
length, the depth to which it is filled, and the temperature of the water.
As the current which traverses the water does not affect the patient, it
follows that only so much water should be used as is required to cover the
l>;itiiMit comfortably. Xo salt should be added to the water, as the latin-
thereby becomes a better conductor.
CATAPHOEESIS. HYDKU-ELECTKIC BATH.
The duration of the bath should be ten minutes daily for the first
week, but after that it should be given on alternate days. The choice of
current will depend upon the condition present. Thus, in the early stages
of general neuritis, in acute neuralgia, and in acute sciatica, the direct
current is indicated. In gout, rheumatism, and arthritic conditions, the
galvanic current is preferable. The induction-coil bath and the sinusoidal
currents are useful where general nutritive effects are sought.
Among local baths may be mentioned :
THE ARM: BATH.
THE MONOPOLAR AND DIPOLAR BATHS.
THE ELECTRIC DOUCHE BATH.
The arm bath is useful in paralysis of the muscles of the forearms
and hands, in rheumatism and gouty affections, in chilblains, Raynaud's
disease, etc. The constant current, the current from the coil, or the
r F. Th UK
—S> 9
FIG. 35.— Diagrammatic view of the direction of current, as is illustrated in Schnee's four-celled
battery.
sinusoidal current may also be employed. The bath can be arranged in
any non-conducting vessel ; stone-ware troughs, easily procurable and
inexpensive, are valuable for the purpose.
In the ni»n<>i>ol«r bath only one electrode is immersed, the whole cur-
rent passing from it to the patient. In the full-length bath, the patient
grasps a metal conductor, usually a bar or handle which is covered with
a piece of flannel, and secured above the water level. The current
passes from the conductor to the hands, thence to the body, and finally to
the water of the bath to reach the other conductor.
80 ELECTRO-THERAPEUTICS.
The electric douche bath originated with Trautweiu in 1884. J Dr.
Guy6not,2 of Aix les Baius, has described a method of electrical ap-
plication by the means of douches. The current is led to and from the
patient by two streams of water, the conductors being connected to
the nozzles through which the water flows, the jets of water carrying
the current to the whole surface of the body or to the special part
desired. Those interested in this method will find a detailed account in
the original paper.
Dr. SchneVs four-celled battery is convenient and practicable for
hydro-electrotherapy (Figs. 34 and 35), in that the patient1 s extremities
are alone exposed without additional disrobing. It is comfortable to the
patient, the current is regulated by a switch-board, and the parts im-
mersed allow of a large area for cataphoresis. Duration of the bath
10 to 15 minutes. Current 5 to 30 ma. By means of this bath elimina-
tion of metallic poisons from the body has often been accomplished.
1Zeitschrift f. klin.Med., viii., p. 279, 1884.
a Revue Internationale d'Electrothe'rapie, June, 1894.
CHAPTER VI
ELECTKO-DIAGXOSIS.
THE examination of the motor nerves and muscles is of paramount
importance in electro-diagnosis, consisting in localizing the current with
the requisite intensity upon these parts.
The following rules should be followed : Apply one and only one
pole for each irritation ; the effect of the other pole should be repressed
as much as possible.
For the local irritant effect use the active or irritant electrode ; the
other is termed the indifferent electrode.
Have the active electrode as small as possible so as to secure the
greatest density of current.
Have the indifferent electrode as large as possible, so that the density
may be slight and ineffective. Place the indifferent electrode upon the
sternum, the back of the neck, or the small of the back.
The changes liable to occur in testing nerves and muscles are changes
in the visible muscular responses. As there may be changes in the
behavior of the muscles both to the coil and the cells, both forms of exci-
tation are used in examining a muscle. The active electrode should be
applied either to the muscle or near its motor point. In testing a muscle,
the indifferent electrode should be applied to the skin with an even and
firm pressure. The electrodes and the surface of the body should be well
moistened. "Water containing a saline diminishes the resistance of the skin,
but offers the disadvantage of acting upon the electrode. With some
of the small muscles of the hands and feet, it is convenient to apply both
electrodes over the part, so that the current may pass directly through.
The Motor Points.
These are the points to which the testing electrode should be applied,
in order to effect contraction in the adjacent muscle, or they are the
points at which the motor nerve trunks can readily be reached. The
positions of the motor points vary somewhat in different individuals.
The motor point can be absolutely located only by experiment. Sub-
cutaneous fat acts as a barrier, and the examination of the deeper muscles
is more trying than the superficial ones. The limb should be supported
by the operator and the muscles relaxed as much as possible. Begin with
a current capable of producing a small muscular contraction, applying
the current for a brief period only.
Points favorable for the stimulation of nerve trunks.1
1 The subjoined series of tables are taken from the work of H. Lewis Jones, M.D.,
on "Medical Electricity."
6 81
82
ELECTRO-THERAPEUTICS.
IN THE UPPER LIMB. (Figs. 36, 37, 38, and 39.)
1. The mwlian, along the inner border of the biceps, and at the bend
of the elbow.
Caput externus M. tricipitis
N. radialis
M. brachialis interims
M. supinator longus....
M. radialis externus longua--
M. radialis externus brevis
FIG. 36.— Motor points of the arm
M. supinator lonpus „
M. radialis externus longus
M. radialis externus brevis
M. extensor digitorum communism
M. extensor indicis proprius
M. extensor indicis proprius et M.
abductor pollicis lonpus
M. abductor pollicis longus -
M. extensor pollicis brevis
M. flexor pollicis longus
M. interosseus dorsalis I
M. interosseus dorsalis II
M. interosseus dorsalis III
_M. ulnaris externus.
M. extensor digiti minimi pro-
prius.
M. extensor indicis proprius.
M. extensor pollicis longus.
•M. abductor digiti minimi.
.M. iuterosseus dorsalis IV.
FIG. 37.— Motor points of the forearm and hand.
2. Th< nhmr. in the groove between the internal condyle and the
oleeranon.
ELECTRO-DIAGNOSIS.
N". Musculo-cutaueus. M. biceps.
83
N.musculo- Caput in- N. Media-
cutaiK-us. ternusM.
tricipitis.
nus. M. brachialis
internus.
N. ulnaris. Kami X. median!
pro M. pronatore
radii terete.
FIG. 38.— Motor points of the arm (front view)
Ranii Nervi median! pro M. pro
natore radii terete
M. palinaris longus..
M. ulnaris internus.
M. flexor ditritorum snblimis
(digitt. II et III.)
N. ulnaris
M. flexor digitorum sublimis
(digitt. indiiis et miniin)
Kami volar. prof. Nervi ulnaris.
M. palmaris brevis
M. abductor digiti minimi ,
M. flexor digiti minimi
M. opponens digiti minimi
Mm. lumbricales II, III et IV
M. radialis interims.
M. flexor digitorum profnndua.
M. flexor digitorum sublimis.
M. flexor pollicis longns.
N. medianus.
M. abductor pollicis brevig.
M. opponens pollicis.
M. flexor pollicis brevia.
M. adductor pollicis.
M. lumbricalis I.
FIG. 39.— Motor points of the forearm and hand ( front view).
S4
ELECTRO-THERAPEUTICS.
3. The musculo-spiml, at the point where it emerges from the triceps,
namely, on the outer side of the upper arm about the junction of the
middle and lower thirds.
N cruralis
N. obturatorius.
M.sartorius
M. adductor longjs
Kami N. cruralis pro M. quadrici-
pile.
M. cruralis
Bami N. cruralis pro M. vasto in-
teruo
M. tensor vaginae femoris. (Rami
N. glutsei superioris.)
M. tensor vaginae femoris. (Ram!
N. cruralis.)
M. rectus femoris.
M. vastus externus.
M. vastua externus.
Fig. 43.- Motor points of the thigh.
M. peroneus longus
M. tibialis anticus
• '• '."'•< f •',.:'."
•
.N. peroneus.
.M. gastrocnemius externus.
.M. soleus.
.M. extensor digitorum longua.
M. peroneus brevis.
M. soleus.
... M. flexor hallucis longua
II. extensor hallucis longus
Rami X. pcronei prof, pro M.
extensore digitorum brevi
Mm. interossei pedis donates. < —-*$£,
.M. extensor digitorum brevis.
.M. abductor digiti minimi
pedis.
Fro. 41.— Motor points of the leg and foot.
4. The musculo-cutaneous, between the biceps and coraco-brachialis
muscles.
ELECTRO-DIAGNOSIS. 85
5. The long thoracic (serratus maguus), on the inner wall of the
axilla.
6. The supra-clavicular point of Erb. " At a spot one inch above
the clavicle, and a little externally to the posterior border of the sterno-
niastoid, immediately in front of the transverse process of the sixth cer-
vical vertebra, a simultaneous contraction can be produced in the deltoid,
biceps, coraco-brachialis, brachialis auticus, and supiuator lougus."
This is a motor point for the fifth and sixth cervical roots before they
reach the brachial plexus.
IN THE LOWER LIMB. (Figs. 40, 41, 42, and 43. )
7. The anterior crural, in the fold of the groin just outside the
femoral artery.
8. The sciatic, just below the gluteal fold at the back of the thigh.
9. The internal popliteal nerve, in the popliteal space, and to the
inner side of the teudo Achillis.
10. The peroneal nerve, just above the head of the fibula, beside
the biceps tendon.
IN THE FACE. (Fig. 44.)
11. The facial, through the cartilage of the lower surface of the
meatus auditorius. Its chief ramifications can be reached where they
emerge from the parotid gland. Erb chooses for stimulation three main
branches of the facial : (a) for muscles above palpebral aperture; (b)
for muscles in front of upper jaw, between the orbit and the mouth ;
(c) for muscles of the lower jaw. He tests each of these in two places,
first at points just in front of the ear, and secondly for (a) at the temple,
for (b) at anterior extremity of zygomatic bone near its lower border,
for (c) at the middle of the inferior border of the horizontal ramus of
the lower jaw.
12. The fifth, at the supra-orbital foramen, at the infra-orbital
foramen, at the foramen mentale, on the side of the tongue.
IN THE NECK. (Fig. 44.)
13. The spinal accessory, at the top of the supra-clavicular triangle,
where the nerve pierces the sterno-mastoid.
14. The phrenic, on the outer edge of the lower part of the sterno-
mastoid.
15. The hypogJossaJ, along the upper border of the great cornu of
the hyoid bone.
16. The recurrent laryngeal, along the outer border of the trachea.
17. The pneumogastric and glosso-pharyngeal, along the track of the
ELECTEO-THERAPEUTK S.
Kami inferiores N glutsei inferioris
pro M. glutaeo maxiuio
N. ischiadicus -1^---- \ ;!:;iw — -M. adductor mapnus.
M. biceps (caput longum) -IP— -/;- •••• • -^ >: •emitendlnomia.
:IS ----- -M. Bemlmejnbnuuma
•fc .
M. biceps (caput breve)
N. tibialis
N. peroneus
M. gastrocnemius externus
M. Boleus
M. gastrocnemiua
FIG. 42. — Motor points of the thigh and leg (posterior view).
M. gastrocnemius internus
1C. soleus
If. flexor digitorum longus
N. tibialis
M. abductor hallucis
Fio. 4:?.— Motor points of the leg and foot (inner side).
ELECTRO-DIAGNOSIS.
87
carotid artery just below the angle of the jaw. Fig. 45 illustrates the
motor points of the chest and abdomen.
When paralysis affects certain groups of muscles, and difficulty is
!; M.corrugatorsupercil. ; 2, M.eonr
pressor nasi et pyramidal, nasi : :;. M
orbicular, palpebr. : 4, M. levator lal>
sup. alaeque nasi : 5, M. levator lab. sup-
propr. ; 6, M. zygomatic. minor : 7. M.
dilatat.narium ant. et post.: S. M. zygo-
matic. major: y, M. orbicularis oris:
10, Ram. comm. pro Mm. triangular.
et levator menti: 11, M. levator menti :
12, M.quadratus menti: 13, M.triangii-
laris menti; 14, Ram. subcutan. colli
X. facial.; 15, Ram. cervical, pro Pla-
tyMiiat.; 1C. M. stern o-hyoideus : 17. M.
o'mo-hyoideus ; 18, M. sterno-thyroi-
deus ; 19, M. sterno-hyoideus ; 20, M.
frontalis : 21, Mm. attrahens et atlol-
lens auriculae ; 22, Mm. retrahens et
attoll. auriculae; 23, M. occipitalis ;
24, Xerv. facialis; 25, Ram. auricular,
post. prof. X. facialis; 2f., M. .-tylo-hyoi-
d.'us ; 27, M. digastricns: 28, Ram. buc-
cales, X. facialis: 29, M. splenius capi-
tis : 30, Ram. subcutan. maxill. infer.;
31, Ram.ext. X. accessor!! Willisii; 32,
M. .-terno-cleido-mastoideus : 33, M.
cucullaris : 34, M. sterno-cleido-mas-
toideus ; 35, M. levator anguli scap-
ulae ; 36, N. thoracic, post. (Mm. rhom-
boidei) ; 37, X. phrenicus ; 38, M. omo-
hyoid ; 39. X. thoracic, lateral. <M.
serrat. magn.) ; 40, X. axillaris ; 41,
Ram. plex. brachialis (X. musculo-
011 tan., pars X. medianii; 42, X. tho-
racic, ant. (M. pectorales).
Fio. 41.— Motor points of the head and neck.
M. rectus ab-
dominis.
(Nervi intercos-
tales abdomi- -
nales.)
M. serratus Mag
nus.
M.latissimus dorsi.
M. obliquus ab-
dominis exter-
nus.
f (Nervi intercos-
tales abdonii-
nales.)
M. transversus ab-
domiuis.
7
Flo. 45.— Motor points of the chest and abdomen.
experienced, as it frequently is, in tracing the nerve supply of the mus-
cles involved back to their spinal roots, advantage may be gained by
employing the table by Dr. Allen Starr.1
1 Brain, 1894.
88 ELECTRO-THERAPEUTICS.
SEGMENTS.
4th cervical. — Diaphragm, levator auguli scapulie, deltoid, rhom-
boids, spinati, biceps, supiuator longus.
5th cervical. — Rhomboids, spinati, teres minor, deltoid, pectoralis
major (clavicular portion), biceps, serratus magnus, supiuator longus
and brevis.
6th cervical. — Latissimus dorsi, pectoralis major, serratus magnus,
pronators, biceps, triceps, brachialis auticus, extensors of the wrist and
fingers.
7th cervical. — Teres major, latissimus dorsi, subscapularis, pectoralis
major and minor, triceps, flexors of the wrist and fingers.
8th cervical. — Flexors of the wrist and fingers, extensors of the
thumb, intrinsic muscles of hand.
1st dorsal. — Extensors of the thumb, intrinsic muscles of the hand
(thenar, hypothenar, interossei).
For the lumbar enlargement Dr. de Watteville1 gives the following
distribution : —
3d lumbar. — Ilio-psoas, sartorius, adductors, extensor cruris.
4th lumbar. — Extensor femoris et cruris ; peroneus lougus ; adductors.
5th lumbar. — Flexors and extensors of toes, tibial, sural, and perom-ul
muscles, extensors and rotators of thigh, hamstrings.
1st sacral. — Calf, hamstrings, long flexor of great toe, intrinsic
muscles of foot.
2d sacral. — Intrinsic muscles of the foot.
Dr. Herringham2 has also tabulated the results of numerous dissec-
tions of the brachial plexus in new-born infants as follows :
USUAL XEEVE SUPPLY.
3d, 4th, and 5th cervical. — Levator anguli scapulae.
5th. — Rhomboids.
5th, or 5th and 6th cervical. — Supraspinatus, iufraspinatus, teres
minor.
5th and 6th cervical. — Subscapularis, deltoid, biceps, brachialis
anticus.
6th cervical. — Teres major, pronator radii teres, flexor carpi radiales.
Supinator longus and brevis. Superficial thenar muscles.
5th, 6th, and 7th cervical. — Serratus magnus.
6th or 7th cervical. — Extensores carpi radiales.
7th cervical. — Coraco- brachial is, latissimus dorsi, extensors at the
back of the forearm, outer head of triceps.
7th and 8th cervical. — Inner head of triceps.
1 Lancet, July 14, 1883.
»Proc. Roy. Sec., March, 1866.
ELECTKO-DIAGXOSIS. 8l>
7th, 8th, and 1st dorsal. — Flexor sublimis and profuudus, flexor carpi
ulnaris, flexor longus pollicis, and pronator quadratus.
8th cervical. — Long head of triceps, hypotheuar muscles, interossei,
deep thenar muscles.
The pectoralis major from 6th, 7th, 8th, and 1st dorsal.
The pectoralis minor from 7th, 8th, and 1st dorsal .
Hints for Practical Testing.
Always begin testing with the induction coil and finish with the
cells. Do not use very strong currents from the coil. If the muscles do
not respond to these currents, increase the strength of the latter. The
operator should first apply the current to his own person, so as to reas-
sure the patient. With battery currents start with about 16 cells for
the limbs and 8 cells for the face. The testing electrode should be the
cathode. If upon passing no noticeable contraction is discerned in the
muscles, increase the number of cells, upon the first closure contraction,
look for the most effective spot for stimulating the muscle, and compare
the AC1C with the CC1C. Observe the character of the contraction,
whether quick or sluggish. Compare the direct with the indirect stimu-
lation through the nerve trunk ; compare the reactions obtained with
those of the unaffected side.
Disease or injury may cause quantitative changes or changes in the
amount of reaction to a stimulus, the quality of the reaction remaining
unaltered, as is exemplified in simple increase of excitability and simple
decrease of excitability to coils and cells.
In unilateral disease, the recognition of increased or decreased ex-
citability is easy when this increase or decrease is marked ; but when
slight, there are many disturbing factors that may lead to an error of
judgment.
With the battery current, the galvanometer is a reliable guide.
Unequal pressure of the electrode, when comparing two points, may
cause an apparent difference in irritability. The resistance of the skin
is likewise inconstant during a test.
Increased irritability usually occurs in those conditions presenting
increased reflexes, as in chronic myelitis, in degeneration of the lateral
columns, in hemiplegia, and in tetany.
Decreased irritability is evidenced in many diseases, offering quali-
tative changes also when the condition is more severe. Thus in neuritis
we may observe either qualitative or quantitative changes, according as
the attack is mild or severe.
Qualitative changes are changes affecting the quality of the reaction.
This includes the reaction of degeneration, both complete and partial,
also the myotonic reaction, etc.
90 ELECTRO-THERAPEUTICS.
Reaction of Degeneration. (De. R. ) or (R. D.)
This term was proposed by Erb, to signify the series of changes
occurring in electrical irritability, both qualitative and quantitative,
owing to a certain definite morbid condition of nerves and muscles.
The effect of the faradic current diminishes and disappears, but with the
galvanic current, decided changes are manifested. Lesions of motor
nerves, either at the spinal centre or in the course of peripheral dis-
tribution, of sufficient importance to produce paralysis, will rapidly
show pronounced galvanic and faradic changes. The nerve will exhibit
a progressive diminution of electrical excitability, and a few days sub-
sequently it will have ceased entirely. Rarely a fortnight elapses before
complete cessation of excitability is noted. The point of departure is
always at the extremity, nearest the injury or lesion, degeneration pro-
ceeding thence toward the periphery. When reparative action has
begun, excitability returns, recovery showing itself at the point of begin-
ning degeneration. Frequently muscles may respond to the patient's
will, but they do not respond to electrical currents; showing that while
the nerve will transmit the voluntary impression, it will not necessarily
transmit other impressions.
DEGENERATION OF MUSCLES.
In degeneration, muscles differ from nerves in their electrical reac-
tions. With the faradic current, however, the reactions are identical Vxrth
in quality and quantity. The faradic current has no effect on muscle
tissue, save for the nerve supplying it. With the galvanic current, mus-
cular tissue for the first few days contracts, with a somewhat lessened ac-
1 ivity ; its response to a certain strength of current is not so marked as in
the normal condition. For several succeeding days, the irritability of
the muscle is increased. This may last for weeks, and sometimes during
this condition a change in the normal sequence of contraction occurs.
the contractions changing in character as well as in quality. They assume
a slow tetanoid form, which continues during the flow of the current,
the strength of the current required being notably small. Soon in the
stage of degeneration the AnCIC = CaCIC, and a little later exceeds it ;
this is accompanied by the CaOC gaining upon the AnOC, but never
being equal to it. Thus we obtain the following formula for the normal
muscular reaction to galvanism :
CaCIC > AnCIC > AnOC > CaOC.
For the reaction of degeneration, the formula :
AnCIC : CaCIC or AnCIC > CaCIC > AnOC diminished, but always > CaOC.
ELECTRO-DIAGNOSIS. !>l
PARTIAL REACTION OF DEGENERATION.
This term is applied to cases in which contraction is evidenced to
some degree by the coil, but to the battery current the response is
sluggish.
The existence of partial reaction of degeneration makes it necessary,
when testing, always to corroborate the results obtained from the coil by
employing the battery current. In partial reaction of degeneration there
is found an alteration in the coil reactions, but this may be overlooked,
and thus, conclusions arrived at from the presence of coil reactions
would be wrongly interpreted. The degree of sluggishness of contrac-
tions may vary within wide limits, the reaction to the coil may be faint
or very strong. By some it is held that partial reaction of degeneration
represents a changing state of the nerve or muscle, and that a change to
complete reaction of degeneration on the one hand, or to a normal re-
action on the other, may be looked for in cases showing partial reaction
of degeneration.
THE SENSORY SYSTEM.
Little can be said on the subject of alterations in the electrical
reactions of the sensory nerves, and but faint light can be thrown on the
irritability, conductivity, location, etc., of the sensory nervous system.
An increase in the impressions conveyed by the cutaneous filaments of
the sensory nerve-fibres indicates electrical cutaneous hyperaesthesia,
while impairment of this function, corresponding largely with the definite
reactions of the motor system, constitutes electrical cutaneous anesthesia.
In diseases involving the sensory tractvS of the cord, the diagnosis is
materially aided by finding this anaesthesia and hyperaesthesia.
XERVES OF SPECIAL SENSE.
Under this heading we shall only notice the auditory nerve, which
allows of material aids in diagnosis, through its irritablity in tinnitus
auriuin. Like motor nerves, the auditory responds more readily to
cathodal than to anodal stimulation, the response being the production
of a subjective sensation of sound ; in certain abnormal conditions the
auditory nerve answers to electrical currents more readily than it does
in health. In these cases it is contended that a state of hyperaesthesia
exists in the nerve, and that tinnitus is an expression of that state. To
test the auditory nerve, use a bifurcated electrode applied to both ears at
once. By this method there is less likelihood of provoking giddiness.
If a biuaural stethoscope is used as a temporary expedient, the lower
portion should be removed, and the tubes closed up with small corks;
the battery wire is attached to the metal and the other electrode is
placed indifferently.
CHAPTER VII
ELECTRO-PHYSIOLOGY.
THE diagnosis of pathological conditions can in many instances be
more accurately investigated by a thorough preliminary understanding of
a study of the electrical current influences upon the normal physiological
functions.
INFLUENCE OF ELECTRICITY UPON MOTOR NERVES AND MUSCLES.
The motor nerves, when irritated by the galvanic or faradic current,
give rise to a muscle contraction. According to Du Bois-Reyniond :
' ' The absolute amount of the density of the current at any certain
moment does not act as a stimulant to the motor nerves, but merely the
change in its amount from one moment to another, i. e. , in the density ;
these act so much more powerfully the greater they are in a unit of
time, or, their amount being equal, the more rapidly they occur ; most
powerfully therefore upon sudden closure and opening of the current.
" Thus the reason of the marked irritative effect of the faradic cur-
rent on motor nerves at once becomes apparent ; whilst, on the contrary,
a constantly flowing galvanic current, or a very gradual increase or
decrease in the current strength, produces no stimulation whatsoever. If
induction currents are applied to a motor nerve, a series of brief muscular
contractions, corresponding to the strength of the induced current, will be
produced ; these contractions necessarily being greater during the open-
ing than during the closing current of the secondary coil. A long series
of these irritations results in a tetanic contraction. ' '
PFLUGER'S LAWS OF CONTRACTION.
"With weak currents in both directions, contraction occurs on closure
alone, but none is produced on opening ; the contraction on closure of
the ascending current is somewhat stronger than that of the descending.
"With moderate currents contraction occurs on opening and closing
in both directions ; but the former are always weaker than the latter.
"With very strong currents (never employed upon human beings)
contraction occurs on opening, but none on closure of the ascending cur-
rent ; and it also occurs on closure, but not on opening of the descending
current."
These laws only hold good when the nerve is laid bare and well
isolated.
92
ELECTRO-PHYSIOLOGY. 93
In illustration of the above laws we need only refer to the irritative
effect produced by the galvanic current, which occurs only at the poles,
and starts from them, and note that the irritation upon closing the circuit
occurs only at the cathode, and upon opening, only at the anode. Long
ago it was proved that the irritant action of the cathode was greater than
that of the anode ; thus the irritation on closure is greater than at the
opening, with the same intensity of current. Likewise the central part
of a nerve is more irritable than the peripheral portion, and with very
strong currents considerable resistance occurs at both poles and increases
with the strength and period of closure of the current. Furthermore
motor nerves are non-irritable to the transverse passage of the faradic
or galvanic current, and a motor nerve which is still connected to a
central organ has its opening contraction of the ascending current con-
siderably later than when the (motor) nerve is isolated.
Thus far we have been dealing with electrical currents on motor
nerves studied physiologically, but the results obtained are not analogous
with the practical results obtained by the physician. The latter deals with
nerves, surrounded by tissues of good conduction and which are followed
by large numbers of threads of currents ; illustrating the absolute futility
of maintaining a uniform density of current in a nerve. The greatest
density of current must occur directly at the electrodes. Because of the
various threads of current, the direction of the latter must be omitted
from consideration in applying electricity to the healthy human body.
In the polar method of examination, one electrode, called the
"active," is applied closely to the nerve and then connected with either
the anode (An) or cathode (Ca) of the battery. The other electrode,
termed the "indifferent," is placed upon some distant part of the body,
as the sternum, spine, epigastrium, etc. If the cathode is upon the
nerve and the circuit is closed, the term "making a cathode closure"
is employed, and is written CaCl ; if the circuit is open it is desig-
nated "cathode opening," and is written CaO, and similarly with the
anode.
Begin with a definite strength of current by examining CaCl in
about three closures, at the same time studying the CaO, and thus also
with the auodal contractions.
For the opening contraction, keep the current closed for a brief
period, as the irritability on opening the circuit is thus augmented. By
an increase of current, we gauge the degree of intensity of current for
the various forms of contraction.
By this method it is readily demonstrated that with most of the
motor nerves the cathode chiefly produces stimulation on closure, the
anode principally on opening, and that the stimulant action of the cath-
ode is much greater than that of the anode.
!'l ELECTRO-THERAPEUTICS.
Iii inediciue three stages of contraction are distinguished :
First stage ( feeble current ) CaClC.
Second stage (moderate current) CaClC' is stronger. AuCIC and
AnOC also occur and are fur all practical purposes of about equal
strength.
Third stage (strong current) CaClC" becomes tonic and equals
CaClTe ; AuCIC (and especially AnOC') becomes more powerful and at
the same time weak CaOC occurs.
UPON VOLUNTARY MUSCLES.
Du Bois-Reymond's law of motor nerve stimulation holds equally
good for muscle stimulation.
" Currents of very high duration occasion less reaction upon muscu-
lar tissue than upon nerves ; but the summation of the individual con-
tractions produced by each single induction stroke results in tetanus, as
was observed in the excitation of nerves. The laws of muscular contrac-
tion produced by galvanism are analogous to those already formulated.
"Depending upon the strength of the current, living muscles it-act
with more or less tetanic contraction to faradisin, and with single con-
tractions to individual contraction currents. This occurs so much more
readily the nearer the electrodes are approximated to the points of
entrance of the motor nerve-branches into the muscle, or touch these
points (motor points) directly.
"The galvanic reaction of the muscles occurs in such a manner that
they respond to stimulation with both poles, by a closure contraction
alone, the opening contraction being absent, or obtained very excep-
tionally. To some extent, an isolated irritation of the muscles of the
body by the galvanic current may effect a local galvanization, founded
upon the same principles and methods as local faradization. Another
very important group of effects are the modifying, irritability changing,
electrotonic action, which are manifest in the electrical, thermal, or me-
chanical irritability of motor nerves (and muscles) during the passage
and after the cessation of the current."
ELECTROTOXUS.
When a galvanic current is passed longitudinally along the course
of a motor nerve, the nerve changes its irritability along its entire
length, which is especially pronounced in the vicinity of both poles. At
the cathode and its vicinity there is an increase in the electrical, me-
chanical, and thermal irritaltilit \ . and that portion of the nerve is said
to be in a state «»f •• cateN-ct lotoims : " at the anode and its vicinity it is
decreased, whence the term •• aneleetrotonns." I loth increase with the
duration and intensity of the polari/.ing current, and touch one another
ELECTRO-PHYSIOLOGY. 95
in an indifferent point of the intrapolar region. Upon breaking the
current, the negative modification of the irritability of the anode
(anelectrotouus) is immediately changed to a marked positive, requiring
some time for its disappearance ; at the cathode, a brief negative irri-
tability rapidly followed by a vigorous positive modification, with an
increase of irritability which gradually returns to the normal. Thus
after breaking the current, there remains a normal or less prolonged
increase of irritability at both poles.
SENSORY CUTANEOUS XERVES.
The application of the galvanic current to the skin produces a
pricking followed by a burning sensation, which may increase, and cause
intense pain. Possibly these sensations may in a large measure be due
to the effects produced by the chemical substances liberated at the surface
of the body by electrolysis ; many asserting that the reaction of the sen-
sory terminal organs is not identical with the reaction observed in the
conducting paths.
The sensory irritations appear not only in that part of the skin
covered by the active electrode, but likewise in the area of distribution
of that nerve or nerves lying in the territory of the electrode.
SENSORY XERVES OF MUSCLES.
These can only be studied satisfactorily when muscles have been ex-
posed by wounds, or in complete anaesthesia of the skin. Every vigorous
muscular contraction is accompanied by a distinct sensation, which has
nothing in common with cutaneous sensibility, and which may increase
to actual pain during tetanic contraction (electro- muscular sensibility).
The sensation produced is in direct proportion to the degree of muscular
contraction, and is usually described as dull and tensile ; it is likewise
produced with strong galvanic currents as soon as they produce tetanic
m uscular contractions.
UPON THE SPECIAL SENSES.
To the galvanic current, the special senses respond with readiness by
means <>f their specific sensations, the latter being dependent upon the
inlluence of both poles. The optic nerve or retina reacts quickly to the
galvanic current. Pass a current through the temples or cheeks and
upon making or breaking the current a flash of light will appear. Ap-
ply a stronger current some distance from the eye (as upon the neck or
chest or back), and the same phenomenon resulting illustrates the great
sensitiveness of the retina to galvanic currents. The muscular tissue of
the iris promptly responds to the faradic current ; even the pupillary
96 ELECTKO-THERAPEUTICS.
sphincter can be made to contract independently, which may also be
accomplished by stimulation of the motor oculi and the cervical
sympathetic nerves.
The auditory nerve being very deep seated, its excitation can only
be effected by a current that must be so strong as to product- most
unpleasant associated phenomena. Galvanization of this nerve is accom-
plished by placing a large moist sponge electrode immediately in front
of the auditory canal, pressing slightly upon, but not occluding the
tragus. The indifferent electrode is placed upon the back of the n«-ck.
The strength of the current being increased, repeated cathodal closures,
at times And, are made, or if the irritability is very slight, repeated
changes of polarity are to be instituted. The normal auditory apparatus
therefore, only gives a sensation at closure upon irritation with the ("a,
and only on opening upon irritation with the An. Healthy individuals
usually hear sounds described as whistling, buzzing, hissing, or roaring.
The AnO reaction is, as a rule, feeble and short. By an increase in
the strength of the current, the auditory sensations increase in intensity.
distinctness, and duration, and assume a more musical and whistling
character.
By the galvanic taste is meant the peculiar acid, salty taste which is
produced by placing the simplest galvanic element (a piece of zinc and
copper) on the tongue, or by passing stronger currents through the
cheeks, throat, temples, etc.
If two medium electrodes be placed upon the cheek, gustatory sen-
sations appear at both poles. The sensation is more marked at the anode,
where it is metallic, alkaline or perhaps very acid. At the cathode it
is milder, biting and salty. The sensation is present at making, breaking,
and during the passage of the current.
On the olfactory nerve, galvanic stimulation is little understood.
By some it is said to produce a phosphorus- like odor.
UPON THE SYMPATHETIC SYSTEM.
The study of the galvanic current upon the sympathetic
system needs to be further prosecuted. Physiologists are too problem-
atic in their deductions as to the functions of the sympathetic nerves
and their interposed ganglia, to lead to other than hypothetical con-
clusions.
Faradization of the cervical sympathetic causes contraction fol-
lowed by dilatation of the vessels of the corresponding side of the
head and face ; slight exophthalmos, dilatation of the opposite pupil,
and an accelerated action of the heart. Galvanization of the cervical
sympathetic is much slighter and less certain.
In the human subject, this is a most difficult procedure. The cervical
ELECTRO-PHYSIOLOGY. 97
sympathetic, being very deeply situated, has in its close proximity
the vagus, the carotid with its vaso-iuotor fibres, the base of the braiii,
the cervical region of the cord, etc.
UPON THE SKIN.
Galvanization of the skin will first produce pricking and burning
(as detailed under its action on the sensory cutaneous nerves), rapidly
followed by an intense hyperaeinia at both poles ; this redness may remain
for hours, and be marked by the presence of papules or wheals, and
finally succeeded by desquamation of the epidermis.
If the current strength be augmented, pallor of the surface is noted
at t he cathode, followed by a rosy redness ; the skin becomes infiltrated
and surrounded by a deep border ; upon opening the circuit the redness
persists. At the anode a pronounced scarlatinal color appears, the
skin is not infiltrated but covered with small elevations ; upon opening
the circuit, the redness persists for a long time, and is followed by
desquamatiou.
UPON THE HEAD.
Vertigo is the earliest symptom manifested in galvanization of the
head, when a strong current is passed transversely or in the antero-
posterior direction (frontal bone to the back of the neck). The giddiness
is most pronounced when the current is passed transversely. It has been
maintained by some observers that ocular movements play a dominant
part as a result of the severe vertigo, and that there is a disturbance of
the muscular sense. With a strong transverse current passed through
the inastoid processes, oscillation of the eyes occurs, the direction being
that of the positive current. If the anode be on the left side, both eyes
will be turned to the right. In some persons, galvanization of the head
has resulted in nausea, vomiting, syncope, duluess or mental confusion.
UPON THE SPINAL CORD.
Large, flat electrodes should be placed upon the neck, very strong
currents should be employed, and closure and opening should be resorted
to. If the negative electrode be placed on the upper lumbar vertebrae,
CaCl or change of polarity to Ca will produce vigorous contractions of
the muscles supplied by the sciatic nerve, proving that the current has
invaded the cord.
UPON THE ABDOMINAL ORGANS.
Vigorous faradization of the gall-bladder in cases of catarrhal jaun-
dice, has caused the widely contracted gall-bladder to suffer a marked
7
98 ELECTRO-THERAPEUTICS.
contraction. Likewise in enlargements of the spleen, by direct faradi/a-
tion with large moist electrodes, or by employing t\vo faradic brushes
over the splenic urea.
The pharynx and the velum palati may be faradized and galvani/cd
by applying the positive electrode on the upper posterior part of the
neck, and by rapidly passing the cathode over the lateral surface of the
laryngeal area. Contraction of the muscular wall of the esophagus can
be obtained by introducing electrodes, similar in shape to oesophageal
bougies.
The stomach and intestines react to currents by slow contractions,
which gradually spreading induces a peristaltic action. Faradism is
more effective in these cases than is galvanism.
Vigorous faradization of the abdomen is often associated with a
gurgling sound, and with the production of visible, palpable peristaltic
movements of the stomach and intestines. The digestive tract may be
reached by one electrode placed on the back, the other stabile or slowly
moving over the corresponding portion of the abdominal wall ; or by
the introduction of an electrode into the stomach or into the rectum, the
other being applied labile or stabile upon the external abdominal wall.
Faradization of the bladder may be accomplished by introducing a
tirethral electrode as far as the vesical neck. Galvanic currents may
likewise be employed. The contraction of the vesical sphincter and the
urethral muscles is readily perceived.
ELECTRICAL CURRENTS IN DISEASES.
This is a most complicated process. Remak believed (and this
view still obtains) that with the passage of the current there results a
dilatation of the blood-vessels and lymphatics, causing an increased flow
of blood and nutritive material, thereby favoring absorption of effete
matter: that there. is also an increased osmotic power of the tissues,
changes in disassimilation and nutrition of the nerves, changes in the
molecular arrangement of the tissues and the mechanical transportation
of fluids from one pole to the other. To this series of changes the name
"catalysis" is applied.
CHAPTER VIII
PEACTICAL APPLICATIONS IN DISEASED CONDITIONS.
I. Cutaneous Affections.
To a very large extent electric currents have been employed in the
treatment of skin diseases, and, as the technic differs greatly in numerous
cutaneous affections, it seems best to enumerate the various skin lesions,
detailing under each the technic that seems most applicable.
ACNE.
In this affection Liebig and Eohe have obtained favorable results.
I have seen a few cases improve by the use of hyperstatic sparks, and
in one or two instances by the ordinary breeze.
ECZEMA.
The local effect of the static current is specially indicated in eczema,
where the brush discharge may be most advantageously employed.
Eczema yields to electrical treatment more easily than any other skin
lesion. Eockwell recommends the application of the galvanic current
applied either locally or centrally. Bordier (quoted by Hedley) reports
a case of eczema thus treated, the result being very satisfactory. He uses
the positive breeze, and this frequently reversed. The hydro-electric
bath has given very satisfactory results in the practice of Gautier and
Laret.
PRURITUS.
In pruritus the electric breeze is most useful. The duration of treat-
ment should be between fifteen and twenty minutes. The metallic point
should be held 10 to 15 cm. from the part.
ALOPECIA.
Local galvanization and also the static breeze are often beneficial in
some cases.
SYCOSIS.
M. Boisseau du Rocher employed the following method for sycosis.
Ten to fifteen silver needles attached to the positive pole are inserted into
different points, the indifferent electrode is applied to the nape of the
99
100 ELECTKO-THERAPEUTK S.
neck, current three to four milliamperes, duration about ten minutes,
application every second day. By this means the oxy-chloride of silver
is formed, which is diffused into the tissues by the current. It may take
three or four weeks, and 20 to 30 seances, to complete an absolute cure.
HYPEETRICHOSIS.
Since we are able to cause a general or local epilation with the
X-rays, the process of electrolysis is gradually being abandoned. The
method with the electric needle, formerly so prevalent, but tedious and
painful in operation, has largely given way to the X-rays. I have
succeeded in removing hair from the forearm by a weak but constant
current, but it never should be forgotten that an acute and active derma
titis may thus be readily produced. If the hairs are few in number and
scattered over the face, I believe the electric needle safer and less dan-
gerous though more painful than the Rontgen rays. On the contrary, a
burn with the X-rays may leave a life-long scar. For the face, therefore,
it is advisable to resort to electrolysis.
The method of epilation is as follows : Place the patient on a high
chair, take a fine needle which is attached to the negative pole of the
galvanic current, while the patient holds the positive pole in the hand.
A sponge of fair-sized dimensions and well wetted is attached to the latin
electrode. The number of cells used is 5 to 8, so that a current of from
3 to 4 milliamperes is produced. A current of smaller amperage than
this may be used ; 1 to 2 milliamperes being often sufficient. The hair
is seized with a pair of tweezers, at the same time the disengaged hand
inserts the needle slowly into the hair- follicle. The patient squeezes the
sponge to complete the circuit, which is indicated by small bubbles
emanating from the point where the needle is inserted. The needle is
usually allowed to remain 10 to 15 seconds. The patient now loosens the
hold so as to break the circuit. An interrupting handle (Fig. 4(i) is
FIG. 46.— Interrupting needle-holder for electrolysis.
employed by many for this particular purpose. If the hairs are not
loosened readily, defer the procedure until another time. The needle
should be heated to redness, when its repeated introduction will
be necessary for each individual hair. This method is for coarse hair.
For the downy hair seen on the lip or chin in women, this method is
unsatisfactory, and it is advisable to resort to the X-rays.
APPLICATIONS IN DISKASHI) COXDITIOXS. 101
PSORIASIS AND PITYRIASIS.
In both of these diseases, the negative pole of the galvanic current
seems to be the more efficacious. Sometimes both poles, bearing large
electrodes, are employed.
ElNGWORM AND SCLERODERMA.
Both of these diseases are markedly improved and often cured by the
application of the galvanic current.
PRURIGO.
Dry faradization may give relief from the intense itching, and at
times will effect a cure.
CUTANEOUS ANESTHESIA.
For this condition Rockwell believes faradization to be a specific.
The electric brush should always be given a trial.
HERPES ZOSTER.
Dr. Larat 1 reports several cases of acute herpes zoster in the erup-
tive stage with fever and unbearable lancinating pains, which were cured
by the continuous current. The method is simple and can be employed
by any physician owning a galvanic battery. The positive pole (repre-
sented by an electrode 3^ by 5 inches [9 x 13 cm.], covered with absorb-
ent cotton and well moistened) is applied over the point of emergency
of the affected nerve or nerves. The negative pole is connected to
an electrode placed over the affected area. The absorbent cotton cover-
ing the electrode should be made large enough to cover all the1 vesicles,
whether formed or forming. A current strength of from 6 to 10 ma. is
employed for 25 or 30 minutes. The sensation produced by this current
is that of a severe pricking, but it is well borne by the patient.
Two applications are made daily, but in case of failure at first, the
author recommends that more be used. Under their influence the pain
ceases, the eruption is arrested, the vesicles show a tendency to dry up,
in fact all the local manifestations of the disease appear aborted. A
cure is accomplished in from 24 to 48 hours, unattended by the usual
subsequent neuralgia.
The probable explanation of these good results, is the accepted hy-
pothesis, that herpes zoster is a trophic and sensory peripheral neuritis, in
which the continuous current has the same curative effects as are manifest
in other forms of peripheral neuritis.
1 Revue Internationale d'Electrotherapie, October, 1904.
102 KLFA TIN MTHERAPEUTK \s.
N.KVUS.
Electric treatment should be instituted ;us soou after birth as is prac-
ticable. The needles may be alternately negative and positive, or all
attached to one pole, and an ordinary pad electrode used for the other
pole. Current may be employed up to 30 ma. Duration 5 minutes.
Current must be gradually lowered to zero before withdrawing the
needles.
PORT- WINE MARK.
For these disfigurements use a number of needle-points attached to
a disk, so that punctures may be effected simultaneously; the current is
gradually turned on, allowing 2 to 3 ma. for each needle. This proced-
ure is to be repeated every 3 weeks. The needles should be insulated,
except at the point. The pole selected will vary with the vascularity,
the prominence, and the extent of the uyevus. With large blood channels
use the positive pole; for flat spots some of the needles may be positive,
some negative. Current 30 ina. Duration 10 to 15 minutes. The
needles are left in place half a minute, so as to produce a slight eschar,
they are then shifted ; the whole surface being thus dealt with.
MOLES AND WARTS.
The indifferent positive electrode is placed in the neighborhood of
the growth. A needle attached to the cathode is inserted at its middle,
or just above its base, parallel to the integument. Current about 5 ma.
Allow the current to flow till the growth changes color and resembles a
cluster of herpes. Then bring the current to zero. Time required is 2
to 3 minutes for each wart. In a fortnight the growth disappears,
no scar remaining. Another method is to attach both poles to sharp
needles and transfix the growth by the needles inserted parallel to the
skin.
FURUNCLES AND CARBUNCLES.
The local treatment of these growths by electricity is advocated by
Marcus.1 Previous to the appearance of suppuration, lie opens the folli-
cles of the affected area and introduces into them an epilation needle con-
nected with the negative pole. Through this, a current of one to two
milliamperes is passed at first, which is afterwards increased to ten. By
slightly moving the needle around, the opening of the follicle is consider-
ably enlarged, and a quantity of frothy serum is soon poured out. con
taining portions of tissue and numerous cocci. Then the needle is
removed and the spot is carefully cleansed ; the needle is again introduced
1 Miinchener medizinische Wochenschrift, May 23, 1905, No. 21.
APPLICATIONS IX DISEASED CONDITIONS.
103
aud one or two uiilliainperes of current are again allowed to pass. The
positive pole is now to be connected with the needle, and the current again
raised to ten milliauiperes. This causes the liberation of acid, which is
always more energetic in its nascent condition. In two or three minutes
the treatment is suspended aud the surface again washed with water.
Each atfected follicle is treated in the same manner. If suppuration
has already commenced, a larger needle is introduced into the folli-
cles and moved around, until the entire greenish-yellow pus plug is
broken up and disappears in foam. Then the positive pole is intro-
duced and is again followed by the negative pole. A wet dressing is
applied. This treatment is not applicable to very large carbuncles or
extensive swellings.
II. Muscular System.
MYALGIA.
Employ local faradization with a mild current, either stabile or
labile. Stabile galvanization with a mild current is often effective. Do
not cease if .the condition is unaffected or aggravated at first, but continue
the applications. Static electricity by means of a roller electrode (Fig. 47)
or general frauklinizatiou is frequently curative.
FIG. 47.— Roller electrode with insulated points for muscular faradization.
When employing the battery, Erb advises that a current up to 20
ma. may be used, applying the anode to the painful parts, and the seance
terminated by a few reversals.
General electrization by means of the nionopolar sinusoidal bath,
faradic current applications, and static friction have also many advocates.
WRITERS' CRAMP.
It is assumed that this disease is due to a weakness of the central
nervous system. General galvanization of the spinal column and pe-
ripheral nerves should be resorted to. Faradic electricity is useful when
applied directly to the muscles or groups of muscles of the hand and
forearm. Seen in the very beginning, its course is often arrested by
using the above forms of electricity.
104 ELECTKO-THERAPEUTICS.
Weiss l recommends the use of constant currents of 2 to 5 or 8 ma.
for 15 to 25 minutes, with absolute rest from writing. Applications
twice daily should be employed during the first weeks, diminishing later
to 2 or 3 times a week. If extension is the chief symptom, the anode is
to be applied to the palm ; if flexion be marked, place the positive pole
to the dorsum of the hand. Apply the cathode to the nape of the neck
or the upper, inner surface of the arm and the anode to the sensitive
parts for 10 to 20 minutes. Treatment should also be applied to the
motor cortex and to the lower cervical region of the spine.
TORTICOLLIS.
In torticollis galvanization of the muscles of the affected side with
currents of from 5 to 15 ma. , and faradization of the muscles of the
opposite side often prove most efficient. Galvanization of the sympa-
thetic and the upper portion of the spinal cord should always be tried ;
but long- continued applications are contraindicated.
MUSCULAR CONTRACTIONS.
These may arise in hysteria, myelitis, meningitis, Pott's disease, or
they may be reflex. These affections may be treated by galvanization of
the affected muscles or of the antagonistic muscles with stabile currents,
or by galvanization of the head, spine, or sympathetic, etc.
SECONDARY CONTRACTURES OCCURRING IN HEMIPLEGIA.
Charles S. Potts* claims that in cases of hemiplegia where con-
tractures have been allowed to develop, the patient's disability proceeds
more from the deformity so produced than from muscular weakness. As
the deformity is caused by the overaction of one set of muscles, usually
the flexors, and is only aggravated by their stimulation, the indications
are for measures which tend to relax the contracted muscles. This can
be effected by the application of the positive pole of a galvanic current
over the motor points of the affected muscles, and the indifferent elec-
trode (negative pole) to any part of the sound limb, as over the sternum,
or to the nape of the neck. Anelectrotouus should be aimed at. The
current employed should be gradually increased from 0 to 5 or 10 milli-
amperes (about as much as the patient can bear), and kept at this maxi-
mum for five minutes, then gradually reduced to zero. Unless the
current is gradually reduced to zero, catelectrotonus will follow and the
condition of increased irritability thus set up will prevent the accomplish-
ment of our object. After these applications of a continuous current, a
1 Centralblatt fur die gessam. Therap., April, 1891.
1 University of Pennsylvania Medical Bulletin, October. 1905.
APPLICATIONS IN DISEASED CONDITIONS. 105
weak faradic current should be employed, just strong enough to cause the
muscles to contract moderately, about a dozen times and no more, as over-
stimulation defeats the end we have in view. The method is also of
service as a preventive ; it may be started any time after the end of the
second week following the seizure. Three treatments a week for several
months should be given, followed by an interval (several weeks) of rest.
MY ASTHENIA GRATIS.
When tetanized by the interrupted current, the myasthenic muscle
shows a rapid decrease in the degree of response to the current, evincing
the normal physiological effect of fatigue with excessive and abnormal
rapidity ; but after tetanizatiou it remains just as responsive to a single
closing shock, proving that the muscle is not diseased, but that the
trouble resides in the nervous system.
III. The Articular System.
SYNOVITIS.
In acute synovitis all forms of electrical applications are contraindi-
cated. Subacute and chronic synovitis will be benefited by galvaniza-
tion or faradization. When a cure cannot be effected by these means,
the application of percussion static sparks is sometimes effective.
HYDRO-ARTHRITIS.
In the acute stage, as in synovitis, any form of electricity is irritat-
ing. In the subacute and chronic forms the active electrode (negative)
of 20 to 25 ma. current should be employed. Each treatment should last
no longer than 10 to 15 minutes. The indifferent electrode is placed on
the back of the patient. The treatments should be made on alternate
days, or every third day.
EHEUMATOID ARTHRITIS.
In this affection the sinusoidal bath is very beneficial. Dr. Roques1
treats the affected joints by the electrolytic introduction of ions of
salicylic acid into the surrounding tissues. Many electro-therapeutists
believe that the beneficent action thus obtained is partially ascribable to
a nutritional change in the diseased area.
CHRONIC ARTICULAR RHEUMATISM.
Chronic or subacute articular rheumatism frequently yields to static
or galvanic treatment ; with the former it subsides gradually. The
1 Arch. d'Electricite medicale, 1903, page 689.
106 ELECTRO-THERAPEUTICS.
condition will usually be benefited by local faradization. In very acute
and painful cases, it is well to resort to anesthetization with cocaine
by the cataphoric process.
GOUT.
This disease is benefited by static electricity. This stimulates all
the tissues of the part, improving the circulation, and in general doing
much good. The continuous flow of current has been recommended, but
I have failed to obtain any appreciable result from its employment,
Lithium dipolar baths are prescribed by some authorities.
Guilloz l reports two severe cases of gout treated by monopolar elec-
tric baths containing lithium carbonate. He recommends currents up
to 200 ma. , and places the positive pole in the bath, the cathode of large
size is applied to the patient's back. Similar reports by Bordier, in the
same journal, are recorded.
It is usually maintained that the various currents applied directly to
the joints will cause a stimulation of the tissues of the part, resulting in
an absorption of the urates. Prolonged applications may aggravate the
condition.
TUBERCULOUS ARTHRITIS.
Chanoz and LeVeque2 report three cases, where the direct current
proved of inestimable value in tuberculous arthritis. In one case Leveque
himself was the sufferer, and his treatment directed to his own person
was eminently satisfactory. He Relieves that the negative pole is effec-
tive for relieving the superficial pain, the deeper parts being more
influenced by the anode. The current should range from 25 to 50 ma. ;
the electrodes should be of large size and placed on either side of the
diseased joint.
FIBROUS ANKYLOSIS.
Apply large electrodes moistened in a solution of sodium chloride to
each side of the joint. The negative pole should be placed nearest the
joint, Use a current strength of 25 to 35 ma. Duration of each treat-
incut from 10 to 25 minutes. Treatments 2 or 3 times a week. These
electric treatments should be instituted only when there is no inflamma-
tory process present.
M. A. Zimmermann3 has reviewed the medical literature, and with
the exception of a case treated by Leduc, of ankylosis of the elbow -joint
1 Arch.d'£lectricite mldicale, June, 1899.
2 Arch. d'fclectricit£ m£dicale, 1903, page 264.
•Revue Internationale d'felectrotherapie, October, 1904.
APPLICATIONS IX DISKASKI) < OXD1TIOXS. 107
reported cured by electricity, lie has found nothing on the subject. Many
surgeons recommend electricity iu such cases for its action on the mus-
cles surrounding the all'ected joints, but that is a form of electrical mas-
sage, and not an electrical application. Zimmermaim has obtained good
results, both iu hospital and private practice, in cases of fibrous anky-
losis, without paiu or discomfort to the patieut, by the employment of the
continuous current. It is of importance to determine the nature and
severity of the affection, because in cases of bony ankylosis no more
good is accomplished by electricity than with other forms of treatment.
However, in some cases, severe fibrous aukylosis in which massage and
passive motion failed to afford relief, some degree of mobility was
obtained ; whereas in adhesions resulting from a gouorrhceal or other
arthritis or from prolonged immobilization, cures were speedily attained.
It should never be forgotten that radiographs are of inestimable value
in making a differential diagnosis. The negative electrode should be
placed over the most superficial part of the diseased joint, and the posi-
tive electrode on the part of the joint directly opposite, so that the lines
of flux will pass iu a straight line through the joint. The maximum
intensity should be at least 40 ma. , and the applications made every other
day.
The number of applications necessary to effect a cure will depend
upon the severity and chrouicity of the affection ; from 15 to 20
applications are required in cases of moderate severity.
IV. Digestive System.
TOMITING.
According to Apostoli and Bordier1 two electrodes, each 2 cm. in
diameter, are attached to the positive pole of the battery, and .are placed
over each pneumogastric nerve, between the insertions of the steruo-cleido-
mastoid muscle. The indifferent electrode (100 sq. cm.) is placed upon
the epigastric region attached to the negative pole. The strength of
current should be from 5 to 10 milli amperes. If nausea is threatened,
the current must be at once run up to 15 or 20 milliainperes and there
maintained, so long as any ill effects are experienced by the patient. The
duration of the seance varies from 4 to 20 minutes. Two sittings a day
may be required at the beginning of the treatment.
DILATATION OF STOMACH.
Dilatation of the stomach is best treated by the static induced cur-
rent. The outer cover of the Leyden jar is attached to an ordinary
exciter, terminating in a small ball. This is applied over the uncovered
1 Therapeutic Electricity, quoted by W. S. Hedley.
108 ELECTRO-THERAPEUTICS.
epigastric region ; the distance of the pole of the machine should be
such as to produce sparks at the rate of from 10 to 15 per second. The
exciter is to be left on one spot for a couple of minutes, then displaced to
another, and so on.
The duration of each treatment should be from 10 to 15 minutes ;
the usual requisite number of sittings is from 18 to 20, which should be
given every second day.
NERVOUS DYSPEPSIA.
For this affection the galvanic current does most good.
The negative pole is usually placed over the epigastric region and
the positive pole opposite the lumbar region. The strength of the cur-
rent should be from 30 to 40 milliamperes ; the duration of each treat-
ment should be from 10 to 15 minutes : the number of treatments to bring
about relief is from 8 to 10. A cure cannot be effected by this method
of treatment.
CONSTIPATION.
In these cases, applications over the cord or the sympathetic system
frequently produce most excellent results. Direct action on the digestive
tract is often advantageous in promoting peristalsis.
Method of Application. — The patient is placed on the insulated plat-
form, and the indirect static spark is applied to the various parts of the
abdomen. This should be done by starting in the right iliac or inguinal
region, gradually ascending to the liver, thence across the upper abdomen
along the course of the transverse colon. This is followed by descending
to the left side of the belly toward the upper part of the rectum. The
object is to excite peristalsis in the normal direction.
The galvanic current is also applied for this condition, but in my
experience the results obtained are not so satisfactory as with static
electricity. A large-sized electrode (100 sq. cm.) is attached to the
negative pole of the battery, and the electrode is applied to the belly in
a similar manner as outlined above. The indifferent positive pole is
applied to the lumbar spine. The faradic current may be applied instead
of the galvanic.
Dr. Wahltnch1 has reported seven cases in which the continuous
current produced good results. He used a large sponge for the positive
pole and an ordinary medium-sized one for the negative. The former
he applied to the epigastrium, while the latter was slowly moved over
the whole abdominal surface. The current was from 5 to 30 milliamperes.
The operation was repeated on alternate days, from three to six weeks.
'British Medical Journal, 1883, vol. 11, 623.
APPLICATIONS IX DISEASED CONDITIONS. 109
A method, which lias become popular in France, is the introdun ion
into the rectum of a bougie electrode, the other pole being kept ou the
abdomen. To avoid the risk of electrolysis, and injury to the rectal
mucous membrane, a combined douche and electrode has been devised.
ENTERITIS.
Dr. Zimmeru1 describes the excellent results he had obtained in
mucous membranous enteritis by the use of the galvanic current applied
externally to the abdomen. The treatment consists in applying the two
electrodes in the right and left iliac fossae, aud using a current which
starting from 0 is slowly aud gradually brought up from GO to 150 inil-
liamperes, then as slowly again reduced to 0. The direction of the cur-
rent is then reversed. Each treatment lasts about 20 minutes, and is
repeated three or four times a week. No special attention is paid to
the diet, though highly spiced food is of course forbidden. All enemas
or cathartics are strictly prohibited, save with the following exceptions.
If there is much constipation, two spoonfuls of castor oil are giveu every
five days, or a large lavage of the intestine is to be practised if the castor
oil does not produce the desired effect. Every day a very small enema
of cold water (100 grammes) is given so as to start defecation reflexly,
which is more or less dulled by the lack of sensibility of the mucous
membrane.
According to Zimmern, the results obtained are not so much due to
action on the muscular coating of the intestine as to action on the general
circulation of the intestine. Out of 30 patients treated in this manner
only 2 were refractory to the treatment, and 20 were absolutely cured,
the remaining eight were only ameliorated. Dr. Delherm, another
specialist in this line, describes the results obtained by the galvauo-faradic
treatment in 53 patients : 46 cases were very much ameliorated by the
treatment, and 36 remained cured after a year.
Rene Desplats, in a communication to the Societe des Sciences Medi-
cales,1 stated that he had successfully treated twenty-five cases of rnuco-
membranous colitis and spasmodic constipation by electricity of high
voltage.
His method consists in placing two large metallic electrodes (tin
plates, eight by ten centimeters) covered with several double folds of
buckskin, moistened with warm water, upon the surface of the abdomen,
one in each iliac fossa, and passing for ten minutes a current of sixty to
seventy milliamperes. a little more or less, according to the tolerance of
the patient. He also reverses the current at the end of each minute. If
the sudden reversal causes too great a shock, he lowers the current even
1 La Presse Medicale, No. 27.
* Journal des Sciences Medicales de Lille, April 14, 1906.
110 ELECTRO-THERAPEUTICS.
to zero before reversal. The resort to all purgative remedies is suspended
during the treatment (which is repeated every t\vo or three days), but
if there is no spontaneous movement by the third day, he orders an
enema, and this is gradually reduced. In atouic constipation the results
were very satisfactory, even iu children.
M. W. Peyser l employs a short, soft-rubber rectal tube in which is
placed a metallic conductor; this is passed into the rectum, coiling in the
ampulla being prevented if possible. The metallic conductor is attached
to the positive pole. The tube is connected with the tube of a fountain
syringe which contains saline solution. A large pad electrode, well
moistened with saline solution or thoroughly soaped, is attached to
the negative pole. While the solution is flowing, or after the syringe
is emptied, the current is turned on and gradually increased in strength
till from 15 ma. to 20 ma. are passing, or till the patient complains of
burning at the negative pole. There should be no sensation from the
current at the positive pole. The solution in the bowel acts as one of the
terminals, thus spreading the current over a large extent of surface and
permitting more current to be used. Similarly, the large pad permits
increased amperage. In a varying period of time desire for defecation
conies on — sometimes immediately, sometimes not for several hours.
Should it come immediately, the patient should be persuaded to endeavor
to continue the treatment for a while longer. The number of treatments
required varies from six to ten, rarely less than the former or more than
the latter. The tolerance of the patient should be the standard as to the
quantity of current, some taking 20 ma. even at the first treatment,
others never being able to take more than 12 ma. at any. The time of
each treatment should be from fifteen to twenty minutes, seldom more,
repeated daily till positive effects are obtained, and then at lengthening
intervals till success is assured or failure manifested.
FISSURE OF THE ANUS.
The indifferent electrode is placed upon the abdomen, while the
anode, covered with absorbent cotton saturated with a 10 per cent solution
of cocaine (Massey), is applied to the fissure, using a 1 to 5 ina. current
for several minutes.
AFFECTIONS OF THE RECTUM.
In paresis of the sphincter and in prolapse, the use of the farad ic
current has produced most successful results.
Dr. (}. Bet ton Massey- treated a case of rectal prolapse in a middle-
aged woman, by placing a felt-covered, flat electrode under the sacrum j
1 Virginia Medical Semi-Monthly, Feb. 9, 1906.
2 Therapeutic Electricity, W. S. Hedley.
APPLICATIONS IX DISEASED CONDITIONS. Ill
the patient being in a dorsal position. An ordinary rectal electrode was
inserted into the rectum, connected with the positive pole. With the
proper regulation of the current, slow interruptions were effected, by
touching one of the terminal posts with the tip of the conducting cord.
This produced a good form of muscle contraction. Duration 10 minutes.
No prolapse occurred after the first treatment.
HEMORRHOIDS.
The treatment of internal and external hemorrhoids by electricity is
by no means easy. I have never seen any good accomplished by this
agent, except in those cases where the electric current was employed
cataphorically. Some have suggested the use of electric needles, and
one or two succeeded in obtaining very satisfactory results. The electric
cautery, of course, is a method for the relief of piles; the procedure is
rapid, aseptic, and painless.
STRICTURE OF THE RECTUM.
The treatment of rectal stricture with electricity is identical with that
of stricture of the urethra. The instrument used is larger (Fig. 48), and
Km. 48. — Double rectal bulb electrode.
should also have a flat surface in front or below. The indifferent elec-
trode should be held by the patient's hand, or it may be applied to the
anterior abdominal wall. The strength of the galvanic current should be
from 5 to 15 millianiperes.
V. Genito-Urinary System.
STRICTURE OF THE MALE URETHRA.
Crussel, in 1839, was the first to employ electrolysis for the cure of
stricture of the urethra ; Mallez and Tripier were the first to practise it
systematically.1
Dr. \V. E. Stevenson 2 asserts that : The electrodes for this purpose
arc catheter-shaped gum-elastic bougies, terminating in a metal nickel-
plated piece connected to a binding screw on the handle. Place the
indifferent electrode on the patient's back ; the metal plate is made
'"De la guerison durable des restrecissements de 1'urethre par la galvano-
caustique chimique," Paris, lMi7.
''Annual Meeting of the British Medical Association, 1886.
112 ELECTRO-THERAPEUTICS.
positive. Estimate the distance of the stricture from the meat us. by
marking on aii ordinary bougie which has been passed. Suppose this
bougie was a No. 3 (English). A No. 5 electrode is passed down to
the stricture, where it is arrested. Corroborate this by previously mark-
ing the electrode, corresponding to the mark made on the bougie. Place
the electrode again in position, connect it with the negative pole ; the
circuit is closed, aud the current gradually increased without breaks,
until the maximum strength is reached, about 5 or 0 milliamperes. The
electrode is gently pressed against the stricture in the normal direction
of the urethra until, from the dissolution of the obstacle in front of it,
it passes into the bladder. The current should at once be cut oft', and
the bougie withdrawn.
The late Dr. Robert Newman, of New York City, advocated the
following : The patient is placed in the dorsal position, the thorax,
abdomen and lower extremities being in one horizontal line, while the
head of the patient is slightly elevated by raising the head-rest of the
table. A large electrode in the terminal, on the positive side of the
battery, is placed over the abdomen in a fixed position, and well pressed
upon the tissues, so as to make a perfect circuit.
The negative electrode, in the form of a whalebone bougie, has at
the inner extremity an olive-shaped head of the proper size. This is
introduced into the urethra as carefully as possible. The current is then
turned on with the lever of the rheostat, so as to prevent shocking the
patient.
The galvanic current that is used usually varies between three aud
five milliamperes. The treatments should last for a period of from 10 to
15 minutes. Two of these treatments are essential to start with, then
discontinue for another period of two days or two weeks, according to
the indication. Care should be exercised to pass through the lumen of
the stricture a bougie of very little larger dimensions than that of the
calibre of the opening. At the second treatment a bougie with a
metallic ovoid should be passed, the dimensions of it being slightly larger
than that used primarily. By doing this, there is a gradual dilatation of
the lumen. After two weeks a bougie of little longer dimensions should
be employed, and exactly the same process carried out as outlined above.
The treatment should consume a little more time, and the current used
should be 5 milliamperes. The third treatment should be given on the
16th day, the fourth on the 19th, and so on. The operator should always
remember that in active inflammation of the urethral tract, elect i it-
applications are contraindicated.
After the dilatation of the stricture,1 Selhorst inserts an Ober-
laender's urethroscopic tube, passing along the whole length of the
1 British Med. Journal, March 24, 1906.
APPLICATIONS IN DISEASED CONDITIONS. 113
stricture. In examining the urethra, the tube is withdrawn slowly until
the surface of the constriction is shown in the opening. The needle,
ending in a strong platinum point from 1.5 cm. to 2 cm. in length, iso-
lated quite close to its point, is forced to a depth of from 0.5 cm. to
1 cm. into the fibrous tissue, according to the dimension, thickness, and
hardness of the stricture. The needle is the negative pole of a galvanic
battery, the positive pole of which, a large moistened disk, is placed
on the thigh or on the abdomen. The electric current, of from 4 to 6
inilliamperes, is turned on for three minutes. Before withdrawing
the needle Selhorst interrupts the current, and drives the needle into
another part. This operation may be repeated four or five times during
a sitting, and if executed by an expert hand, is said not to be very pain-
ful. During the whole period of treatment a bougie is introduced once
weekly, followed by an irrigation with a nitrate of silver solution to pro-
mote reabsorptiou, and to maintain the passage of the urethra at the size
required.
Philippe1 credits electrolysis with many cures of simple stricture,
but maintains that a combination therewith of lavage with carbonic acid
is required when chronic urethral inflammation exists as a complication.
He records excellent results in varicose ulcers, torpid wounds, fistula, etc.
The gas is heated to 45° C. and driven into the urethra under a pressure
that may be regulated. It is saturated with essence of cinnamon as an
antiseptic agent. Miuet and Aversenq use rigid bougies with a mercury
bisulphate battery. A current of 3 to 4 milliamperes is passed for a
period of 15 minutes, once weekly. This treatment is preceded by
progressive dilatation with ordinary sounds, but the permanent results
are mainly attributed to the electrolysis.
PROSTATITIS.
This condition may be treated with local faradization or galvaniza-
tion. One of the poles is applied to the urethra or to the prostate
through an insulated sound or catheter. The other electrode is in the
form of an insulated rectal sound. The terminal of the electrode passed
into the urethra is of course allowed to remain uncovered, as it is to
come indirectly in contact with the prostate. The current should be of
such a strength as to produce a sensation of warmth in the deep urethra.
Dr. John V. Shoemaker,2 of Philadelphia, has devised an electrode
which is well adapted to prostatic work. The instrument (Fig. 49) is for
use in the reduction of hypertrophy of the prostate by means of the gal-
vanic current from the negative pole. The usual flexible rheophores are
1 La Presse Medicale, May 11, 1904.
'The Times-Register, January 17, 1891.
114 ELECTKO-THEKAPEUTICS.
attached to the terminal binding posts (the negative pole of the battery
being associated with the handle X, and the positive pole with the handle
P). The reophores having been thus previously fastened, the rectal limb
of the instrument (which has a movement in the vertical plane) is pressed
down toward the sponge -covered moistened pole ; the olive-shaped bulb
pole, B, having been previously slightly oiled. The instrument is then,
with the handle X held in the rear, passed under the crotch. The cur-
rent of the battery is supposed to have been previously set flowing.
Grasping then the rear handle, N, with the right hand, and allowing the
front handle, P, to fall away from the crotch, the patient now presses the
olive-shaped bulb, B, gently into the rectum; any slight error of judg-
ment as to direction being compensated for by the movement of that
limb in the vertical plane. The patient then grasps the front handle,
FIG. 49.— Shoemaker's prostatic electrolyzer.
P, and raises the lever formed by the hinges, H, thus bringing the mois-
tened sponge-covered positive pole, S, in contact with the perineum. By
exercising more or less pressure with this pole against the perineum, the
current is then regulated to the greatest nicety by the patient's
sensations.
The resistance to the current varies from 25,000 to 30,000 ohms, the
milliamperemeter indicating from 2 to 3 milliamperes, the duration of
administration being, according to Dr. Shoemaker and other authorities,
from 3 to 5 minutes.
PARALYSIS OF THE URINARY BLADDER.
The electrical treatment for paralysis of the bladder is divided into
the internal and the external. The currents employed are both the gal-
vanic ami faradie. Some suggest the use of the static current, but in my
experience this has accomplished little good.
APPLICATIONS IN DISEASED CONDITIONS. 115
The external application is conducted by placing the negative pole
or electrode over the symphysis pnbis, and the positive to the back of
the neck.
The internal application can be made by placing the insulated cathe-
ter clt-d rode or Diichenue's double vesical electrode into the urethral
tract. Tlu1 negative pole of the battery is attached to the leader in the
rubber catheter, while the positive pole is applied to the hypogastric
region, or back of the spine.
INVONTIXKNVE OF URINE.
This condition is treated electrically, as in paralysis of the bladder.
In the adult, both the internal and external methods may be employed.
In children the external method alone is usually used.
Faradic treatment is to be preferred in cases of children and
especially in those who have had incontinence from earliest infancy. Of
40 subjects, 55 per cent, were cured by Genoiiville and Compain ;l 63 per
cent, of the children were between 6 and 12 years old. The sittings
numbered from 5 to 8 in congenital cases, and in nou- congenital cases
from 6 to 16 treatments, with the exception of 5 patients, who had 20 to
29 seances. Slight improvement during the first week is a favorable
sign. The current may be applied directly to the sphincter or to that
immediate region. All but 20 per cent, of the subjects were improved
or cured, and in 16 cases a complete recovery occurred in a maximum of
16 visits.
Xociurnal Incontinence. — In this affection, the application of elec-
tricity stimulates the cerebral and spinal centres, by producing painful
local impressions, which tend to bring the inhibitory cerebral mechanism
into closer relation with the reflex centres in the lumbar cord. For
women and older girls, a bare metal sound is introduced into the urethra
as one electrode, the indifferent electrode being placed upon the lower
dorsal spine. The sound must not enter the bladder for more than a
short distance, or else the current will pass to the urethral walls. For
male patients the applications can be made to the perineum.
SPERMATORRHOEA AND SEMINAL EMISSIONS.
These conditions can be treated either by the application of local
or general galvanic or faradic currents, either internal or external. The
internal method consists of introducing an electrode, insulated by a rub-
ber catheter, into the urethral tract, as outlined in cases of prostatitis.
In the treatment of vesiculitis or ordinary spermatorrho?a, care must be
exercised to cause as little irritation internally as possible. The results
1 La Presse Mt'dicale, 1904, No. 38.
116 ELECTRO-THERAPEUTICS.
obtained are due to the electrolytic action on the mucous membrane, as a
result of the mechanical pressure of the catheter, or upon a combination
of these two factors. Sparks and the static breeze to the perineum, also
the brush discharge over the lumbar and sacral vertebrae, may prove
useful in some of these cases.
IMPOTENCE.
If this condition is the result of an organic lesion, electricity
will do little good ; on the other hand, benefit may be gained by the use
of the static breeze, spark, etc. Cases of impoteucy due to a psychical
influence may likewise be improved by the use of electricity.
ORCHITIS.
Scharff1 employed electricity successfully in the treatment of epi-
didymitis. During the acute stage he applies the anode to the lower
part of the scrotum with the patient in the dorsal position, employing a
large electrode with a maximum current of half a millianipere ; dura-
tion of the first application three minutes ; very gradually increased to
five, and later to ten minutes. About the seventh day the current can
be increased to three millianiperes. The cathode is placed over the
groin and on the abdominal wall. The advantages of this treatment
are its rapidity, and the early relief from pain and swelling. Good
results have been obtained by Ouimus and Duboc, of Rouen ; 2 Picot, of
Tours, has succeeded in forty cases.
NEPHRITIS.
Rockwell reports five cases of nephritis treated by electricity, four
of which recovered. Treatment covered a period of from two to eighteen
months ; after a few months osdema and ascites disappeared.
The technic of treatment consists in the employment of a high-ten-
sion faradic current, and also the use of the static wave current, the
latter being the more preferable. He suggests that these currents should
be employed alternately.
VI. The Nervous System.
NEURALGIA.
Electricity is applied to neuralgia in the following forms :
General faradization and central galvanization.
Local faradization or galvanization.
Central and peripheral, or a combination of both.
'Centralbl. f. Krankh. d. Harn und Sex. Organe, 1, 1894.
»Arch. d'fclectricifcS medicale, 1894.
APPLICATIONS IN DISEASED CONDITIONS. 117
Galvanization of the cervical sympathetic.
Cataphoresis.
The sinusoidal current.
Electric brush.
Electric moxa.
Static electricity.
Electric bauds and disks.
The magnet.
The initial applications should be mild, owing to the pain frequently
becoming intensified, especially after prolonged sittings. The applica-
tions should be made daily, or every other day. Either the positive or
negative pole may be applied over the painful points. There is no rule
for the direction of the current. The duration of the seance should be
brief.
Should the faradic current be tried without effect, resort should be
made to the galvanic current, or the two may be used alternately. Cen-
tral and general galvanization are to be conducted on general principles.
Cataphoresis will at times benefit, when other methods fail. The
sinusoidal current often acts most happily. The electric moxa is some-
times efficacious, but its use is attended with great pain. It acts partly
as a counter-irritant.
Cephahdgia. — Dry faradization with the hand is most useful in many
forms of headache. Stabile galvanization or faradization, uniform or
increasing, may be used. General faradization is more effective than
local applications. Central galvanization is at times the only effective
measure.
Tic Douloureux. — In this exquisitely painful condition, peripheral
galvanization or faradization should be tried ; the electric moxa, or gal-
vanization of the brain or cervical sympathetic, has in some cases proved
effective.
Professor S. Leduc, of Nantes,1 reported several cases in which he
had obtained excellent results in neuralgia by the electrolytic intro-
duction of salicylic ions (galvanic Cataphoresis). Recently he has again
resorted to this method with success in a case of tic douloureux of thirty-
five years' standing. This patient was cured, according to Dr. Leduc,
in three seances by salicylic ionizatiou. The method followed was to
apply the cathode, moistened with a solution of sodium salicylate,
to the right side of the face, and at the first treatment the current
was raised gradually to an intensity of 45 milliamperes and maintained
there for forty minutes. After the second stance, which took place
three days later (when the current was allowed to pass for one hour,
with a current of 35 milliamperes), he experienced decided ameliora-
1 La Semaine Medicale, November 22, 1905.
118 BLBCTBO-THBBAPBUTIOS.
timi. Finally, a third and last ionizatiou, of forty minutes, brought
about a final cessation of the pain. The pain now only returns during
exposure to cold.
r< ripheral Neuralgia. — Whatever the cause, these cases should IK;
treated by stabile Eradication and galvanization, or the electric inoxa.
lu rebellious cases, central and general electrization should be tried.
Sciatica. — Faradization is to be recommended in this condition. For
the novice, galvanization is to be preferred, owing to the extreme
evenness of the current required. Au ill-directed, prolonged current
often aggravates the condition. I have had good results with the static
spark.
PARALYSIS.
Rheumatic Paralysis. — In these cases faradization is extremely useful.
The electro-muscular contractility in recent cases is normal, in long-
standing cases diminished. It is important to institute treatment before
the occurrence of muscular atrophy. Static and galvanic electricity are
also valuable in rheumatic paralysis.
Syphilitic paralysis is treated in a manner similar to rheumatic pa-
ralysis.
Lead Paralysis. — In this affection the electro- muscular sensibility is
diminished and frequently lost, and diplegic contractions may appear. If
the electro-muscular contractility is completely lost, apply a galvanic cur-
rent, 5 to 15 ma., to the paralyzed part before the faradic current is
employed. The latter current should be used daily, 10 to 15 minutes at
each sitting. When the slightest contractions occur from the faradic
current, the galvanic may be discontinued.
Paralysis from opium, stramonium, arsenic, etc., is to be treated by
general faradization.
Hemiplegia. — Treatment should not be commenced until four or five
weeks after the attack. Vigorous electrization of the affected limbs may
completely restore them. Further efforts may be directed to the cranial
lesion by the application of the continuous current. The anode is applied
to the forehead and to the sides of the head, the cathode to the nape of
the neck ; the former electrode being moved slowly to and fro without
interruptions. Current strength 1 to 5 ma. The active electrode should
be of medium size. Daily treatments for one month ; duration of each
sitting, 5 minutes. If aphasia be associated, the anode may be applied
to the third left frontal convolution. I prefer the static breeze over the
head, with indirect sparks to the affected side.
Paraplegia. — Early in the disease the galvanic and the faradic reac-
tions may be normal. Where the posterior columns arc a fleeted, electro-
amesthesia may likewise coexist. Treatment consists in galvanization or
APPLICATIONS IN DISEASED CONDITIONS. 119
faradization. The electro-muscular contractility is frequently so much
diminished that it becomes necessary to give particular attention to the
motor points in order to produce contractions.
I'dcitil Paralyxix. — Facial paralysis should be treated by local faradi-
zation and galvanization. When response is not obtained by the faradic
current, it is of little use to employ it ; it being far better to depend
upon the galvanic current. In this disease the current- re verser electrode
is exceedingly convenient. A current just sufficient to produce contrac-
tion is better than a stronger current, and short applications are
preferable to long ones.
Poliomyelitis. — In poliomyelitis, the paralysis precedes the wasting.
The faradic irritability soon becomes lost, with temporary increase of
galvanic irritability and degenerative reactions. The latter are often
mixed, due to the nerve-fibres being unequally affected, an increase of gal-
vanic irritability in the muscles with retention of faradic irritability in
the nerve. In infantile palsy, there is loss or absence of electro- muscular
contractility. Treatment consists in the galvanization and faradization
of the affected muscles, and the constitutional methods of treatment of
general faradization, central galvanization, and static electrification.
Locomotor Ataxia. — The electro -muscular contractility may be normal
or increased, as distinguished from ordinary motor paralysis, depending
upon anterior or lateral spinal sclerosis. It may, however, be dimin-
ished. The disease may be treated by galvanization of the spine, central
galvanization, and general faradization, when cerebral disturbances or
general ataxia of the nervous system appear, galvanization of the cer-
vical sympathetic and peripheral faradization with sponges and the
metallic brush. Static electricity by means of long percussive sparks
over the spine is often useful.
CHRONIC SPINAL MUSCULAR ATROPHY.
The use of central galvanization is here indicated, with faradization
and galvanization of the affected muscles. Static electricity is strongly
commended by many electro-therapeutists.
EPILEPSY.
Erb recommends the following method : u Place the anode over the
forehead, and the cathode to the neck. Current 1 to 2£ milliamperes.
The duration of each treatment is about one minute. The position of
the electrode is then changed ; the anode is then placed to the middle line
of the head and the cathode to the occiput."
I advise the administration of the static current ; especially the wave
current or breeze over the head, has in some cases done good. The cur-
rent should be applied every day, if possible, and continued for months.
120 ELECTROTHERAPEUTICS.
INSOMNIA.
This affection frequently yields to treatment by electricity. I have
seen patients fall into sleep while I was treating them with the static
breeze. The galvanic current applied to the sympathetic system, or the
faradic current applied to the head and spine, and also general farad i/a-
tion have given most encouraging results. The majority of electro-
therapeutists incline to the opinion that the most favorable results are
attained by employing the static current.
HYSTERIA.
In this condition a psychical effect is produced by the static
and also by the galvanic current. It is also possible in many cases that
a lessening of nervous irritability results from the electrical applica-
tions. In fact very little, if any, good is done in this disease by the use
of electricity.
HYPOCHONDRIASIS AND MELANCHOLIA.
In these conditions both general galvanization and faradization of
the cervical sympathetic do good by the psychical effect upon the patient.
Static electricity in some cases would appear to be beneficial.
INSANITY.
The various forms of insanity are at times favorably influenced
by using the same treatments as are referred to in the preceding para-
graph. It is unfortunate that in asylums electricity has not been more
extensively employed. The use of the static bath would seem to be
beneficial, and to this end experiments are being conducted at the Phila-
delphia Hospital.
NEURASTHENIA.
Dr. Charles K. Mills ! believes that electricity used only in the form
of general faradization, with a slowly interrupted current, is less useful
than massage. In not a few cases, the nurse who attempts to give faradic
electricity to a patient is unskilful or irritating in her method of admin-
ist ration. On the whole. Mills prefers the method of direct muscular
faradization, supplemented with gliding or labile currents, applied to the
entire limb or part. The nurse holds two moistened electrodes in one
hand, and passes from one muscle to another ; then placing one elec-
trode to the spine or in the neighborhood of the nerve plexus, the
electrode is passed from point to point down the limb.
1 Transactions of the Philadelphia County Medical Society, Nov. 29, 1905.
APPLICATIONS IN DISEASED CONDITIONS. 121
Dr. W. B. Snow1 says in reference to the electrical treatment <>f
neurasthenia: '" For the general tonic effects indicated in every case of
neurasthenia, the wave current should be administered, by placing the
long, spinal electrode (one inch in width and 18 to 22 inches in
length) over the vertebral column from the cervical to the lumbar iv-
gioii for from at least 15 to 20 minutes, and employing as long a spark-
gap as may be used without causing uncomfortable muscular contractions.
••Patients will usually take a treatment with a four-inch spark.
Though persons with small muscles and but little fat may not bear a two-
inch spark-gap current, large or fat persons will bear and require one
measured by a five- or six-inch spark discharge. After the first few
applications, the patient perspires gently with each such treatment
Not only does the activity of sweat glands resume, but there is a grad-
ually increasing resumption of other functions. There is marked in-
crease in the daily excretion of solids in the urine, digestion improves,
appetite returns, the bowels become more regular.
• • While many cases have been cured by no other agency than the
wave current, we believe that the active peripheral stimulation and mas-
sage afforded by the long and friction sparks hasten the recovery of every
case, the time factor of which will depend on the duration of the affec-
tion, the adherence to regimen, the extent of functional derangement,
the recuperative powers of the patient, the regularity with which the
treatments are administered, and the technic employed. Treatment
should be given daily for at least two weeks, when every second day may
suffice."
EXOPHTHALMIC GOITRE.
In the treatment of exophthalmic goitre, Dr. Francis B. Bishop,2 of
Washington, believes that the only rational method of procedure is by
means of the electric current.
The vagus is easily stimulated in the neck from the subauricular
fossa to the clavicle, and with a much weaker stimulus and in much less
time than the sympathetic. So with care we may get the inhibitory and
other influences of the vagus, without unduly exciting the sympathetic.
Preference for the application to the vagus, has been for the
continuous current, and the method of application has been to stimulate
both nerves at the same time. A large sponge-electrode, attached to the
positive pole, is placed high up on the back of the neck. A bifurcated
cord is used for the negative side, and two small sponge-electrodes are
placed one on each side over the pneumogastric, in the lower part of the
neck and impinging upon the thyroid.
1 Poet-Graduate, December, 1900.
2 The Journal of Advanced Therapeutics, February, 1904.
l_>i> KLECTRO-THKRAPHTTK S.
"The current is gradually turned on and the pulse noted," says
Bishop; "the current is allowed to remain at that point for ten or fifteen
minutes, or longer, until a decidedly quieting effect has been produced.
Then the small sponges are placed directly on the gland and the current
turned on to the point of tolerance, and is allowed to pass from five to
eight minutes. This treatment is persisted in every other day. and in
many cases a decided improvement will be noticed in a month. Later,
I have been using the high-potential, high-frequency current as an
auxiliary, and have been much pleased. One patient begged me to dis-
continue all other treatment, as she was so much benefited by the high-
frequency spark applied directly to the thyroid and cervical spine, over
the liver, spleen, kidneys, abdomen, and over the region of the ovaries.
A letter received some time ago states that she continues to improve."
Heiimau's1 experiences with electro-chemical treatment of exophthal-
mic goitre encourage further work in this line, he thinks. He applies
the cathode over the goitre with the continuous current, 25 to 40 milliam-
peres, similar to Bordier's tehnic, except that he uses a cathode which
contains potassium iodide. In one case, for instance, he applied a cur-
rent of 20 niilliamperes for about twenty minutes a day, the positive
electrode on the back, and the negative on the neck. The cathode was
placed on a thin sheet of lead, shaped to the neck, over several layers of
sterile gauze impregnated with a concentrated solution of potassium
iodide, covering the entire goitre. The current was turned on and off
very gradually. After a week of this treatment all the symptoms of the
exophthalmic goitre had disappeared, and the size of the neck had been
reduced from 39.5 cm. to 38 cm. The patient felt perfectly well and has
continued in good health since that time — November, 1905. The im-
provement in another case described was almost equally striking, and in
this case iodide was found in the urine five days after the last appli-
cation. He also detected iodine in gauze under the anode of the back.
Other cases from his experience are described and some of the laws of
electro-chemistry are cited to explain the phenomena observed.
VII. Gynecology.
The value of electro- therapeutic measures in gynecology has been
for many years a subject of heated discussion among its many champions,
and among the equally numerous opponents to its employment in diseases
peculiar to women.
Dr. Barton Cook Hirst,' of Philadelphia, remarks that of late he
has found galvanism and faradism of value in a limited number of
1 Hygieia, Stockholm, La>t Iii«l»«x, p. 903.
1 "Limitations and Possibilities in the Treatment of Diseases of Women," read
before the Philadelphia County Medical Society, January 25, 15)05.
APPLICATIONS IN DISEASED CONDITIONS. 123
conditions in gynecological practice. As a liiemostatic in uncomplicated
vSinall fibroid tumors, with no other symptom than metrorrhagia, he
regarded it as a most efficient agent. He found it peculiarly useful in
the treatment of amenorrlKua and sterility, the results of imperfect
development or atrophy of the uterus. Two illustrative cases were
reported in which normal menstruation was restored and conception
occurred after the use of this treatment. In one woman there had been
amenorrho3a for a year. In the other, the menstruation had been reduced
to a scanty discharge lasting less than a day, as a result of lactation
atrophy. The third indication was to restore tone to a paretic sphincter
aui muscle, after its imperfect restoration by surgical means, in which
there had been no contractile power exercised for a number of years. A
FIG. 50. Vesical electrode, for hydro-electric application to female bladder. Useful in atony, dila-
tation, chronic cystitis, etc.
FIG. 51. — Goelet's iutra-uteriue electrode, with interchangeable tips.
fourth indication was found in certain types of dysmeuorrhoea associated
with an ill-developed uterus. Local treatment, however, he believed,
was very rarely practicable in such cases.
In disease of the uterus, local, central, and general treatment may be
employed. Local treatment may be external or internal.
The uterus and the appendages may be treated electrically by
applying one pole over the hypogastrium and the other over the lumbar
region. In virgins this method should always be tried first.
In the internal method, one pole may be applied to the os by means
of an insulated electrode with a metallic belt, while the other, bearing a
broad electrode, is applied to the back, or on the hypogastric region, or
over an ovary.
In using the faradic current, both poles are applied internally. The
sinusoidal current is of great value for the alleviation of uterine pain.
Figs. 50 and 51 illustrate two valuable electrodes in gynecological work.
li' 4 ELECTKO-THEKAPEUTICS.
AMEXORRHCEA.
For ameuorrho3a Dr. Golding Bird1 believes in the value of shocks
from the Leydeii jar. He transmits twelve successive shocks, from the
sacrum to the pubes. Panecki uses the induction coil. In chlorosis,
marked benefit is said to accrue from the nutritional effects of the electric
bath. In healthy women who menstruate regularly, electricity often
hastens the flow, especially when applied to the abdomen or pelvic re-
gion. Another method consists in having the patient lie on a large elec-
trode, and in applying a circular one with the handle alternately to the
epigastrium and hypogastrium, stabile, using 30 millianiperes. This
should l>e succeeded by a strong primary faradic current.
When this affection is due to a cervical stenosis, electrolysis is indi-
cated. For dysmenorrhrea, independent of stenosis or structural change,
the galvanic current is of value in relieving congestion and pain. The
applications are to be made prior to menstruation and repeated daily.
These same applications offer most beneficial results in dysnieuorrhoea
dependent upon pelvic cellulitis ; occasionally the faradic current is of
value.
FIBROID TUMORS.
The electrical treatment of uterine fibromata has been elaborately
studied by Bartholow, Massey, Engelmauu, and many others. Indeed
since the brilliant investigations by Apostoli, the literature of uterine
fibromata has assumed massive proportions. In 1882 Apostoli, in an arti-
cle to the Academic de M6decine, expounded his views on a subject here-
tofore unthought of, that at once aroused attention and invited thought.
He advised the use of an internal platinum positive electrode, and an
abdominal negative electrode, of large surface, made of moist china clay,
with a continuous current of 60 to 70 milliamperes. Applications 5 to
15 minutes. Stances once or twice weekly. The current was to destroy
the mucous membrane, which was succeeded by a healthy repair process
and by a cicatrization to check the metrorrhagia.
Bergonie and Boursier2 sum up the results they obtained in one hun-
dred cases of uterine fibroids as follows: "The electric treatment of
fibro-myomata is undoubtedly efficacious as a palliative method of treat-
ment. When hemorrhage was the chief symptom complained of, 90 per
cent, were relieved. The general state of health was improved in 79 per
cent.; the pain was relieved in 50 per cent., while a decrease in the size
of the tumor was observed in 10 per cent, only."
'Electricity and Magnetism, 1840, Lecture V, and Appendix B.
7 Arch, d'Etectricit.' in.-dicale, 1893. L'l 1.
APPLICATIONS IN DISEASED CONDITIONS. 125
OVARIAN TUMORS.
The electrolytic treatment of these tumors, which was formerly so
largely in vogue, has been completely abandoned by electro-therapeutists.
The danger incident upon operation is less than that incurred by
electrolytic means.
CHRONIC METRITTS.
In these cases either the faradic or galvanic current may be used.
The more usual method is to apply the galvanic current. Place the
anode (per speculum) upon the os, and the cathode upon the epigastrium,
stabile 5 to 10 minutes, 2 or 3 times a week. Current about 20 milli-
amperes.
PERIUTERINE H.EMATOCELE.
Apostoli's method is intended to effect a chemical caustic change by
means of the cathode. A fistula is thus established, which tends to
remain open, with adhesions between the seat of the affection and the
external mucous membrane.
STENOSIS OF THE CERVICAL CANAL.
In these cases galvanism is of great value. Introduce a sound, con-
nect it with the cathode, apply the anode to the abdomen. Current 50 to
75 milliamperes ; application 5 minutes.
SUBINVOLUTION AND ATROPHY.
Early in the condition, the faradic current is most useful, applied by
means of the bipolar electrode. Later in the affection the galvanic cur-
rent is to be employed, and the treatment to be instituted is similar to
that for chronic metritis.
URETHRAL CARUNCLE.
If pedunculated the galvano-cautery snare is passed around the
caruncle and the current turned on. The carbon or platinum electrode
is used, covered with absorbent cotton saturated in a solution of cocaine.
Current 5 to 15 milliamperes. When no pedicle exists, puncture with a
negative needle ; current 10 to 15 milliamperes.
POST-PARTUM HEMORRHAGE.
Use current of the primary wire with an inter-uterine electrode, with
the indifferent electrode on the abdomen. A pocket faradic battery
answers admirably, that of Gaiffe of Paris being deservedly popular.
1L'(5 ELECTRO-THERAPEUTICS.
VOMITING OF PREGNANCY.
In vomiting of pregnancy the induction coil of fine wire is preferably
employed. Apply the anode to the nape of the neck, the cathode to the
epigastrium. Avoid the uterine region.
SLOW LABOR.
This may be hastened, and atony and inertia of the uterus overcome
by the use of the faradic current. Electrodes of large size are applied
on each side of the fimdus, near the umbilicus. A powerful current is
passed with the occurrence of a pain.
Dr. C. A. Covell, in a paper entitled "A Case of Asthma with Fi-
broids and Pelvic Adhesions Cured by Galvanism,'1 ' mentions the case of
a patient, aged 37, married, who suffered with marked dysmeuorrhoea and
bearing-down pains. The pelvic trouble became constant, and she was
advised to undergo an operation for hysterectomy and ovariotomy. The
author then says, " because of the great tenderness and pain I used the
vaginal abdominal alternations, a large pad of absorbent cotton and wire
being placed over the abdomen and a Leclanche zinc insulated with rub-
ber tubing, the tip covered by cotton, was placed in the vagina. Gradu-
ally turning the current on and off, and reversing it occasionally, from 25
to 100 milliauiperes were used, she being able to bear more current .sonic
days than at others. Treatments were given at first every other day and
later twice a week only. Improvement was rapid. In six mouths the
exudate was absorbed, and in one year the pelvic organs were nearly
normal. The fibroids were reduced to the size of a walnut. The pain
ceased, and as the pelvis cleared the asthma became less and less, finally
ceasing also.
"I did not see her again professionally for four years. One
year since she became pregnant, without any unusual symptoms. She
went to full term, and in May last was delivered at the Good Shep-
herd Hospital of a nine- pound boy. Labor lasted five hours and was
normal in all respects. While she was under chloroform I carefully
examined the uterus and found two interstitial fibroids the size of my
thumb.
uTo me the interesting things about this case are these : The asthma
was of reflex origin and ceased as the pelvic condition was relieved.
"The method of application of the current in periuterine inflam-
mation.
"The uterus, which the leading gynecologist of central New York
said it was necessary to remove to save the patient's life, under elec-
trical treatment prodnc«-«l fi.nr years later a healthy child."
1 Read at the Thirteenth Annual Meeting of the American Electro- Therapeutic
Association, Atlantic City, .September 23, 1903.
APPLICATIONS IX DISEASED CONDITIONS. r_>7
VIII. Aneurism.
Treatment of aneurism by electro- puncture dates back to Prava/,
(IS.'iX), Peterkin (. IS45), and Ciniselli (1870).
Ciniselli ' lias collected 23 cases of aneurism, six of which were appar-
ent ly cured by electro- puncture, 16 died, and in one case result is not
known. The operators sometimes used one needle in the sac, sometimes
both. Tripier advocates the insertion of the positive needle only, on
account of its property of coagulating albumen. In Ciuiselli's cases, 20
to 10 cells were used from 10 to 30 minutes. The method now frequently
employed is to take a fine coiled wire of gold, silver, or platinum, so drawn
out that it may be readily passed through a thoroughly insulated needle.
The anode is the active electrode, the cathode, a clay pad on the abdomen.
The current may gradually ascend to 80 milliamperes. Duration 30 to
(JO minutes.
Cornelius A. Griffith2 describes an interesting case of sacculated
aneurism of the abdominal aorta, treated by the introduction of silver
wire and the passage of the constant current.
The tumor was in the epigastric region, lying almost directly to the
left of the middle line, extending up under the ribs and downward nearly
to the umbilicus, its size being about that of a cocoanut ; it caused some
bulging of the epigastrium, was distinctly pulsating, and presented a
well-marked systolic bruit. Pain was constantly present in the back
and at the left side, and also in the epigastrium, following the taking
of food ; occasional retching was experienced, but there was no actual
vomiting.
Subsequently an operation was determined upon, when a fine, long,
metal trocar and canula were thrust well into the sac, the trocar was
withdrawn, and a vulcanite insulating canula substituted, through which
fine silver wire was introduced into the sac. About six feet of wire were
passed in, connected to the negative pole of a constant current battery,
and 15 to 25 milliamperes passed for 15 minutes. At the end of this
time it was noticed that the tumor was harder and the pulsations
had grown less. The cauula was then withdrawn and the operation
completed, whereupon it was noticed that the bulging caused by the
tumor had almost disappeared. Patient died in about five hours,
apparently from shock. Port-niortem examination showed that the
sac was filled with a dark clot about the coiled wire, and that a double
loop of the wire had been passed for about two inches up into the
thoracic aorta. The introduction of coils of wire in aneurismal sacs
1 Lnigi Ciniselli ("Sugli aneurism! dell' aorta toracica finora trattati colla elletro-
puntura ") , Milliano, 1870, quoted in Dr. Reyes's paper on " Practical Electro-Therapeu-
tics," New York Med. Journal, Dec. 1871.
2 London Lancet, August 12, 1905.
128 ELECTRO-THERAPEUTICS.
should be avoided if possible, and the immediate clotting of the blood
within the sac by the passage of a small current is believed to be of
advantage.
Dr. H. A. Hare1 reported eight operations of this nature, the three
now reported, making a total of eleven, in his own experience.
The first of these three cases occurred in a woman of 50, the aneu-
rism involving the superior and posterior portions of the transverse arch
of the aorta, and included the origin of the large vessels arising from this
part of the aorta. The occurrence of severe symptoms made relief
imperative, and gold wire to the amount of eight feet was passed into the
sac through an ordinary insulated needle, and through this wire was
passed an electrical current started at 5 milliamperes and gradually
increased to 50 milliamperes for 30 minutes. The immediate effect of
the operation was to relieve the pressure symptoms, and for several
weeks afterward she was able to sleep in a reclining posture with perfect
comfort. Six months later the growth began to enlarge at the margin of
the clot, and death finally occurred from pressure and exhaustion.
Autopsy confirmed the diagnosis in every particular, and revealed the
wire embedded in the clot.
The second case occurred in a man aged 42, and was probably trace-
able to heavy lifting. There was some paralysis of the right vocal cord,
but no interference with swallowing ; the growth filled the epiclavimlar
space at the right side, and passed backward under the steruo-mastoid
muscle, pushing apart the bellies of the two branches of this muscle
and protruding prominently into this space. Two feet of gold wire were
passed into the tumor and the current passed as before, from 5 to 50
milliamperes being used in the course of 40 minutes. The patient was
relieved immediately after the operation, and his voice, to some extent,
soon returned. Four months later, however, he died from exhaustion and
pressure. Autopsy confirmed the diagnosis, but, strangely enough, no
trace of the wire could be found in any part of the clot.
The third case occurred in a woman aged 50, and involved the
thoracic aorta just below its descending portion. Erosion of the ribs
was noted upon the left side, so that the sac projected to the extent of
two inches outside of the line of the body between the vertebrae and the
lower third of the left scapula. Nine feet of wire were introduced and
the current passed as in the preceding case, from 5 to 50 ma. during a
period of three-quarters of an hour. The immediate effect of the opera-
tion was to diminish the expansile pulsation. At the end of four mouths,
however, the patient died from pressure symptoms and exhaustion. The
autopsy confirmed the diagnosis and revealed the wire embedded in the
centre of the clot.
1 Therapeutic Gazette, July 25, 1905.
FIG. 52.— Ozone inhalation. The generator should be suspended to within a few inches from
the mouth of the patient, and attached to the positive pole of the machine. The patient is placed
upon an insulated platform connected with the negative pole. The oxygen of the air confined within
the globe is broken up, forming ozone, by the convective discharge of the current passing from the
numerous points of the brush within. It is of paramount value where sprays or medicated vapors
cannot reach the part by other means.
CHAPTER IX
APPLICATIONS IN THE SPECIALTIES.
I. Rhinology and Laryngology.
ATROPHIC EHINITIS. t
IN atrophic rhinitis, Delavan1 suggests the application of the nega-
tive pole to the retro-nasal space, and the positive pole to the nape of the
neck. The strength of the galvanic or faradic current should be from 4
to 0 milliamperes. Each treatment should last from 5 to 12 minutes. The
applications should be made every other day.
PHARYNGITIS.
Hahn 2 asserts that he obtained good results in cases of pharyngitis
by the use of the faradic current. Violet rays and high-frequency cur-
rents have frequently proved useful. In pharyngitis, and in many
pharyugeal and laryugeal affections, ozone inhalations have been warmly
commended (Fig. 52). Many ingenious electrodes for nasal and pharyu-
p-ul work have been devised, two very useful ones being shown in Figs.
53 and 54.
FIG. 53.— Curved sponge electrode for application to throat.
FIG. 54.— Electrode for hydro-electric applications, post-nasal and pharyngeal.
OZ.ENA.
In this affection some electro-therapeutists apply cupric electrolysis.
In 1895 at a meeting of the Belgian laryngologists and otologists, Cheval
'Transactions of the American Laryngological Association, 1887, p. 14»i.
* Journal de Medecine, Paris, November, 1902.
9 129
130 ELECTRO-THERAPEUTICS.
announced the cure of 91 per cent, of cases of ozrena at a single seance.
He employs a copper needle (positive pole) and inserts it into the mucous
membrane of the middle turbinated bone, and introduces a steel needle
into the mucous membrane of the inferior turbinated bone of the same
side. The strength of current is between 18 and 20 milliamperes. for a
period of 10 minutes.
ANAESTHESIA OF THE PHARYNX.
Induced or continuous currents, percutaneous or pharyngeal, may be
used in such cases. Short static sparks are often beneficial.
LARYNGEAL FATIGUE (fatigue vocale).
Bordier ' states that Moutier and Granier of the Opera in Paris,
had been able to prove that electro-static applications exerted a
favorable influence upon laryngeal fatigue. The patient was charged
negatively and the anode or grounded point electrode was applied
near the mouth and nose. Applications daily for 15 or 20 minutes
showed an increased duration of the respiratory movements, the pitch of
the laryngeal sound was raised, and the quality of the voice became
more agreeable.
ATROPHIC PHARYNGITIS.
Shurley ! used cocaine in the treatment of atrophic pharyngitis and
then applied one electrode through the nose, and the other to the pos-
terior and lateral wall of the pharynx. The current increased both the
color and secretion of the membrane. With the use of the faradic
current, Sajous has obtained good results.
ANOSMIA.
Anosmia may result from long continued rhinitis or from a
peripheral lesion.
The treatment maybe external and internal. The external treat
ment is the same as for rhinitis, save that the current is stronger. The
internal treatment consists in the direct application of a metallic elect n»de
to the nasal mucous membrane.
Rockwell mentions a case of anosmia8 of six years' duration, where
the patient could only perceive the odor of kerosene oil and freshly
ground coffee, and who was entirely cured liv two applications of the
faradic current.
1 " Medical Electricity.'' by H. Lewis Jones.
'Transactions of the American Larynpological Association, 1887, p. 146.
$ Medical and Surgical Electricity, by A. D. Rockwell, p. 482.
APPLICATIONS IN THE SPECIALTIES. 131
ASTHMA.
Tin- galvanic current over the pneumogastric and sympathetic
regions has been frequently used in asthma, with asserted good results.
The faradic current is sometimes effective. In some instances persistent
faradization of the chest and neck has been followed by marked relief.
Courtade, in a communication made to the Societe Medico-Chirur-
gicale.1 recommended the application of electricity to the lateral cervical
region. The positive pole is placed on the neck, so as to produce a con-
dition of elect rot onus, — /. <•., a diminution of the excitability of the nerve.
Thus directed the current acts upon the pneumogastric at first in a cen-
trifugal manner, so as to excite the bronchial and laryngeal muscles j
following this it acts centripetally upon the phrenic nerve, and upon
the great sympathetic. The excitation of the latter is able to modify
the vaso-motor activity of the vessels of the medulla oblongata and the
respiratory centres. The results were found to be very favorable in
essential asthma.
II. Otology.
AUDITORY-NERVE DEAFNESS.
This is best treated by the bifurcated electrode and the battery cur-
rent, using the cathode to the ears. Gradually vary the current by
employing a rhythmic interrupter, or by turning the current on and off
with the current collector. Ten milliamperes is the maximum. Seancea
of 5 or 6 minutes are long enough. Apply to both ears simultaneously,.
so as to prevent vertigo. Use electrodes of a one-inch surface. Place »
small pad of moist absorbent wool between the electrode and the skin,
because, the electrode being small, the density of the current is great.
One variety of the double ear electrode is shown in Fig. 55.
FIG. 55.— Double sponge-tipped ear electrode insulated with hard rubber.
CHRONIC SUPPURATION OF THE MIDDLE EAR.
Rockwell states that in experimenting on these cases he used the gal-
vanic current. The theory on which the experiments were based was
that ulcerous conditions in the ear might be treated electrically, similarly
to the same conditions elsewhere. An electrode with a long, narrow
extremity, covcm! with a little cotton, was inserted into the auditory
1 Le Bulletin Medicale, February 21, 1906.
1 U'2 ELECTRO-TH KRAI' 1 ] UTICS.
canal through a rubber speculum, the canal being filled with tepid
water. The electrode is usually connected with the negative pole of the
galvanic current, though sometimes with the positive. The circuit is
completed by the hand of the patient holding a sponge electrode, or rest-
ing on a stationary electrode. Weak currents and short applications are
to be employed, while some form of rheostat is indispensable.
TINNITUS AURIUM.
Subjective noises can sometimes be dispelled at once by battery
currents.
In chronic ear disease, when patients are electrically treated, the
tinnitus is often found associated with great increase in the irritability of
the auditory nerve.
In treating tinnitus aurium select two small, well-padded electrodes,
of about 2 cm. in diameter, to form a divided anode ; apply one to each
ear, just in front of the tragus. The cathode (an electrode of large size)
is applied to the nape of the neck. The current is slowly raised to 5
milliamperes. Duration 10 minutes. The anode usually diminishes the
tinnitus, the cathode iurceases it ; sometimes the reverse occurs. If no
improvement follow either application, it is futile to continue.
Dr. William S. Bryant l details excellent results obtained from elec-
trical treatment- in tubal tinnitus wherein other methods had failed. The
negative pole can be applied to the tube, preferably through the nose.
It is best made in the form of an eustachiau catheter, conical at the tip,
and iu three sizes. It should be insulated to within three-quarters of an
inch of the end of the electrode. Duell's electric bougie is very satis
factory in the most refractory cases. Atrophy calls for stimulation and
electricity.
As a complete rfaumS of the uses of electricity in aural diseases and
affections, I can do no better than append the following abstract from the
excellent paper of Dr. J. J. Richardson, of Washington, D. C., entitled
"Electricity in Otology."
u * * * * j am noj. an enthusiast, who claims electricity to be a
panacea for all diseases, but after careful experimentation audobscr\a
tion, lam convinced that it at least possesses great possibilities along eer-
tain lines. * * * * I know from practical experience that we can
by its employment iu one form or another l > stimulate weak muscles,
(2) relieve pain, either by direct action of the current or by the cata-
phoric application of anaesthetics, (3) stimulate absorption of inflam-
matory exudates, (4) overcome stenosis or complete strictures, and i B at
times revive nervous activity. A thorough knowledge of the physiology
1 Laryngoscope, July, 1904.
2 New York Medical Journal, February 25. 1905.
APPLICATIONS IX THi: SPECIALTIES. 133
and pathology of tin- parts we are treating and also of electro-physiology
and electro-physics is demanded. Tin- apparatus must be of the high-
est standard and under perfect control, as otherwise we are assum-
ing a risk which is unjustifiable, and may inflict injury instead of
affording relief. For example, in the application of galvanism, the
polarity of the current is of the greatest importance. The negative pole
will often do good whilst the application of the positive may be painful
and even injurious. * * * * Again, a mild current will fre-
quently relieve or cure conditions where a stronger one would aggravate
them.
a * * * * There are different methods of applying electricity to
the ears. The one which I employ for both the galvanic and faradic cur-
rents, when both ears are to be acted upon, is a bifurcated intra-auricular
electrode, the metallic ends of which I cover with moist absorbent cotton.
For the indifferent pole, an ordinary sponge electrode is placed in the
hand or over the nape of the neck. I frequently apply it to the
enstachian tube by introducing a hard-rubber catheter in the ordinary
way, and passing through it a metallic bougie electrode, applying the
other electrode over the mastoid region. In this way it acts directly <»n
the muscles of the tube, which at times lose their normal tonicity, and it
also stimulates the circulation of the parts. For this purpose I usually
employ the faradic current, which produces a sort of tingling sensation,
but no vertigo or other symptoms of cerebral irritation.
"The active pole for therapeutic purposes should most always be
the positive, unless electric torpor exists, as it is the sedative, deconges-
tive one. The negative pole, which we employ in studying the auditory
nerve excitability, acts in the inverse sense ; with the faradic current the
polarity is unimportant.
"In the distressing symptom of tinnitus, electricity will frequently be
beneficial where other forms of treatment have been of no avail. It is
in these cases where the ordinary treatment of inflation, eustachian and
middle ear medication have been instituted, and where the naso-pharynx
and nasal cavities have been treated with negative results, that electricity
offers some encouragement. A fair percentage of the patients will be
greatly l)enented, and one occasionally cured. When the tinnitus is of
labyrinthine origin, or due to chronic inflammatory changes in the middle
ear, the constant current is the one mostly employed. One to three
milliamperes are sufficient and should be allowed to pass from 6 to 10
minutes. Where there is ankylosis of the ossicles, the interrupted
current has been more satisfactory in cases, although less frequently
employed than the constant current. The good effects are to be found in
its mechanical action on the adhesions, and to its stimulating action on
the circulation, and also upon the weakened muscles of the middle ear.
134 EL !•:< T R( >-T 1 1 1-: i i A i • i-: UTICS.
"True strictures of the enstachian tube are rare, and are lx?st treated
by electrolysis. The galvanic current is utilized for this purpose. A
hard-rubber or silver catheter, properly insulated with rubber up to its
point, is introduced, and a small gold bougie is passed through the cathe-
ter and up to the point of constriction in the tube ; the bougie is the
active electrode. It is to be attached to the negative pole of the battery.
the current turned on slowly, and 3 to 0 milliamperes are to be allowed
to pass. After 6 or 8 minutes, by a gentle pressure on the bougie, it will
be felt to pass the softened stricture. The operation is a little painful,
and for a few days following there will be an increased amount of deaf-
ness and ringing and fulness iu the ear. On the third day usually a
celluloid bougie is to be passed and at the same intervals of 3 or 4 days
for 2 or 3 weeks. The dispensing electrode is held in the hand in pref-
erence to the mastoid region, or over the neck, where there will be less
tendency to cerebral irritation.
" Complete success, by electrical treatment, for deafness cither of
tympanic or labyrinthine origin, is of rare occurrence. I do not recall
any cases that I have treated where the hearing was greatly improved,
except those naturally resulting from the diminution of the subjective
noises. Hysterical deafness, like hysterical aphonia, is best treated by
the faradic current. Pruritus of the auricular canal is often benefited
by this form of treatment. In neuralgic otalgia the interrupted current
is very efficacious when applied by means of an intra-auricular electrode.
The incomplete anaesthetic effect of cocaine may be aided by the action
of the constant current. This cataphoric process is utilized in producing
anaesthesia of the tympanic membrane and external canal for slight oper-
ative procedures. The auricular canal is filled with a 10 per cent, solu-
tion of cocaine and a mild current allowed to pass for 5 to 10 minutes,
when amesthesia ensues. This same process has been utilized by some
with various drugs as a means of curing deafness, but I have had no
personal experience along these lines, and the results published are not
encouraging. The positive pole should be in contact with the fluid, and
the negative pole applied over the neck."
III. Ophthalmology.
PARALYSIS OF THK MTSCLES OF THK EVK.
This maybe cerebral or peripheral in character. For this paralysis,
galvanic currents are preferable. When the condition is thought to be
cerebral in origin, galvanization of the sympathetic should be resorted
to. Treatments of a half-minute duration are to IK? employed.
Bi.i.ni AROSPASM.
Galvanization or faradi/at ion is here indicated, for t hesame reason that
it is indicated in torticollis. Ptosis is to be treated in a similar manner.
APPLICATIONS IX THE SPECIALTIES. 135
CATARACT.
The Russian observer Crussel ' claimed t<> have obtained perfect suc-
cess in cases of cataract by the galvanic current. His method was to
introduce a needle into the lens, which was connected with the negative
pole, while the positive was applied to the tongue: in this way, the cata-
ract was subjected to mechanical disintegration by the needle, to the
chemical influence of the negative pole, and probably also to the macer-
ating action of the aqueous humor penetrating the lens, through the
puncture made in the capsule by the needle.
ELECTROLYSIS ix DISEASES OF THE LACRYMAL CANAL.
Lotine 3 reports a number of cases of disease of the lacrymal pas-
sages in which he successfully employed electrolysis applied by electro-
lytic probes, which were insulated along the greater part of their length
by a coating of the same material as that used to cover elastic bougies.
The particular portion of the probes so insulated could thus remain in
the canaliculus and the lacrymal sac, while the non-insulated part could
occupy the lacrymal duct. The techuic was as follows : After dilating
the canals and finding the stricture, the insulated probe, connected with
the negative pole, is introduced into the strictured portion of the lacry-
mal duct. Then the positive pole, wrapped in cotton, moistened in salt
solution, is held in the patient's hand or introduced into the correspond-
ing cavity of the nose. The resistance is gradually decreased for half a
minute until the current measures from four to five mi lliam pares. The
prol>e is then moved along the strictured portion, and the electrolysis is
continued for about five minutes as a rule. The size of the probe used
at first should correspond to that of the ordinary sound which just passes
the stricture. Later the size of the electric probe may be increased.
RETINAL AN.-KSTHESIA AND ITS TREATMENT BY VOLTAIC ALTERNATIVES.
Dr. L. Webster Fox * defines retinal anaesthesia as a functional disorder
characterized by reduction in acuity of vision and marked contraction
of the visual fields (30° to 55° in both vertical and horizontal meridians),
unaccompanied by reversal in the color fields. * * * * The treat
meut recommended is the daily application of a weak current of 1 or 2
milliamperes, the session being often minutes' duration. The indifferent
electrode is applied to the temple or nape of the neck : the active elec-
trode is applied over the eye or eyes. A convenient form of electrode for
this purpose is shown in Fig. 56. Improvement follows within a few
'Evetzky " OH the Nature of Cataract," New York Medical Journal, July, 1880.
'Roussky Vratch. May, 1904.
'Journal of the American Medical Association, January 7, 1905.
13G ELECTRO-THERAPEUTICS.
days, and recovery is rapid. Errors of refraction should be noted, but not
corrected until the cessation of electrical treatment. Voltaic alternatives
are defined as a series of sudden reversals in the polarity of the electrodes
of a voltaic battery, so as to produce an interrupted alternating current.
The reversals used were at intervals of two seconds. Twenty-eight cases
FIG. 56.— Adjustable eye electrode, for one or both eyes. Adjustable to any pupillary distance.
were treated with invariable benefit, the only return case being one of
progressing myopia, which was fitted with glasses before completion of
electrical course. The author asserts "eminent success in numerous other
lesions of the eye, vitreous opacities, retinitis pigmentosa, chorio-retinitis,
and choroiditis, treated by this method."
MISCELLANEOUS OPHTHALMIC AFFECTIONS.
Dr. W. Franklin Coleman1 details an extensive experience with the
use of electricity in ophthalmic practice, with the galvanic and sinusoidal
currents.
The cases seletted were very chronic and regarded as incurable ; and
in order that the results obtained could be ascribed to the current, t he-
diagnosis had been confirmed by confreres and all other forms of treat
ment avoided.
Prior to 1890, he employed the galvanic current of zinc-carbon ele-
ments, excited by a solution of potassium bichromate ; since that time,
however, he has used the Edison street current, controlled and measured
by the rheostat and meter of the ordinary wall plate.
The alternating or sinusoidal current was taken from a transformer,
he using 30 to 35 measured volts, and a quantity measured at 5 milliam-
peres. With a force of 30 volts taken from the direct current, and t he-
electrodes placed on the lids and nape <>f the neck, the meter registered 5
milliamperes, hence the same voltage from the alternating current and
the same resistance.
He prefers galvanism, in consecutive optic atrophy, because of the
existing exudates : while in primary atrophy, the alternate current would
1 Transactions of the Section on Ophthalmology of the American Medical Asso-
ciation, Boston, June 5-8, 1906.
APPLICATIONS IX THE SPECIALTIES. 137
appear more stimulating to the nerves. This can be shown by comparing
a thirty- volt current from the dynamo with a thirty- volt galvanic cur-
rent; the former is not unpleasant and causes a brilliant mosaic of dark
and light, while the latter causes no phosphenes, unless the current is
interrupted and the burning is so intense that it cannot be endured for
more than half a minute.
He summarizes his cases as follows :
Optic Atrophy. — Fourteen patients, 23 eyes. In 5 eyes in which
vision = light, 40 per cent, were improved, — one to seeing hand move-
ments and one to 20/67.
In 18 eyes in which vision = form, 64 per cent, were improved.
Four, 60 to 125 per cent. ; two, 300 per cent. ; three, 500 per cent. ; one,
1500 per cent. ; two from seeing fingers to reading. In six there was no
improvement.
Vitreous Opacities. — Seven patients, 12 eyes. In 5 eyes vision =
light, one improved to counting fingers at 6 inches ; one was unimproved.
In 12 vision = form ; 90 per cent, were improved ; seven, 40 improved ;
four, 20 to 100 per cent. ; six, 200 to 700 per cent.
.1 mhlyopia. — Seven patients, 10 eyes, all were improved. Four, 20 to
100 per cent. ; six, 200 to 700 per cent.
Sequels of Iritis. — Two patients, 4 eyes. All were improved; one
from light perception to 20/70 ; one, 100 per cent, ; two, 200 per cent.
Intra- Ocular Hemorrhage. — One eye, vision improved from light to
20/20.
Retimtis Pigmentosa. — One patient. One eye improved 100 per cent.;
one eye was not improved.
Itetinal Thrombosis. — One eye, vision was improved from fingers at
14' to 6.15 and 0.5 at 12 inches.
Sequela? Central Pet i nit is. — One patient, two eyes, no improvement.
Asthenopia. — Three eyes. Recovered.
Xanthelasma. — Two patients. Recovered.
Paresis of Ocular Muscles. — Two patients. One recovered and one
was much improved.
Alopecia of Lids. — One patient. Improved.
XiHitatitm. — One patient. Recovered.
Pterygium. — One eye. Xo improvement.
Thus, contrary to the contention of the erudite and lamented Noyes,
and •• most oculists'' (Burnett), electricity does seem to justify its claim
to usefulness in ophthalmic practice.
CHAPTER X
HIGH-FREQUENCY CURRENTS.
A COMPREHENSIVE study of high- frequency currents, the phenomena
connected with them, and their remarkable modes of application, has not
as yet been thoroughly mastered. Literature upon the subject is rapidly
increasing, but it is a perplexing matter, in the present state of our
knowledge, to discriminate between the good and the faulty. In present
ing the appended chapter on high-frequency currents, no attempt at
originality has been made ; on the contrary, difficulty was encountered in
selecting authoritative statements bearing on the subject.1
I. Historical Introduction.
The employment of high-frequency currents for the cure of disease
was introduced to the profession by D' Arson val. In 1842 Professor
Joseph Henry asserted that the discharge from a Leyden jar was oscillatory
in nature. Later Lord Kelvin, Helmholtz. and others confirmed the view
advanced by Henry.
In 1881 \V. J. Morton, of New York, published in the Medical Record
an article entitled "A Xew Induction Current in Medical Electricity."
In 1886 and 1887 Hertz and Lodge gave to the world a study, new in
conception and reasoning, that dealt with experimentation on electric
waves.
In 1870 Ward asserted that sparks generated by an induction coil
operated by a very rapid rotary interrupter were capable of giving 8000
interruptions per second.
In 1890 D' Arson val showed that beyond 5000 excitations per second,
the muscular contractions diminish in proportion to the increase in the
number of alternations. To support this assertion, he had made an alter-
nater capable of giving 10,000 alternations per second, and in April, 1 S!» l .
he indisputably demonstrated that a current of high frequency and
potential could be made to traverse the human body ; increasing the oxi-
dation consequent upon respiration, diminishing the excitability of the
tissues, and lowering arterial tension.
In 1893 Oudin devised the " resonator ;" but it was Tesla who, in
1891, aroused greatest enthusiasm by the employment of altei naters with
1 Although of late I have largely employed currents of high frequency, I have not
hesitated to avail myself of the excellent work on " High-Frequency Currents in the
Treatment of Some Diseases," by Chisholm Williams, published by the Rebnian Com-
pany, New York.
138
HIGH-FREQUENCY CURRENTS. 139
a multiplicity of poles, and, by the introduction of transformers, he was
enabled to increase the potential to an almost incredible number of volts,
making possible the assertion and proof that high-frequency and high-
potential currents could be made to pass through the human body, with
sufficient energy to light up several incandescent lamps, without the
slightest danger to the person through whom the currents were passing.
II. Principles and Apparatus.
The nature of a discharge is dependent upon the character of the
electro -motive force producing it, and likewise upon the manner of dis-
charging it. Thus, when a ball prime conductor of a static machine is
made to discharge, the discharge occurs in a disruptive manner, consist-
ing of a series of discharges between the ball and the object at which
it discharges. When a condenser, as a prime ball conductor, charged
FIG. 57.— Oscillatory nature of the Leyden jar discharge.
with a very high potential, is discharged into a conductor having a cer-
tain self induction and a slight resistance, there result extremely rapid
isochronous oscillations, constituting the so-called high-frequency cur-
rents. Hertz showed the frequency of these oscillations to be hun-
dreds of millions per second. The alternations of a Ruhrnkorff coil
are about 200 per second, with an electro-motive force of from ten to
two hundred thousand volts, while the alternations of the high-frequency
currents are from 100,000 to 1,000,000 volts, depending upon the means
employed.
The current is obtained from the main, bichromate batteries or from
an accumulator. A Ruhmkorff coil is required to transform the current
to one of high tension. The interrupter employed may be the motor-
mercury interrupter, or the Wehnelt or turbine break. The alternating
current generated by the coil must be transformed by the condenser into
a high-frequency current. The condenser consists of two Franklin plates,
enclosed in a flat box, whose exterior exhibits the small solenoid and the
spark-gap with connecting screws. Another construction is where two
Leyden jars are placed behind the spark-gap, and under a bell jar to
140
ELECTRO-THERAPEUTICS.
dampen the sound. Two conductors arising from the outer tin-foils
of the Leyden jars end in two terminals, between which a third is inter-
posed. As is well known, the vibrations from a Leyden jar are oscilla-
tory in nature (Fig. 57). Where general D' Arson valizatiou is required,
the large and small solenoid are joined to this terminal.
The following are the principal and most widely used varieties of
high-frequency current apparatus :
Morton's ....
D'Arsonval's
Tesla's . .
Oudin's..
high-frequency apparatus.
f resonator and
I its varieties.
MORTON'S "STATIC INDUCED CURRENT" HIGH-FREQUENCY APPARATUS.
The modus opemndi of Morton's1 apparatus is as follows : The pat in it
is directly in circuit with the outside coatings of two Leyden jar con-
densers iu series (Fig. 58). The spark-gap and machine are in multiple
FIG. 68.— Morton's "static-induced current" high-frequency apparatus.1
with each other. With the patient included in circuit in the manner
shown in the diagram we do not know the value of the inductance and
resistance offered by him. The arrangement of two condensers of small
capacity is conducive to the production of oscillatory currents of rela-
tively high frequency, and such currents will be produced if the patient
offers a sufficiently low resistance and inductance.2
'.Journal of Advanced Therapeutics, January, 1903.
2 For a detailed account see articles by Dr. W. J. Morton in The Medical Uecnrd.
pp. ::ti")-371, 395-398, 438-440, April 2, 9, and 16, 1881 ; and pp. 97-104, January :M, 1MM.
HIGH-FE I :Q I I : N < V CUEREXTS.
141
D'ARSONTAL HIGH-FREQUENCY APPARATUS.
In the D'Arsonval apparatus1 (Fig. 59) the terminals of the second-
ary of an induction coil are respectively connected with one terminal of
each of two condensers. A spark-gap is placed across the secondary
li
INDUCTION COIL
In
FIG. 59.— D'Arsonval high-frequency apparatus.
circuit. The other two terminals of the condensers are connected with
the ends of a short coil of a few turns of thick copper wire. One elec-
trode is connected with one end of the short coil and the other electrode
is adapted by a sliding contact to include in circuit with the patient any
desired length of the short coil, and thus regulate the effect produced
upon him. A straight rod, or tube, of copper may be substituted for the
'In Comptes-rendus, vol. cxvi., 1893, pp. 630-633, D'Arsonval (quoted in the
Second Report of the Committee on Current Classification and Nomenclature, and
read before the American Electro-Therapeutic Association, September 24, 1903) stated
in substance (a) that he had communicated to the Societe de Biologie, February 24 and
25, 1891, the "astonishing fact" that when the frequency of a current was very great
excitation of the nerves and muscles was not produced ; (b) that the sparking distance
— and therefore potential difference — between conductors connected with the ends of
the short, thick wire coil was greater than at the spark-gap across the secondary ter-
minals of the induction coil ; (c) that a very strong oscillating, high-frequency current
was produced, sufficient to raise a one-ampere incandescent lamp to a white heat when
in series with two persons completing the branch circuit between the terminal of the
thick wire coil ; (d) and that he had been able to generate in a branch circuit, includ-
ing his own body, a current of more than three amperes without any other effect than a
sensation of heat in the hands.
142
ELECTRO-THER APEUT I ( S.
short coil to increase the frequency of the current, by diminishing the
inductance. A static generator may be substituted for the induction coil.
Currents of exceedingly high frequency are produced by the D' Arsonval
apparatus. When currents of much higher potential are desired they can
be obtained from a fine wire coil of relatively many turns, inclosed in a
glass tube filled with petroleum, and inserted in the thick wire coil.
That the frequency must be exceedingly high is proved by an experi-
ment made by Dr. Sheldon. In place of the induction coil for producing
the spark at the gap, he employed a Holtz machine.
TESLA'S HIGH-FREQUENCY APPARATUS.
This is described by its author as follows : ' ' The writer's experiences
tend to show that the higher the frequency the greater the amount of
I
Fio. 60.— The Tesla transformer.
electrical energy which may be passed through the body without serious
discomfort • * * * * By taking the globe of a lamp in the hand,
and by bringing the metallic terminals near to or in contact with a con-
ductor connected to the coil [that is to say, connected to one terminal of
the secondary of an induction coil whose primary is energized by an
alternating current of very high frequency], the carbon is brought to
FIG. 61.— Diagram of the Oudin resonator. The Tesla coil is omitted. The current from the
induction coil is connected with the inner tin-foil of the Leyden jars. The outer coat of one Leyden
jar is in connection with the resonator, and is also grounded. The outer coat of the other Leyden jar
is connected to the handle, H, which, by a sliding movement either in the vertical or the horizontal
direction, decreases or increases the amount of winding of the resonator, if is the spark-gap for regu-
lating the amount of current.
FIG. 62.— The Oudin resonator and Tesla coil, with electrode. (Biddle.)
FIG. 63. — Glass electrodes. This set of electrodes has been especially designed for convenience in
changing from one electrode to another. The hard-rubber handle is made very long and provided
with a universal socket in which any of the electrodes may be fastened or loosened by merely moving
the ring upon the sleeve which holds the stem of the electrodes.
IIMrH-FREQUK.M V < TIMJENTS. U:J
bright incandescence and the glass is rapidly heated. With a 100-volt
10 c. p. lamp, one may without great discomfort stand as much current
as will bring the lamp to a considerable brilliancy ; but it can be held in
the hand only for a few minutes, as the glass is heated in an incredibly
short time.''1
In Tesla's apparatus (Fig. 60) the inner tin-foils of the Leyden jars
are positively and negatively charged from the secondary terminals of the
Iiiihmkorff coil. The outer foils are in connection through the primary
winding of Tesla's transformer, as is shown in the illustration, and through
the spark-gap. These high-frequency alternating currents induce alter-
nating currents in the secondary coil, combining high frequency with
high tension.
Tin: Ounix RESONATOR. (Figs. 61, 62.)
Although Hertz had previously employed the phenomenon of reso-
nance in his experiments, it is to Dr. Oudin that the resonator owes
its introduction into electro-therapeutics. The apparatus consists of a
laruv solenoid of uninsulated copper wire of medium thickness, wound
spirally about a vertical cylinder of well paraffined wood. The length
of the wire employed varies from 45 to 60 meters, and its diameter from
2.5 to 3 millimeters.
It makes 50 or more turns about a wooden cylinder, 40 to 50 cm. in
height and 30 cm. in diameter; while the distance between the spirals is
about 8 millimeters.
GLASS VACUUM ELECTRODES. (Figs. 63, 64. )
These consists of glass tubes of various shapes and sizes, which offer
a barrier for retarding the entrance of high-frequency currents to the
part being treated. Tesla's electrodes have as a resisting medium the
rarefied air contained within them. Those of Dean are made up of a
series of pieces of thick, hollow glass, in which there is a very high
vacuum. The glass is sufficiently thick to prevent sparking, thus pre-
serving the integrity of the vacuum. If the finger be approached to one
of these glass electrodes when connected to the apparatus, a violet brush
discharge will be observed between the glass and the finger. This dis-
charge is produced at the outer side of the tube by induction. The bet-
ter the contact between the glass and the skin, the less will be the amount
of brush discharge and of heat produced. The glass tube electrode with
'Transactions, American Institute Electrical Engineers, vol. viii. pp. 267-319,
New York. May I'O, 1891 ; and Journal, Institution, Electrical Engineers, vol. xxi.
pp. 51-163, London, February 3,1892 ; article on Phenomena of Alternating Currents
of Very High Frequency, published in the Electrical World, vol. xvii. pp. 128-130,
Xc\\ V.u-k, February 21, 1891.
144
ELECTKO-THEKAPEUTK'S.
partial vacuum becomes luminous from the discharge of the Current
through this vacuum, which acts as a conductor: the luminosity of the
WAITE & BABTLETT M'F-C Co.
FIG. 64.— Piffard's glass electrode.
gas is due to its incandescence and tends to heat the glass wall of the tube,
and these tubes occasionally crack from this cause.
CATAPHORESIS ELECTRODE.
The cataphoresis electrode made by K. Schall is most useful for
applications to large areas, such as the abdomen, chest, and back. It has
a diameter of 8 inches, and consists of an aluminium disk over which is
stretched a sheet of parchment.
Dr. William J. Morton, of New York, long ago found a deficiency
in vacuum tubes for phoric action, for high-frequency currents. He
remarks : "A deficiency of all such electrodes is that the bulk of the
current passes at the periphery of the flat disk. To obviate this I have
•elongated the entering metallic conductor to the region of the flat sur-
face and have made it a sharp point.
" Again, if desired, I attach a thin metallic plate of tin-foil or other
metal upon the outer side of the glass upon its flat side. The diameter
Tin fa" c.nO«n»r pUt.
Fio. 65.— Morton's cataphoric electrode. (Waite & Bartlett Manufacturing Co.)
of this plate is considerably less than the diameter of the circular and
flat surface of the electrode (Fig. 65).
u As now arranged the current's action is concentrated to this Hat
surface of the electrode and the cataphoric action is correspondingly
HIGH-FREQUENCY CTKKENTS. 145
enhanced. But the tiu-foil adds to the pain ul' tlie application, and I
prefer to use the sharp-pointed electrode without the tin-foil condenser."
Other varieties of electrodes are the condenser (vide Fig. 61, CE,
supra) and the brush or effluve.
An effluver or electrode for applying high-frequency currents con-
sists of a piece of metal, generally cylindrical in form, having on its
upper surface a series of fine points, from which the discharge jumps to
the patient. The character of the effluve may be modified by the type
of effluver used: the greater the number of points, the more thinned will
be the effluve (vide Fig. 07, infra).
III. Physical Properties.
A. INDUCTION EFFECTS.
B. ELECTRO-STATIC EFFECTS.
C. DYNAMIC EFFECTS.
D. RESONANCE EFFECTS.
A. INDUCTION EFFECTS.
Induction effects are most intense in their action, as the apparatus
giving rise to them is of a potent nature. Induction is the effect of an
electro-magnetic flux on a neighboring body susceptible of an induced
magnetic saturation, the intensity of the electro -motive force being pro-
portional to that of the rate of variation of the magnetic changes or
multiplied by the frequency. Therefore, upon the human body, one
may bring about a high frequency and a low tension equal to that of a
high tension, and low frequency on the same or equivalent mass.
B. ELECTRO -STATIC PROPERTIES.
Most high-frequency apparatus is so constructed as to permit of the
production of physical phenomena analogous to the modern static
machine. For, if we connect the two ends of the short solenoid to two
plates of insulated metal which are separated from each other, a power-
ful electro-static field will be created ; which can be demonstrated by
bringing a Geissler tube between them, when a glow will be manifested,
as though attached to the terminals of an induction coil. If a similar
plate of glass, covered on either side with tin-foil, be interposed, and
each side have attached to it a wire to which an electric lamp is fixed,
it will be seen that the filament will glow ; proving the presence of
electrical waves proceeding from an electro-static field.
C. DYNAMIC PROPERTIES.
This is proved by the ease with which these currents circulate in an
open circuit. Imagine a conductor connected to a high-frequency appa-
ratus by the two poles, and in the middle of this conductor a piece of fine
10
140 ELECTRO-THERAPEUTICS.
wire of high resistance be interposed ; circulate the currents and the wire
will glow and perhaps fuse. If sealing-wax is employed to couple the
wires, the current will jump from each wire, producing sufficient heat to
fuse the wax.
D. RESONANCE.
A resonator is an accessory to the apparatus, whose purpose is to
augment the tension of the current and to create in the vicinity a more
powerful electro-static field. When two bodies vibrate in unison they are
said to be syntonous. The Hertz resonator is one of low resistance and
capable of giving very rapid oscillations, it is likewise of small capacity
and self-induction. It consists of an induced current formed by a length
of copper wire so bent as to form nearly a circle, but having two balls at
the extremities where they are brought near one another.
This resonator is brought into the field of another vibrator and tuned
in syntony with the latter; as soon as the resonator is put in action,
Hertz's resonator will emit sparks from the two balls. All the other
resonators are founded on the above principle.
IV. Methods of Application.
There are four chief methods of applying high frequency currents,
as distinguished by D' Arsonval :
1. Direct application or by derivation.
2. Indirect application or auto- conduction by the solenoid.
3. An to- condensation (Apostoli).
4. By local application.
1. DIRECT APPLICATION.
Connect the patient by two large handles to the ends of the small
solenoid. The currents will pass through him by derivation ; for by
virtue of the phenomenon of self-induction, the solenoid offers a uivat
resistance, which can be proved by interposing an incandescent lamp in
the circuit, when it will glow. If the connection between the patient's
skin and the handles be defective, small sparks will be observed to pass.
To increase the area of penetration, connect some part or member of the
patient to one end of the small solenoid, and the other end to a metallic
plate in the water of the bath, near, but ndt in contact with the skin.
If the contact be imperfect, small ulcers may result. With powerful
installations, when the handles are used after prolonged electrification,
and with 500 or more milliamperes, heat and tingling may be experienced
in the hands and arms. The above methods are termed stabile or
bi-polar.
HIGH-FREQUENCY (TKKEXTS. 147
Iii the labile method, a fixed electrode connects the patient to the
solenoid. The other end is manipulated by the physician, who, with an
insulated handle, is enabled to apply its electrode end to the desired part
In approaching the skin with the insulated electrode, sparks appear, and
the momentary contact produces an erytheinatous flush.
The stances should be brief. In systemic affections begin with a
lew minutes' direct auto-condensation or auto-conduction every day.
Note any subjective symptoms. If the dosage has been in excess, the
patient experiences a feeling of fatigue. The D' Arson val milliampere-
meter should be employed, the range of which should extend to 700
milliamperes.
In the local treatment we observe that a reaction is produced at the
time and continues for some hours thereafter. Thus, in a patch of lupus
vulgaris, a glass electrode of low resistance connected to the free end of the
resonator and placed in actual contact with the patient would be used,
and by a judicious choice of the number of spirals called into play, the
discharge is reduced to almost nil. After an application lasting five
minutes, the part feels hot and looks inflamed. The warmth increases
until the sixth hour, but by the following morning has entirely dis-
appeared. The inflammation, however, has persisted. After a few
seances the patch dries up and scales, but the pigmentation remains.
The treatment may be applied once or twice daily for two weeks,
then once daily, or every other day, for the same period, reducing the
imml)er of applications week by week.
An acute pain, produced by disease, will be augmented at the com-
mencement of energetic treatment. Defective contacts between the
patient and the apparatus, or in the apparatus itself, may cause
unpleasant sensations or shocks.
L'. AUTO-CONDUCTION BY THE SOLENOID.
By this method (Fig. 66) the patient is not in actual contact with the
solenoid; his body becomes saturated in the field of the current, — L e.,
sparks may be drawn from him. If a lamp of 20 volts be used to close
the circuit of a single coil of thick wire, it illuminates with a bright light
at a distance of more than three feet.
Place the patient in a large solenoid, and have him join his arms so
as to form a circuit, which is completed by an incandescent lamp, the
terminals of which communicate with the hand. The lamp is lighted
with the induced current in the circuit thus formed. Any conducting
body placed in this field becomes influenced with induced currents, and
if a single copper wire of one turn is introduced, the induction produced
in the latter will be sufficient, to light up two lamps of 110 volts mounted
in series.
148 ELECTRO-THKIJ A I M; I I I ( S.
3. AUTO-CONDENSATION.
In this method the patient is attached to the solenoid in the usual
way, but the other end is attached to a large metallic plate, brought near
the patient, but insulated from contact with him. Thus the metal
plate and the body of the patient form the armatures or coatings of a
condenser arrangement, having a large electrical capacity, which is
charged and discharged as the potentials at tin- extremities of the sole-
noid vary. The patient lies upon the insulating cushions of the couch,
the current passing to him either by a handle of bare metal held in the
hand, or by an electrode applied to the desired part.
4. LOCAL APPLICATIONS.
These are especially applicable in the form of brush discharges
(Fig. 67). Potentials as high as possible are required for these discharges.
This may be accomplished by employing a secondary coil, which is oil
immersed, or air insulated. In 1892 Oudin devised his resonator, made
of an open solenoid of wire, which could be connect eel as an extension of
one end of the solenoid of a high-frequency apparatus, and served, when
carefully adjusted, to raise the potential to such an extent that a long
brush discharge could be obtained from its free extremity.
V. Physiological Properties.
Currents of high frequency and high potential produce no action on
sensory or motor nerves. When a person or a number of persons are
placed in the external circuit, and there are interposed incandescent
lamps of 125 volts, one ampere, the filaments will light up. without pro-
ducing sensations in the persons in the circuit. With more intense cur-
rents, only a slight sensation of heat will be perceived at the point of
entrance and exit.
H. Lewis Jones controverts the assertion, maintaining that if the
current in each lamp had been three amperes, it would certainly have
destroyed life, whether the direct or the alternating cm-rent had been
employed.
It has been argued that the incandescence occasioned in the lamp
is caused by the increased resistance; in the filament of the lain]), due to
the very high frequencies, and that a smaller cm-rent at a proportionately
high voltage will make it glow.
Another theory advanced to account for this phenomenon, is that the
rushes of current are very considerable while they last, but their dura-
tion is so very brief, that the total current passing in a given time is rela-
tively small. Others maintain that a molecular bombardment, rather
than an electric current, is really the energy dissipated. D'Arsonval
Auto Conduction Caee
FIG. 66.— Treatment by auto-conduction. S S, secondary terminals of induction coil ; B B,
cords to the auto-conduction cage from the Oudin resonator: /, ,7, Leyden jar; I). < >/., spark-gap;
when sliding in the direction " D," the current suffers a loss in intensity, and vice versa.
FIG. 67.— Treatment by the effluvation method. The condenser electrode, B, is in connection
with the top of the resonator. Patient is seated upon an insulated platform, holding the electrode, A,
which is the other pole, from the outer side of the Leyden jar, L J. ( By grounding the outer side of the
Leyden jar, A, the patient's insulation is unnecessary and better effluvation is attained.) S. M. is the
spark-gap.
HIGH-FK Kg I" K X < ' V < T I! UK N TS. 149
affirms that currents of ten times less intensity would be extremely dan-
gerous it' the frequency were decreased from 500,000 to 1,000,000 per
second, to 100. Tesla inclines to the belief that the harmlessiiess of these
currents is due to their lack of penetration of the body at the point of
contact of the electrodes, but that the current traverses the subject in a
path perpendicular to the skin and equally over the entire surface.
])' Arsonval declares that motor and sensory nerves are so constituted as
to respond to vibrations of a certain frequency, studying the phenomenon
of nenro-muscular excitement when one increases the number of electrical
vibrations indefinitely. He has demonstrated that the waves (each of
which produces a muscular shock if sufficiently distanced) no longer
produce the same effect if there is an augmentation of their number in
certain limits per second. Gradually there is a fusion of the contrac-
tions, which ultimately results in a tetanized condition. In order to
arrive at this condition, twenty to thirty excitations per second are
required. The muscle being tetanized, if the number of waves be
increased, the phenomenon of neuro- muscular excitement is increased
equally till a maximum is reached, which corresponds to 2500 or 5000
vibrations per second. From this moment the excitation decreases as the
number of vibrations per second increase.
IV Arsonval regards these currents as inhibitory in nature, because
of the local anaesthesia occurring at the point of entrance of the current,
which lasts from one to twenty minutes ; and also that the excitability of
the body to other stimulation is decreased under the influence of these
currents. He has likewise observed a fall of arterial tension in the dog,
and lastly, that the sensibility of the skin to galvanism and faradism is
materially decreased after the passage of high-frequency currents, although
a greater strength of the former currents can be tolerated, than before
electrification.
VI. Applications in Various Diseases.
TUBERCULOSIS.
Mr. rhisholm Williams' advocates the employment of high-fre-
quency currents in phthisis. In a series of forty-three cases, he found
that by the use of these currents there was a marked improvement in
weight, appetite, and digestive power. For a time the temperature
became elevated, and the tubercle bacilli in the sputum increased in
numbers. Later the temperature dropped to normal, the bacilli
decreased, and the patient's general condition was materially improved.
In 1903 thirty-nine of the forty-three patients were alive, and in one
instance the disease appeared entirely arrested. Dr. H. E. Gamlen*
1 British Medical Journal, October 12, 1901, and October 24, 1903.
-' Archives of the Rontgen Ray, January, 1906.
150 ELECTRO- T 1 1 1 •: 1 I A I ' !•: UTICS.
likewise reports excellent results, by the use of high-frequeiicy currents
in tuberculosis. Dr. Alfred Goss1 remarks : "By the method described
I have treated in the past two years a little over two hundred cases, but
on account of failure to keep my records accurately previous to June 1,
1905, I report my cases from that time, and will merely state in regard
to the previous cases that I had forty-four cases out of eighty recover
within a period of six months. Since June 1 I have one hundred and
seventeen cases recorded, with thirty-eight absolute recoveries so far as
after repeated examinations no tubercle bacilli showed in the sputum.
They regained their weight and ran a normal temperature. They have
since been living in various sections of the country and still remain well,
performing their usual avocations. • '
GOUT.
In this disease high-frequency currents alone, or in combination with
other forms of electricity, have been employed. When used alone, auto
condensation and auto- conduction have been chiefly employed. These
currents must not be applied during an acute paroxysm. Low intensity
and brief duration of seances should first be used, and they should be
progressively increased. The treatment should be continuously applied
within short intervals for several months.
RHEUMATISM.
This affection has been successfully treated by daily applications
of high-frequency currents by means of auto-condensation, seances of
ten minutes' duration. At the end of seven weeks the urine was normal,
treatment was stopped, pain ceased, appetite returned, and the patient
regained his natural sleep. In the seven weeks of treatment, his weight
increased 6J pounds. In chronic rheumatism the greatest benefit is
derived from high-frequency currents. The same statement is vouched
for by Gamlen.1
OBESITY.
Foveau de Courmelles was the first to study the effect of high-
frequency currentvS on this condition. Boiuet and Caillol de Poney'
published a report of a series of cases where the decrease in weight aver-
aged 14 pounds per month. All of these cases were treated by auto-con-
duction. In this class of patients, urinary findings show an increased
excretion of u rates and phosphates.
1 Medical Record, June 9; 1906.
'Ibid.
88oc. de Biologie, July 31, 1897.
HIGH-FREQUENCY < TUKKXTS. 151
HYSTERIA.
In these cases the patient gains in general condition, in weight, etc.
The improvement noted is about on a par with the Weir-Mitchell rest
cure. In sciatica, neuralgia, tabes dorsalis, and chorea, Gauileu has
achieved excellent results with high-frequency currents.1
LUPU8 YULGARIS.
It would appear that high-frequency currents in this disease behave
in a manner similar to the X-rays or the Fiuseu light. Williams reports
that twenty applications of five minutes each, over a period often weeks,
suffice to clear up any non-ulcerated small patch of lupus. The effluve,
the high-vacuum glass electrode emitting X-rays, or the ordinary glass
electrode may be employed.
RODENT ULCER AND MALIGNANT DISEASES.
In rodent ulcer the effluve can be readily and advantageously ap-
plied. In an interesting case of that disease, Williams records how he used
his thumb as an electrode, the patient being on the auto- condensation
couch, and connected to one pole ; the other was connected with the
operator, and the circuit completed by the latter' s thumb on the ulcer.
At the end of the first three applications the dry serum became attached
to the thumb; each additional application seemed to shrink more of the
ulcer. The hard edges, so resistant at first, disappeared, and for eleven
months there has been no evidence of a return. The applications are
painless. Relapses are extremely rare. In 1901 Dr. Allen, of Chisle-
hnrst,2 published an elaborate report of malignant disease treated with
high -frequency applications. The results he obtained were most encour-
aging, some apparent cures being recorded.
TILES, RECTAL FISSURES, AND PRURITUS ANT.
In all three of these conditions, high-frequency currents have proved
most efficient. A special electrode, consisting of a stem with a bare con-
ical metallic extremity, is employed. Doumer has reported 26 cases of
hemorrhoids, with more or less successful results. Benefit is most pro-
nounced in recent acute cases, with marked structural changes. Mr. F.
J. Bokenham 3 offers a summary of results obtained in two years and a
half, with currents of high frequency, in the treatment of hemorrhoids,
rectal fissures, and pruritus ani. The number of cases treated was 118.
He records 52 as completely cured, 37 as greatly relieved, 18 were
improved, and the remaining 11 he pronounces failures. He prefers to
1 Ibid.
Mfdieal Electrology and Radiology, vol. v., page 43.
3 Lniu-et, July '2. 1904.
152 ELECTRO -THERAPEUTICS.
employ high-vacuum glass electrodes. With metal electrodes he uses a
curreut of 450 to 500 niilliainperes ; with glass electrodes, 100 to 150
milliamperes. Duration of each seance about 5 minutes ; he believes
that no one treatment should ever exceed 15 minutes in duration.
COLITIS.
Shenton * remarks that a valuable use of high-frequency currents
consists in their beneficial effects in mucous and ulcerative colitis. In
the first case reported by the author, the abdomen was exposed almost
daily to weak X-rays for a month, but without effect. High-frequency
treatment was then given on the condenser couch, for a period of ten
minutes through the hands, followed by a fifteen-minute local applica-
tion, sometimes from the low tension and sometimes from the resonator.
This resulted in improvement of the general condition, and gradually the
diarrhoaa, hemorrhage, and pain diminished. The treatment was con-
tinued nine months and resulted in complete cure. Seven other cases
subsequently treated, resulted in improvement in the general health,
increase in weight and appetite, and improvement in sleeping. In all of
the cases but one, the results were considered satisfactory.
Hahn2 used the high-frequency currents by means of a special nasal
electrode in the treatment of ozaeua. Bordier and Collet in 1902 applied
high-frequency currents in the treatment of ozsena, and since then Hahn
has used this method in seven marked cases of the disease. He used an
Oudin resonator with an electrode similar to that used by Bordier and
Collet, namely, a metallic rod covered with paraffin or wax, and placed
in an insulating handle. The electrode may also be enclosed in a glass
tube, which allows only the tip to project. Care must be taken to apply
the effluvia to every part of the affected mucosa. The smaller the sparks,
the less irritation and reflex action will there be. No cocaine or
adrenalin was needed before applying the high-frequency current, but
the patient sneezed a few times after the current was turned on, com-
plained of burning, slight pain, and lacrymation. But these symptoms
vanished in two or three minutes if the application was continued.
After three minutes the electrode was withdrawn and the patient was
asked to blow his nose, when all the crusts usually came away at once.
The stance was repeated in from seven to forty-eight hours, and lasted
usually about fifteen minutes, although it can be made twice as long with
out harm. No other treatment, not even irrigation, was used. While the
author does not allege absolute cures in his seven cases, the improvement
'Archives of the Rontgen Ray, August, 1905.
*Gazzetta degli Ospedali, delle Cliniche, March 5, 1905.
HIGH-FREQUENCY ( TRRKXTS. 153
was very marked indeed, and the mucous membrane in some cases
assumed a more normal aspect. In all cases the crusts disappeared and
the odor Mas removed, while the subjective symptoms, including the
headaches, were almost abolished. He believes that high-frequency cur-
rents have an antiphlogistic and resolvent action upon the mucosa of the
nose in ozaeua.
EPILEPSY.
The following detailed reports of the clinical application of high-
frequency currents represent some of the more advanced views on the
therapeutic value of this agent.
Concerning the treatment of epilepsy, Dr. Samuel G. Tracy ' says :
' ' The galvanic and faradic currents of electricity have been used in
former years, but with little success. If Hughlings Jackson's theories
regarding the nerve system are correct, it is reasonable to suppose that
high-frequency, high-potential electric currents will have a beneficial
effect on the nerve centres, and indirectly on epilepsy.
"As a rule each patient should be treated every other day, first
receiving X-radiatiou from 5 to 10 minutes from a high tube. This is
placed about 6 to 10 inches above the head, so that the rays strike
directly upon the anterior and occipital part of the brain (Jackson's
centres of high level). After the X-radiation the patient should be sub-
jected to the influence of a high-frequency current, applied over the brain
for 10 minutes, and for 5 minutes over the spine. In this manner I have
treated the different forms of epilepsy, but I found the best results were
obtained by using the combined treatment of X-radiatiou and high-fre-
quency currents with small doses of bromides. By this latter method at
least 25 per cent, of cases of petit mal may be considered tentatively cured,
20 per cent, of Jacksonian epilepsy, and 12 per cent, of grand mal. All
cases were improved more or less, not only in regard to the frequency of
the epileptic seizures, but also in regard to their severity. In addition to
this the general mental and physical condition was very much improved.
As these experiments have been continued for less than a year, sufficient
time has not elapsed to say how much permanent value there is to this
method of treatment. Nevertheless, such progress has been made in the
cases treated that I believe we are on the right road to get the best
results in the treatment of epilepsy.
ikl am inclined to believe that the high-frequency currents have
some chemical effect on the bromide, possibly liberating a larger quantity
of the bromide as the solution of the salt circulates in the brain, and thus
the drug in smaller quantities has a more pronounced therapeutic effect
in controlling the epileptic sei/Aires."
1 New York Medical Journal, March 4, 1905.
154 ELECTRO-THERAPEUTICS.
SKIN DISEASES.
Dr. Charles \V. Allen1 reports 175 cases of various skin diseases
treated siuce November, 1901. In chronic eczema he has found the dis-
charges of vacuum electrodes of decided value in alleviating symptoms
and in diminishing infiltration. In herpes zoster of the thigh and arm
with hyperaesthesia and neuralgic pain, not only has temporary relief
been afforded immediately after each application, but the whole course
of the disease has been shortened and the lesions have promptly healed.
General effluviatiou with metallic pointed electrodes, the so-called
11 feather-duster" brush, seems to diminish the pruritus, to shorten the
attack, and decrease the duration of the entire course in subacute and
persistently recurring urticaria. Dr. Allen believes that high-frequency
currents are of decided advantage to those treating skin diseases, in
conjunction with other measures. They are curative of themselves in a
restricted class of cases and efficiently meet pruritic symptoms ; but these
currents are inferior to the X-rays in skin diseases, the best work being
accomplished when they are used conjointly, as I have frequently seen.
TRACHOMA.
In the treatment of trachoma, Stephenson and Walsh2 believe a prom-
ising field has been opened as a result of their work with the X-ray
irradiation and the high-frequency current.
In one case, after 22 applications by the high-frequency current a case
of trachoma was apparently cured. A 12-inch spark-coil (Cox) was run
from the main connection with a D'Arsonval high-frequency apparatus.
One end of the solenoid was earthed, while the other was connected with
a vulcanite electrode, with which the closed eyelids were gently massaged.
A small brush discharge of about half an inch was obtainable from the
electrode, which would probably have acted upon the trachoma equally as
well without actual contact of the electrode with the lids. So far as can
be ascertained, this is the first application of. the high-frequency current
to the eye. By this means, as with the focus tube, more improvement
has been effected than could have been expected from the prolonged use
of escharotics.
DULNESS OF HEARING AND SUBJECTIVE NOISES.
Dr. ,T. G. ConnaP says in reference to dulness of hearing and the
occurrence of subjective noises : "The cases were of a class not readily
influenced by ordinary methods of treatment. The types selected were :
(1) chronic dry catarrh of the middle ear with secondary labyrinthine
1 Medical Record, February 20, 1904.
* Medical Press and Circular, No. 7; Progress of Medical Science, 1903.
'Journal of Laryngology and Rhinology, August, 1904.
HK i H-F 1 1 K( v> r i •: x < • v r r KKEXTS. i .*,.-,
involvement ; (2) chronic dry catarrh of the middle ear without marked
labyrinthine involvement: •"> ^clerosis of the middle ear; (4) post-
suppurative conditions of the middle ear (the purulent process having
ceased ). leaving a cicatrix or a dry perforation with or without cal-
careous deposit in the tympanic membrane ; (5) primary labyrinthitis
; traumatic); (6) tinnitus without duluess of hearing. In all the cases
both ears were involved, one ear generally being worse than the other.
Results : 1. Six cases. Xo improvement in the hearing of any of
them. In four the tinnitus persisted ; two thought the noises were slightly
lessened, but were not at all certain. 2. Fourteen cases. In ten, no
improvement in hearing; one was worse ; two noted a slight improve-
ment in the hearing. One patient said she heard much better, but the
improvement was not appreciable by the tests applied. Of the ten
patients who complained of tinnitus, eight reported an improvement ;
two of these said they were very much better. In one case the noise dis-
appeared entirely in one ear for six weeks, when it recurred. 3. Five
cases. One patient said she heard better, but did not respond to tests ;
four reported an improvement in the hearing, confirmed with the watch,
and improvement in the tinnitus. 4. Seven cases. Four reported a
slight improvement in hearing, and four or five who had tinnitus reported
improvement. 5. One case. No benefit. 6. One case. No benefit.
The author urges the importance of techuic in the electrical treatment of
these cases. The common method of applying the current is by means
of the effluve (spray). This method was adopted in the earlier cases,
but was found unsatisfactory. The method of using a condenser elec-
trode in each ear was substituted and gave better results, probably
because the cm-rent is more completely concentrated on the ears.
GONORRHCEA.
Gamlen l treated a rebellious case of gonorrhoea by high-frequency
currents, by means of a bougie connected with the terminal on the top of
the resonator. At the same time, general high-frequency currents were
administered. Sixteen of these combined treatments effected a cure.
Local treatment was given every second day; duration of each treatment
was five minutes. He also mentions the case of a young woman, with a
history of gonorrhoea of three weeks' duration. The usual medicinal
treatment proved futile; high-frequency treatment was instituted and a
vaginal glass electrode was employed. "After the first few applications,''
saysGamleu. "the irritation, and later the discharge, gradually subsided.
Fourteen applications effected a complete cure."
1 Archives of the Rontgen Ray, February, 1906.
PART II
THE RONTGEN RAYS IN DIAGNOSIS
Historical Introduction.
THE discoveries made and the achievements wrought in the domain
of electricity are the recorded efforts of determined and conscientious
minds of all ages. From the remotest periods of the world's history the
mysterious phenomena of electricity have arrested attention and invited
thought from searching inquirers, and slowly but surely the hidden
secrets of this subtle force of nature have been steadily unfolded, until
to-day the mighty achievements ascribable to it confront us on every side,
offering a telling contrast to the methods pursued a few centuries ago,
when men with crude appliances and still cruder ideas led the van in ex-
perimental inquiry.
To Otto von Guericke, the world owes a debt of gratitude for his
successful labors in inventing, in 1650, the air-pump and in ingen-
iously applying it to the laws of science. In 1740 Abbe Nollet em-
ployed the air-pump and continued the studies commenced by von
Guericke. It remained for Sir W. Snow Harris, in 1834, to formulate
boldly the statement, that the length of the spark which an electric
machine will give in the air varies as the inverse ratio of the pressure of
the gas.
In 1838, the immortal Faraday challenged the world' s admiration
with his experiments in electricity, and simultaneously his celebrated
confrere, Heinrich Geissler, made memorable that scientific epoch, by im-
proving on the efforts of Faraday in his study of electric glow discharges.
The principles of and the laws governing electric science were being
surely evolved, when in 1840 Clerk Maxwell turned the search-light on
this special department of science, and gave to the world the electro-
magnetic theory of light.
Sir William Thomson (now Lord Kelvin), not unmindful of the
laborious researches of Sir W. Snow Harris, determined to make a pro-
found study of the relation existing between gas pressure and spark
length, and in 1860 he gave to science the absolute electrometer, an in-
vention that at once brought his name into commanding prominence.
The substitution of the Euhmkorff coil by cells was the very original
thought that occupied the attention of Gassiot. With a battery con-
sisting of more than 3500 cells, this celebrated French physicist proved
156
THE ROXTGEX RAYS IX DIAGNOSIS. 157
conclusively that a vacuum tube glowed incessantly when placed in the
path of its circuit, and in 1865, Hermann Spreugel invented the mercury
air-pump, an instrument devised for tin- purpose of producing very high
rarefactions, with a great degree of rapidity.
In 1869, Hittorf s name became familiar for experimentations along
these lines, and the same work was largely followed by Goldstein in 1876.
It was during the latter year that the brilliant researches of Gassiot were
being still further prosecuted. In 1877. a coterie of scientists were eager
to take up the work where Gassiot had left off; not the least conspic-
uous among these were Warren de la Rue, Hugo Miiller. and W. Spottis-
woode.
From 1877 to 1879, investigators were making extended studies and
investigations into the theories already advanced, and perfecting with
unremitting energy the practical points previously deduced. In the
latter year the celebrated Sir AVilliam Crookes startled the world by his
announcement that matter was radiant. It was he who declared that the
particles that were shot off from the cathode ray possessed strange and
remarkable properties.
In 1883, "Wiedemauu and J. J. Thomson continued these studies and
declared these particles to be ether disturbances of very short wave
length. The study was continued by Professor Hertz at Bonn, leading
to an investigation of high vacua discharge experiments. The work was
continued by his assistant, Professor Leuard, who in 1894 proved the
possibility of cathode rays passing through the walls of a vacuum tube.
Perrin, in France, and Elster and Geitel in Germany, made searching
studies into the latter subject.
It was in 1895, that Professor Rontgeu was experimenting with
Leuard and Crookes tubes when an unusual phenomenon met his gaze.
His tube was completely enveloped in an opaque cover, wheu a near-by
paper containing a fluorescent substance exhibited a most pronounced
visible glow ! How could the phenomenon be explained ? The rays
offered a triumphant resistance to the action of the magnet. These were
the rays so indispensable to the photographers art; the rays that were
destined to revolutionize many preconceived notions in medicine and
surgery. A new radiation had burst forth at the touch of genius ; a new
science had come into being.
Wilhelm Conrad Rontgeu was born in Leuuep, Province of the
Rhine, Germany, March 27, 1845. At an early age the boy showed a
remarkable aptitude for study, and in 1870 he was graduated as a Doctor
of Philosophy from the University of Zurich. Seeing that the youth
gave promise of a bright career, Professor Kundt took a lively interest
in the young man, and in 1873, when Kuudt was elected to a chair at the
University of AViirzburg, the young scientist accompanied him, and at
l.-..s ELECTRO-THERAPEUTICS.
Professor K limit's promotion to the University of Strasburg, Professor
Rontgen became his assistant. In 1875, Professor Routgeu was made
Professor of Mathematics and Physics in the Agricultural Academy at
Hohenheim, retiring from the institution to return to Strasbnrg just
one year later. In 1870, he accepted a call as Professor and also as a
Director of the Department of Physics at the University of Giesseu ; he
likewise accepted a similar position at the University of Wiirzbnrg. —
the latter office he still holds.
The labors of Professor Rontgen have been manifold ; he has had
published his investigations on isothermal crystals, solar ealorimetry,
dust figures, aneroid barometry, absorption of heat by various vapors,
etc. During the past decade his studies have been almost exclusively
devoted to problems in electricity. Space forbids naming even a tithe of
the honors that have been showered upon this celebrated scientist. Re-
quested by the German Emperor to demonstrate his discovery at the
Palace at Potsdam, the Emperor decorated him with a Crown Order of
the Second Class. The University of Munich presented him with a pro-
fessorship in recognition of his immortal discovery. He was awarded
the Barnard medal from the National Academy of Sciences at the com-
mencement exercises of Columbia University, New York City, and he
also received the Nobel prize in 1901.
The Comparative Study of the Properties of the Cathode and the
Rontgen Rays.
CATHODE RAYS.
Production. — Much discussion has arisen as to the true character of the
cathode rays. One school of philosophers declare that they are not rays
of light, but merely a stream of molecules proceeding from the cathode ;
others adhere to the view that these rays are analogous to ordinary light
rays, and represent some process occurring in the atmospheric ether.
Nevertheless the fact remains that, for their production, it is essential to
have a certain degree of vacuum in the tube. If this degree of vacuum
be increased, the production of cathode rays is no longer possible, and
when the tube is as completely exhausted as is possible, the production of
X-rays occurs. Cathode rays can be produced only within the walls of
the glass tube, and must be studied outside of the tube by the introduc-
tion of Lenard's aluminium window.
Radidbiliiy. — Professor Hertz was the first to demonstrate authorita-
tively that thin sheets of metal were transradiable, and Leuard showed
the phenomenon to be true of thin layers of other substances opaque to
light. Gold, silver, and aluminium foil allowed the passage of the rays
without suffering loss of any of their intensity. With gases, it was found
THE ROXTGEN KAYS IX DIAGNOSIS. 159
that the power of penetration varied inversely as the density, — /. e., the
greater the density the less the penetrability. Water was found to be
transradiable only in extremely thin strata.
Fluorescence and Phosphorescence. — Experimentation has proved that
the phosphides of the alkaline earths, calc spar, and uranium glass glow
brilliantly when near the aluminium window. Salts of manganese, cad-
mium, strontium, and lithium luminesce brightly. Liquids are inactive.
A rather curious fact is, that the sulphate of quinine in solution is only
slightly excited, but the same salt in the solid state offers a most bril-
liant glow of a deep blue color. Lenard affirms that the platino- cyanides
exhibit colors, similar to those that are produced under the influence of
the ultra-violet rays.
Reflection, Refraction, and Polarization. — In the vacuum tube the
cathode rays appear to be reflected and to behave in the same manner as
rays of light. Nothing definite has been determined regarding the polar-
ization of these rays.
Chemical and Photographic Effects. — The cathode rays possess a most
energetic chemical action on the alkaline haloids, and on some of the
haloids of the earths. Thus lithium chloride suffers a change to violet,
whilst sodium chloride can be made to change to either a yellow or a gray
color. Upon heating, the former is converted into a red color ; the latter
blue. The cathode rays act energetically on photographic papers and
plates ; thus iodine paper is quickly converted to a pronounced blue on
exposure to the rays.
Physiological Effects. — Neither the eye nor the skin is affected by the
action of the cathode ray; a characteristic odor and taste are produced,
but by some authorities these are ascribed to the presence of ozone.
Theories. — The theories advanced to explain the cathode rays are the
hypotheses put forth by the leading exponents of the English and German
schools of philosophers. The former physicists incline to the belief that
the cathode rays are streams of electrified molecules that are shot off from
the cathode ; in contradistinction to the German scientists, who hold that
Hirst- rays are manifestations of ethereal vibrations; defending this state-
ment with the results of Lenard' s investigations, and declaring, with that
scientist, that cathode rays are propagated through a vacuum in straight
lines, and so void of all matter that through them an electric spark can-
not be made to pass.
Jaumann's theory, which brings into the discussion the subject of
longitudinal waves, has received some support. He asserts that when
these rays are incident at right angles there is caused a high discharging
effect, showing a large longitudinal component. This theory gains cor-
roboration in a magnetic field. In accordance with this investigator's
views, these rays can only be normally reflected when the force applied
160 ELECTRO-THERAPEUTICS.
is parallel to the reflecting surface. Space forbids the presentation of
many other ingenious theories, advanced by Wiedeiiiaim, Hertz, Gold-
stein, Prout, and J. J. Thomson.
RONTGEX RAYS.
Production. — The new radiation — that form of energy called the
Rontgeu rays or the X-rays, requires for its production a highly exhausted
discharge tube. It must be borne in mind that the essential factor in the
generation of the Routgeu rays is that the electric discharge must be made
to take place in a high-vacuum tube, such as the Crookes tube; other
circumstances, as the character of the coil or dynamo, being matters of
minor consideration. Again, if we take Geissler tubes, which are bulbs
in which the air is only partially exhausted, we obtain what is known
as a low vacuum, and it is difficult, or indeed impossible, to generate
Rontgeu rays from such a discharge apparatus. The Routgeu rays re-
quire the one-millionth part of atmospheric pressure.
Radiability and Penetrability. — The peculiar power possessed by the
Routgen rays, of penetrating substances opaque to ordinary light or
cathode rays, has been shown by Professor Routgeu to be largely de-
pendent upon the relative density and thickness of the substance under
examination.1 In an elaborate exposition in his first communication,
he says:
"Sheets of hard rubber several centimetres thick still permit the
rays to pass through them. Glass plates of equal thickness behave quite
differently, according as they contain lead (flint-glass) or not; the former
are much less transparent than the latter. If the hand be held between
the discharge tube and the screen, the darker shadow of the bones is seen
within the slightly dark shadow-image of the hand itself. Water, carbon
disulphide, and various other liquids, when they are examined in mica
vessels, seem also to be transparent. That hydrogen is to any considera-
ble degree more transparent than air, I have not been able to discover.
Behind plates of copper, silver, lead, gold, and platinum the fluores-
cence may still be recognized, though only if the thickness of the plates
is not too great. Platinum of a thickness of 0. 2 mm. is still transparent ;
the silver and copper plates may even be thicker. Lead of a thickness
of 1.5mm. is practically opaque ; and on account of this property this
metal is frequently most useful. A rod of wood with a square cross-
sect ion (20 x 20 mm.), one of whose sides is painted white with lead
paint, behaves differently according as to how it is held between the
1 In this and the succeeding paragraphs the quotations have been taken from
" Rontgen Rays;'' embracing Professor Rontgen's original communications to the
Physikalisches Institut der Universitiit, of Wiirzburg, and translated by George F.
Barker, LL.D.; Harper and Brothers, Publishers.
THE ROXTGEX RAYS IX DIAGNOSIS. 161
apparatus and the screen. It is almost entirely without action when the
X-rays pass through it parallel to the painted side: whereas the stick
throws a dark shadow when the rays are made to traverse it perpendicular
to the painted side. In a series similar to that of the metals themselves,
their salts can be arranged with reference to their transparency, either
in the solid form or in solution.
uThe experimental results which have now been given, as well as
ot hers, lead to the conclusion that the transparency of different substances,
assumed to be of equal thickness, is essentially conditioned upon their
density ; no other property makes itself felt like this, certainly to so high
a degree.
"The following experiments show, however, that the density is not
the only cause acting. I have examined, with reference to their trans-
parency, plates of glass, aluminium, calcite, and quartz, of nearly the
same thickness; and while these substances are almost equal in density,
yet it was quite evident that the calcite was sensibly less transparent than
the other substances, which appeared almost exactly alike. Xo particu-
larly strong fluorescence of calcite, especially by comparison with glass,
has been noticed.
" All substances with increase in thickness become less transparent.
In order to find relation between transparency and thickness, I have
made photographs in which portions of the photographic plate were
covered with layers of tin-foil, varying in the number of sheets super-
posed. Photometric measurements of these will be made when I am in
possession of a suitable photometer.
" Sheets of platinum, lead, zinc, and aluminium were rolled of such
thickness that all appeared nearly equally transparent. The following
table contains the absolute thickness of these sheets measured in milli-
metres, the relative thickness referred to that of the platinum sheet, and
their densities :
Thickness.
Pt 0 018 mm .
Relative Thickness.
. . 1
Density.
21.5
Pb 0.05 mm
3
11.3
Zn 0.10 mm
a
7.1
Al 3.5 mm.
. 200
2.6
* ' We may conclude from these values that different metals possess
transparencies which are by no means equal, even when the product of
thickness and density are the same. The transparency increases much
more rapidly than this product decreases."
Fluorescence ninl Pfu>9pkor«9oenoe, — In his lirst communication Pro-
fessor Routgeu discourses at length on the fluorescent effects of the new
ray. and states its effect on barium platiuo-cyanide, calcium sulphide, etc.
11
162 ELECTRO-T 1 1 K II A P I •: r T I < 'S.
The amount and color of the radiations emitted would seem to be entirely
dependent upon the character of the substance under examination. In
this connection he wrote :
" If the discharge of a fairly large induction coil be made to pass
through a Hittorf vacuum-tube, or through a Lenard tube, a Crookes
tube, or other similar apparatus which has been sufficiently exhausted,
the tube being covered with thin, black card-board which fits it with tol-
erable closeness, and if the whole apparatus be placed in a completely
darkened room, there is observed at each discharge a bright illumination
of a paper screen covered with barium platino-cyanide, placed in the
vicinity of the induction coil, the fluorescence thus produced being en-
tirely independent of the fact whether the coated or the plain surface is
turned toward the discharge tube. This fluorescence is visible even when
the paper screen is at a distance of two metres from the apparatus. It is
easy to prove that the cause of the fluorescence proceeds from the dis-
charge apparatus, and not from any other point in the conducting circuit.
'" The most striking feature of this phenomenon is the fact that an
active agent here passes through a black card-board envelope, which is
opaque to the visible and the ultra-violet rays of the sun or the electric
arc ; an agent, too, which has the power of producing .active fluorescence.
Hence we may first investigate the question whether other bodies also
possess this property.
"We soon discover that all bodies are transparent to this agent,
though in very different degrees. I proceed to give a few examples :
Paper is very transparent ; behind a bound book of about one thousand
pages I saw the fluorescent screen light up brightly, the printer's ink of-
fering scarcely a noticeable hinderauce. In the same way the fluorescence
appeared behind a double pack of cards; a single card held between the
apparatus and the screen behind being almost imuoticeable to the eye.
A single sheet of tin-foil is also scarcely perceptible ; it is only after' sev-
eral layers have been placed over one another that their shadow is dis-
tinctly seen on the screen. Thick blocks of wood are also transparent,
pine boards two or three centimetres thick absorbing only slightly. A.
plate of platinum about fifteen millimetres thick, though it enfeebles the
action seriously, did not cause the fluorescence to disappear entirely.
« * * * * The fluorescence of barium platino-cyanide is not,
the only recognizable effect of the X-rays. It should be mentioned that
other bodies also fluoresce; such, for instance, as the phosphorescent
calcium compounds, then uranium glass, ordinary glass, calcite, rock-salt.
and so on."
Reflection, Refraction, Pohn-izatlon, «n<1 Int< rfrrencc. — The earlier ef-
forts made, tended to show that the Bontgen rays defied reflection, but
later investigations have conclusively proved that a reflection, similar to
THK BONTGEN KAYS IX DIAGNOSIS. 163
that diffuse reflection obtained from the surface of ground glass, could be
demonstrated. It lias likewise been shown that reflection is largely de-
pendent on the character of the substance composing the surface. More
recently Carmichael, of Lille, succeeded in reflecting X-rays through the
agency of steel mirrors. The value of his experiment has not been deter-
mined. In his first paper upon the X-rays Professor Kontgeu said :
•• After I had recognized the transparency of various substances of
relatively considerable thickness, I hastened to see how the X-rays be-
haved on passing through a prism, and to find out whether they were
thereby deviated or not.
"Experiments with water and with carbon distil phide enclosed in
mica prisms of about 30° refracting angle showed no deviation, either
with the fluorescent screen or on the photographic plate. For purposes
of comparison, the deviation of rays of ordinary light under the same
conditions was observed : and it was noted that in this case the deviated
images fell on the plate about 10 or 20 millimetres distant from the direct
image. By means of prisms made of hard rubber and aluminium, also of
about 30° refracting angle, I have obtained images on the photographic
plate in which some small deviation may perhaps be recognized. How-
ever, the fact is quite uncertain ; the deviation, if it does exist, being so
small that in any case the refractive index of the X-rays in the substances
named cannot be more than 1.05 at the most. With the fluorescent
screen I was also unable to observe any deviation.
"Up to the present time experiments with prisms of denser metals
have given no definite results, owing to their feeble transparency and
the consequently diminished intensity of the transmitted rays.
' ' With reference to the general conditions here involved on the one
hand, and on the other to the importance of the question whether the
X-rays can be refracted or not on passing from one medium into another,
it is most fortunate that this subject may be investigated in still another
way than with the aid of prisms. Finely divided bodies in sufficiently
thick layers scatter the incident light and allow only a little of it to pass,
owing to reflection and refraction ; so that if powders are as transparent
to X-rays as the same substances are in mass — equal amounts of ma-
terial being presupposed — it follows at once that neither refraction nor
regular reflection takes place to any sensible degree. Experiments
were tried with finely powdered rock salt^ with fine electrolytic silver
powder, and with zinc dust, such as is used in chemical investigations.
In all these cases no difference was detected between the transparency of
the powders and that of the substance in mass, either by observation
with the fluorescent screen or with the photographic plate.
"From what has now been said it is obvious that the X-rays cannot
be concentrated by lenses ; neither a large lens of hard rubber nor a glass
164 ELECTRO-THKRAI'KITK S.
leiis having any influence upon them. The shadow-picture of a round
rod is darker in the middle than at the edge ; while the image of a tube
which is filled with a substance more transparent than its own material is
lighter at the middle than at the edge.
11 The question as to the reflection of the X-rays may be regarded as
settled, by the experiments mentioned in the preceding paragraph, in
favor of the view that no noticeable regular reflect ion of the rays takes
place from any of the substances examined. Other experiments, which I
here omit, lead to the same conclusion.
a # # # * if we compare this fact with the observation already
mentioned, that powders are as transparent as coherent masses, and with
the further fact that bodies with rough surfaces behave like polished
bodies with reference to the passage of the X-rays, as shown also in the
last experiment, we are led to the conclusion already stated that regular
reflection does not take place, but that bodies behave toward the X-rays
as turbid media do toward light.
11 Since, moreover, I could detect no evidence of refraction of these
rays in passing from one medium to another, it would seem that X-rays
move with the same velocity in all substances; and, further, that this
speed is the same in the medium which is present everywhere in space
and in which the particles of matter are imbedded. These part ides hin-
der the propagation of the X-rays, the effect being greater, in general,
the more dense the substance concerned.
" Accordingly it might be possible that the arrangement of particles
in the substance exercised an influence ou its transparency ; that, for in-
stance, a piece of calcite might be transparent in different degrees for the
same thickness, according as it is traversed in the direction of the axis,
or at right angles to it. Experiments, however, ou calcite and quartz
gave a negative result."
Sir G. G. Stokes,1 "The Wild Lecture," lucidly says : "Everything
tends to show that these rays are something which, like rays of light,
are propagated in the ether. What, then, is the nature of this process
going on in the ether 1 Some of the properties of the Eoutgeu rays
are very surprising, and very unlike what we would be in the habit
of considering with regard to rays of light. One of the most strik-
ing things is the facility with which they go through bodies which are
utterly opaque to light, such, for example, as black paper, board, and
so forth. If that stood alone it would not, perhaps, constitute a very
important difference between them and light. A red glass will stop
green rays and let red rays through ; and just in the same way if the
Rontgeu rays were of the nature of the ordinary rays of light, it is
possible that a substance, although opaque to light, might be transparent
1 Ibid.
THE ROXTGEN KAYS IX DIAGNOSIS. ]<;.-,
to them. So, as I say, that remarkable property, it' it stood alone,
would not necessarily constitute any great difference of nature between
them and ordinary light.
it, * # # * jjut there are other properties which are far more
difficult to reconcile with the idea that the Rontgen rays are of the nature
of light. There is the absence, or almost complete absence, of refraction
and reflection. Another remarkable property of these rays is the extreme
sharpness of the shadows which they cast when the source of the rays is
made sufficiently narrow. The shadows are far sharper than those pro-
duced under similar circumstances by light, because in the case of light
the shadows are enlarged as the effect of diffraction. This absence or
almost complete absence of diffraction is, then, another circumstance
distinguishing these rays from ordinary rays of light. In face of these
remarkable differences, those who speculated with regard to the nature
of the rays were naturally disposed to look in a direction in which there
was some distinct difference from the process which we conceive to go on
in the propagation and production of ordinary rays of light. Those who
have speculated on the dynamical theory of double refraction have been
led to imagine the possible existence in the ether of longitudinal vibra-
tions, as well as those transversal vibrations which we know to constitute
light. If we were to suppose that the Rontgen rays are due to longi-
tudinal vibrations, that would constitute such a very great difference of
nature between them and the rays of light that a very great difference in
properties might reasonably be expected. But assuming that the Ront-
geii rays are a process which goes on in ether, are the vibrations belong-
ing to them normal or transversal ? If we could obtain evidence of the
polarization of those rays, that would prove that the vibrations were not
normal but transversal. But if we fail to obtain evidence of polarization,
that does not at once prove that the vibrations may not after all be trans-
versal, because the properties of these rays are such as to lead us to
expect great difficulties in the way of putting in evidence their polariza-
tion, if, indeed, they are capable of polarization at all. Some experi-
mentalists have attempted, by means of tourmalines, to obtain evidence
of polarization, but the result in general has been negative. Of the two
photographic markings that ought to be of unequal intensity on the sup-
position of polarization, one could not say with certainty that one was
darker than the other. Another way of obtaining polarized light is by
rellection at the proper angle from glass or other substance ; but, unfor-
tunately for the success of such a method, the Routgeu rays refuse to be
regularly reflected, except to a very small extent indeed. The authors of
the paper to which I have already referred appear to have had some
success with the tourmaline. Like others who have worked at the same
experiment, they took a tourmaline cut parallel to the axis and put on
166 ELECTRO-THERAPEUTICS.
lop of ii two others, also ciil parallel to the axis, and of equal thickness,
which were placed with their axis parallel an<l perpendicular respectively
to that of the under tourmaline.
"But they supplemented this method by a device which is not
explained in the paper itself, although a memoir is referred to in which
the explanation is to be found— at least of those who can read the Russian
language, which, unfortunately, I cannot. I can, therefore, only guess
what the method was. It is something depending upon the superposition
of sensitive photographic films. I suspect they had several photographic
films superposed, took the photographs on these, and then took them
asunder for development, and after development put them together again,
as they had been originally. They consider that they have succeeded in
obtaining evidence of a certain amount of polarization. If we assume
that evidence undoubted, it decides the question at once. But as the
experiment, as made in this way, is rather a delicate one, it is important
for the evidence that we should consider well what we may call the
Becquerel rays. I shall say merely that they appear to be intermediate
in their properties between the Routgeu rays and rays of ordinary light.
The Becquerel rays undoubtedly admit of polarization, and the evidence
appeai-s on the whole pretty conclusive that the Routgen rays, like
rays of ordinary light, are due to transversal, and not to longitudinal
vibrations.
ult remains to be explained, if we can explain it, wherein lies the
difference between the nature of the Routgeu rays and the rays of ordinary
light which accounts for the strange and remarkable difference in the
properties of the two. I may mention that, although Cauchy and Neu-
mann, and some others who have written on the dynamical theory of
double refraction, have been led to the contemplation of normal vibrat ions,
Green has put forward what seems to me a very strong argument against
the existence of normal vibrations in the case of light. The argument
Green used always weighed strongly with me against the supposition that
the Rontgen rays were due to longitudinal vibrations; and the experi-
ments by which, as I conceive, the possibility of their polarization has
now been established so completely in the same direction, showing that
they are due, assuming them to l>e some process going on in the ether, to
a transversal disturbance of some kind."
Chemical and Pholoyraphic Effects. — One of the peculiar properties
possessed by the X-rays is that they produce a chemical action upon the
haloids of silver, but have very little activity in other reactions. Dixon1
asserts that these rays affect no combination between CO and O2. "With
such combinations as argentic nitrate in alcohol or HgCl, in ammonium
oxalate solution, the influence of the Rontgen rays is extremely feeble.
•Trans. Them. Soc., 1896.
THE EOXTGEX BAYS IN DIAGNOSIS. 1 < i 7
The following law has been formulated by Yandex \\ er.1 The action of
the rays 011 a sensitive film varies inversely as the distance between them,
instead of inversely as the square of the distance.
Phyxioloylral Effects. — The physiological ;iction of the X-rays will be
dealt with at length, in the chapter devoted to X-ray therapy.
Tfif-ories. — The nature and origin of the Routgen rays is as little
understood to-day as when first discovered. Many and varying theories
have been propounded; principal among these may be cited the views
put forth by Routgeu, Crookes. J. ,T. Thomson, Stokes, etc.
Below are tabulated the theories advanced by scientists regarding the
probable nature of these rays.:
1. Solid particles. { ^^ Tesla'
iSalviom, Att. d. Perug., 8, 1 and 2.
2. Ether wind.
3. Ether vortices. Michelson, Amer. J. Science, p. 312.
4. Ether waves (actual movement) .
5. Electro-magnetic.
Longitudinal. Runtgen, 1895, loc. rit.
Boltzmann, J. f. Gasb., 39, p. 71.
With transverse component. Jaumann, Wied. Ann., 57, p. 147.
Transverse, (a) Very small. Goldhammer.
(b) Short trains. G. G. Stokes.
J. J. Thomson.
6. New phenomenon.
Visibility of the Rontgen Rays.
Prof. E. Dorn3 asserts most positively that the X-rays are visible,
opinions to the contrary notwithstanding. In support of his statement,
he says that when the back of the anti-cathode is presented to the
observer's eye, a faint fluorescence is visible on the screen, whereas,
with the tube iu the correct position, the eye accustomed to darkness
could not detect the smallest action, although the appearance of light was
distinctly seen, both before and later. In corroboratiou, Rontgeu himself
held an absorbing metal plate, containing a narrow slit, before the eye,
when he observed a bright line, either straight or curved in direction,
depending on the relative positions of the anode, the slit, and the eye.
Velocity of Propagation of the X-rays.
R. Blondlot4 lias studied the speed of propagation of X-rays, by the
fact that a discharge passes more readily across a spark-gap when under
'Jour. dePhys., 1897.
2 Hyndman on " Radiation."
3 Archives of the Rontgen Ray, May, 1898, p. 69.
4 Coinptes-rendus, Oct. 27 and Nov. 3, 1902. The Electrician (translation), Nov.
21, 1902.
168 ELECTKO-T 1 1 K 1 1 APEUTICS.
the influence of the rays than when the latter are not present. He also
demonstrated that the X-rays have a definite rate of speed, possessing a
velocity comparable to the Hertzian waves. Believing that the rate of
propagation of the latter through wire is equal to the velocity of light,
Bloudlot asserts that the velocity of X-rays, Hertzian waves, and
ordinary light waves is equal.
Velocity of the Rontgen Rays.
E. Marx ' has succeeded in measuring the velocity of the X-rays, by
a method very similar to that of Fizeau's toothed wheels, as used for
determining the velocity of light ; but in Marx's method the intermit-
tence is inherent in the source and the receiver themselves. Rontgen
rays are generated by Hertzian waves, and, as the Rontgen rays are the
parent rays of the cathode rays, the latter are only emitted during the
negative phase of the Hertzian oscillation, i. e. during the intermission.
The receiver is an electrode, connected with the same exciting agent and
producing secondary cathode rays, under the influence of the incident
Routgen rays, but only when found by them in the negative phase.
Now, as the X-rays produce peculiar oscillations in the leads, Marx has
overcome this difficulty by employing a method in which the source
and receiver are both fed from the same Hertzian oscillating wires,
minimizing infinitesiinally the oscillations by shifting the bridge.
Charging Action of the Rontgen Rays.
That the X-rays are capable of charging bodies has been maintained
by Righi but denied by others. Hahn's2 views are fully in accord with
those of Righi. The discord that exists is solely due to the masking
action of the secondary rays. All bodies acted upon by the X-rays
acquire a positive charge ; hard rays are most effective in charging, as is
also a high atomic weight.
1 Physikalische Zeitechrift, November 9, 1905.
*Annalen der Phyeik, No. 11, 1905.
CHAPTER I
THE ROXTGEN RAY APPARATUS AND ITS MANIPULATION.
I. The Induction Coil.
A. LAWS OF FARADAY, OR THE ELEMENTARY LAWS OF INDUCTION.
THE induction or Ruhmkorff coil is an instrument for converting
low voltage into high E. M. F., thus necessarily involving the principles
of electro- magnetic induction.
In 1831 Faraday discovered that currents may be induced in a closed
circuit by moving magnets near it, or by moving the circuit across the
magnetic field. Further investigation showed that a current whose
strength is changing may induce a secondary current in a closed circuit
near it.
In 1832 Faraday observed that a similar induction of a secondary
current occurred when interrupting an existing primary current, and the
current produced in the secondary circuit on interruption travels in the
same direction as the former. When closing the primary circuit, the
secondary current travels in the opposite direction. By rapidly
" making" (closing) and " breaking" (interrupting) the primary cir-
cuit, there is produced an alternating current in the secondary circuit,
which is constantly changing in direction.
The current strength produced by induction in the secondary circuit
is dependent upon the following principles :
The greater the ratio in the induction coil between the primary sec-
tion and the secondary coil, the greater will be the resulting E. M. F. of
the induced current in the secondary circuit.
By induction, the greater the E. M. F. in the primary circuit, the
greater the increase of current strength in the secondary circuit.
The strength of the induced current will vary with the rapidity
with which the iron core is alternately magnetized and demagnetized.
The working capacity of an induction coil depends upon the circum-
stances that :
The core must be of soft iron that can readily be magnetized or de-
magnetized by an interrupter in the primary circuit.
The secondary circuit must consist of a great many turns of fine
wire, so as not to increase the bulk.
The primary coils carry the current from battery, accumulator, or
main, which magnetizes the core of soft iron, thus creating a powerful
magnetic field around and through the secondary windings. The inter-
rupter causes the current in the primary circuit to vary rapidly, and the
169
170
ELECTBO-THEBAPEUTICS.
resulting variations in the intensity of the magnetic Held react upon the
secondary coil, inducing an electro-motive force in each and every turn of
the wire. The "making" of the magnetic Held is much more slowly
accomplished than its destruction when the current is "broken," thus,
the induced electro-motive force in the secondary at "breaking" is l»y
far the greater. The induced secondary current when "making" is
greatly below that when "breaking," so that the former is found insuffi-
cient in exciting a vacuum tube. Advantage is gained from this phenom-
enon because the induced current
at "make" travels in the wrong
direction and could not cause
the tube to be excited, as it is
in the case with the " break"
induced current.
The induction of currents
in the secondary coil by means
of the currents in the primary
coil may be more readily under-
stood from a consideration of
Fig. 68.
The battery "B" will cause
a current to flow through the
primary coil "P" when the cir-
cuit is closed by the interrupter
"I;" but the current does not
instantly assume its maximum
value. It takes an appreciable
time to rise to the current value
set by the resistance of the cir-
cuit. This gradual rise of the
current is due to the presence
of the self induction of the cir-
cuit, the largest percentage of which exists in the primary coil. During
the time that this self-induction current is rising in the primary
circuit, a magnetic field is being established about the primary wind-
ing. The strength of this magnetic field is at all times directly pro-
portional to the primary current. It is, therefore, zero at the time that
no current flows, and a maximum when the current has stopped rising.
This magnetic field embraces the secondary coil as well as the primary.
While the primary current is rising and the magnetic field is growing, a
voltage is produced in the secondary coil by the expansive lines of mag-
netic force, which voltage tends to produce a current in the secondary
coil opposite in direction to that flowing in the primary.
^HMHHHK
B
Flu. 68.— Diagram illustrating the principles of in-
duction. (After Dona th.)
THE BONTGKN KAY API'AR ATI's. 171
This current, induced at this time, is of low voltage and is not the
current desired in the X-ray tube. It is the ••inverse" discharge which
tends to blacken tin- tubes and lower the vacuum at the time of the
running of the tube.
AVheii the interrupter opens the primary circuit, the primary cur-
rent suddenly stops, and at the same time the magnetic field collap>r>.
inducing a very high voltage in the secondary coil. This tends to pro-
duce a current in the secondary coil iu the same direction as the current
flowing in the primary.
B. THE CONSTRUCTION OF THE INDUCTION COIL.
1. The Primtiri/ Coil. — The first requirement in the construction of
an X-ray induction coil consists in arranging into a cylindrical bundle
many equal lengths of finely annealed charcoal iron wire, and in winding
around this core, several layers iu thickness, a stout insulated (pri-
mary) wire so arranged as to have terminals at one end for future con-
nection. Surrounding this cylinder is another cylinder made of some
specially selected substance, as ebonite, hard rubber, shellac, or resin, to
afford insulation.
2. The secondary coil is composed of a great number of windings of
very fine wire, to effect the principle that a high E. M. F. is in a great
degree dependent upon the number of turns in the secondary coil. The
secondary coil is found on the market made up in sections. This allows
of the easy replacement of any one section ; a source of economy.
The ends of the secondary coil are connected with brass terminals
mounted upon the flanges, an ebonite cover or separate stands. The
whole finished coil is suitably supported upon a stage of wood with the
other necessary appliances.
3. Condenser. — The purpose of the condenser is for the sudden and
complete demagnetization of the soft iron core — the length of the spark
depending upon the abruptness with which the demagnetization is
accomplished. Another use of the condenser is to prevent the sparking
of the extra current passing between the contact studs of the interrupter.
The more recent condensers are .made in sections and are provided with
an indicating dial, designating how much to increase or decrease the
capacity of the condenser, as determined by the size of the primary coil.
The condenser is made up of many sheets of tin-foil separated from
each other by sheets of paraffin paper, or paper impregnated with resin
or plates of mica. The foil is arranged thus : The first, third, and fifth
sheets are so connected as to overlap the paper sheets on one side : the
same method is applied to the union of the even numbered sheets of the
other : these layers are connected with those parts of the interrupter
where the "make" and •• break" occur. The unit of capacity is the
172 ELECTRO-THERAPEUTICS.
"micro-farad." The capacity of condensers used in induction coils
varies from one-half M. F. to 12 or 15 M. F., depending upon the size,
make of the coil, and the voltage upon which its primary circuit is used.
The commutator is an appliance mounted on the base for the support
of the coil, and placed at the side of the interrupter. It is a double
reversible switch capable of changing the direction of the current in the
primary and consequently in the secondary circuit.
C. INTERRUPTERS.
The interrupter (rheotome) is a device employed by electricians for
the purpose of effecting rapidly succeeding induced currents in the
secondary coil, by a corresponding rapidity in the opening ("break-
ing") and closing (" making ") of the primary coil. Interrupters are
divided into the mechanical and the electrolytic, with the following
subdivisions :
1. Mechanical.
Platinum.
Vibrating hammer.
Independent.
Self- starting.
Vril.
Mercury.
Dipper.
Rotary.
Disk.
Johnston.
Jet.
2. Electrolytic.
Wehnelt.
Caldwell and Simon.
Platinum. — The vibrating hammer which vibrates in response to the
magnetism exerted by the primary coil is little used at present.
The independent vibrating hammer is so constructed that a magnet
placed in a shunt circuit can vibrate the hammer independently of the
coil. The diameter of the contacts should be as large as possible, and
the faces absolutely parallel, in order to carry all the current required.
The number of interruptions in this hammer is dependent upon the
number of weights attached to the vibrating hammer. The greater the
number of weights employed, the fewer will be the resulting vibrations.
The self-starting (Figs. 69, 70) mechanical interrupter requires little
attention from the operator, as he is not called upon to effect the vibra-
tions. This ingenious invention is the work of H. C. Snook and Edwin
\V. Kelly, of Philadelphia, who aptly say :
"This interrupter is a form of platinum break which is actuated not
by the magnetic field of the coil itself, but by an independent electro-
FIG. 69.— Self-starting interrupter.
FIG. 70.— Diagrammatic sectional view of the self-starting interrupter.
(Rontgen Manufacturing Co.)
THE ROXTGEX HAY APPAHATI S. 17:j
magnet (9), which is in series with a small spring (11) and a set of plati-
num contacts of its own. and is shunted directly across the supply wires.
"The magnetic circuit is so arranged that a very powerful pull is ex-
erted on the armature at the instant of starting from rest. This provides
the self-starting feature which has given to the interrupter its name.
The break is quite efficient and gives very little trouble.
"This has been accomplished by making the magnetic circuit with
a minimum amount of reluctance, and providing a properly shaped anna
ture and pole piece. The magnetic circuit is completed from the arma-
ture to the base of the magnet coil through the interrupter spring itself.
By this arrangement the only air gap in the path of the magnetic lines of
force is that between the pole piece and the armature itself, making the
tractive force exerted on the armature a maximum for the magnetizing
current employed."
The "vrtt" interrupter is an old type of the spring platinum vari-
ety. It is rapidly passing into disuse, but it possesses the great advan-
tage of being capable of generating a high E. M. F. in the secondary
coil. Sparking is unavoidable, and its occurrence constantly menaces the
integrity of the platinum stud.
To obviate this difficulty the elasticity of the spring is no longer taken
advantage of, but in its place a light piece of flat metal, balanced on its
edge, is substituted for the movable contact.
FIG. 71. — Mercury interrupter.
Mercury. — Mercury interrupters are of two kinds — the dipper and the
rot < try. In the dipper variety an electro- motor (Fig. 71) is employed to
effect the "dip,'' and likewise the withdrawal of a platinum-tipped rod
from contact with the mercury for the greater part of each cycle; it is out
of the mercury for a relatively short period, because the current is not
174 ELECTRO-THERAPEUTICS.
generated at the moment of contact. In this form of interrupter the sur-
face of the mercury is covered with a layer of alcohol, water, or petroleum.
in order to decrease the oxidation resulting from ''sparking." This form
of " break" is cumbersome, being mounted on a separate base. Instead
of being worked by the core of the coil, this interrupter may be brought
into action by employing a small motor. One precaution, however, with
the latter method is necessary. If the breaks are not started prior to the
turning on of the current into the coil, the coil may suffer serious dam-
age by the heavy influx of current upon closing the circuit, should the
dipper be immersed in the mercury.
Davidson- s Rotary Contact Breaker. — Dr. Mackenzie Davidson's inter-
rupter1 (Fig. 72) consists of a vane mounted at the end of a spindle
driven by a small motor. As the latter rotates, the vane makes and
breaks contact with the mercury contained in a trough or box, on the
cover of which the motor is mounted. The motor and spindle are placed
at an angle of about 30° so that the spindle passes down through a hole
in the lid. The mercury is thus closed in, and splashing is prevented.
The break is found to work well with electro-motive force up to 100 volts.
The disk interrupter, a subdivision of the rotary, is included in that
class of ll breaks" in which the contacts are separated by the revolutions
of a disk effected through the agency of an electro-motor. The contacts
and disks are immersed in alcohol or petroleum, to prevent the likelihood
of sparking.
The Johnston Mercury Interrupter. — Dr. Geo. C. Johnston, of Pitts-
burg, exhibited before the American Rontgen Ray Society in Baltimore,
1905, a new form of mercury interrupter (Fig. 73) for which he claims
special features. There is no oxidation of mercury, no sticking, uniform-
ity of discharge, absolute control of speed and current, it will not ex-
plode, it occupies little space, makes little noise, and will run for months
with little attention. He describes the Johnston mercury interrupter as
follows : u The interrupter consists of an inclined shaft at the lower end of
which is a peculiar shaped blade, alternately dipping into a pool of mer-
cury. This shaft is rotated by means of a motor to which a speed con-
trol is attached. The containing case is of heavy cast iron, and the top is
screwed down and insulated from the case with a thick rubber gasket and
insulated bushings. One end of the box is inclined toward the mercury
pool and arranged with grooves, so that when the mercury is thrown to
the top of this incline by the action of the blade, in running back into the
pool, it travels slowly over a considerable section of the cast iron and
leaves any impurities that it might have contained in them.
"The box is arranged to be air-tight, and the pet cock is fastened
in the lid, by means of which the mercury or any other liquid can be
'Archives of the Rontgen Ray, Jan., 11K)1.
FIG. 72.— Davidson's interrupter.
JOHNSTON t*£ACUffY INTERRUPTER
PAT. APPLIED FOR
MAO£ r
UEEN ft
SOLE LI
Fi(i. 73.— Johnston's mercury interrupter.
THE RONTGKN KAY APPARATTS.
175
poured into the interior. It has been found that when the proper amount
of mercury is placed in the pool and a few drops of wood alcohol added,
after the first slight explosion takes place, the interrupter will run along
without any sparking, and consequent oxidation of the mercury, and
break currents of considerable magnitude, as much as 40 or 50 amperes.
The quality of the spark obtained from the secondary of an induction
coil with this amount of current flowing through its primary, is surpris-
ingly thick and heavy, and the discharge is of exactly the right quality
to produce the results in radiography. When the alcohol explodes in
the box, there is a slight pressure produced, which is retained, owing to
the air-tight quality of the box, and the interrupter will run along indefi-
nitely with absolutely no attention. If any irregularity of the secondary
sparking is noticed, all that
is necessary to do is to open
the pet cock, pour in an ounce
or so of mercury and a dozen
or fifteen drops of wood alco-
hol, close the pet cock, and
the interrupter is ready for
n>e again. This interrupter
will run for a long time with-
out interior cleaning, which
FIG. 74.— Wehnelt interrupter.
can be readily accomplished
without taking apart, by un-
screwing a plug in the bottom
of the box, letting the mer-
cury drain out, and filling the u
l)o x with water and giving it
i\\o or three vigorous shak-
ings. After draining the
water out, the plug is re-
placed tightly, and some fre^h
mercury added, when it is ready for another three or four months' use."
In the jet interrupter, a jet of mercury impinges upon a rotating
metallic surface. The jet carries the current, and the length of contact
can be regulated according to the operator's demands by elevating or low-
ering the contact plate relatively to the jet. The break is instantaneous
and complete.
The electrolytic iitfcrrii.jrfrrs are subdivided as follows : Wehnelt and
the CahhceU and Simon.
This type of interrupter depends upon the formation of gas bubbles
at the poles of an electrolytic cell.
Tin- i-h'ctrolytic "break" of Wfhuclt (Fig. 74), the most rapid of all
176
ELECTRO-THERAPEUTICS.
interrupters, consists of a jar holding the electrolyte (dilute sulphuric
acid s. g. 1016 to 1020), a plate of lead (the cathode), and a piece of
platinum insulated except at its extremity (the anode).1
The greater the quantity of sulphuric acid employed, the greater the
current and the better the conductor. A steady electro-motive force of at
least 24 volts is applied to the interrupter, arranged in series with the
primary circuit of the coil. Should the platinum not constitute the
anode, the interruptions will not be sharp and regular. Under these con-
ditions the platinum is very rapidly consumed.
One of the advantages of this interrupter is that either a continuous
or alternating current can be employed. It likewise obviates the use of
the condenser, and in many
instances the rheostat. An-
other advantage is, that it
allows tremendous amounts of
amperage to pass to the pri-
mary coil, averaging any
where from fifteen to fort}'
amperes.
The number of interrup-
tions in this break varies from
1000 to 40,000 per minute,
and is dependent upon the
size of the exposed portion of
the platinum point. This can
be regulated by presenting a
larger surface either by means
of a screwing device, or by
> several thicknesses of these
points in the same electrolyte.
The rate of interruption can
be gauged by the tuning-
fork 5 or as the result of ex-
perience, the operator recognizing a peculiar humming, musical note.
A recent device, added to this instrument, is a spiral leaden tube,
which acts as the cathode, and as the sulphuric acid (electrolyte) becomes
warm the interruptions cease to be regular, and water from a faucet is
passed through the tubing in order to cool the electrolyte.
In the film variety of the Wehnelt interrupter, the interruptions are
brought about by the production of a non-conducting film of vaporor gas
around the anode. The effects produced are. in a measure, proportionate
FIG. 75.— Simon interrupter.
'In 1S!H) \\Vlmelt, of Charlottenburg, first applied the above principles to the
satisfactory working of ihe X-ray coil.
THE ROXTGEN RAY APPARATUS.
177
to the thickness of the wire, so that the employment of three or more wires
of different gauges is often expedient. Most advantage is gained with an
E. M. F. of 50 to 120 volts. The voltage is regulated by ineaus of a rheo-
stat. For short runs a voltage of 40 to 100 volts is all that is required,
but its employment must be for a brief interval only. To continue for a
half hour or au hour would cause the geueratiou of great heat ill the acid,
FIG. 76.— Friedlander electrolytic interrupter. The electrolyte is composed of a 10 per cent, solu-
tion of magnesium sulphate, and the anode is made of German-silver wire. The operator can control
the current for the work in hand by simply turning the thumb-screw. It operates by either the direct
or alternating currents.
with a stoppage of the mechanism. To avoid this drawback, many devices
have been employed. Among the most important are the use of the sul-
phates of magnesia and potash -alum in place of the acidulated solution,
and also by making the container larger, and through it maintaining a flow
of cold water. This type of interrupter is easily managed; its most pro-
nounced disadvantage is its constant humming sound, while its very high
E. M. F. has a tendency to disturb the vacuum of the Crookes tube.
178 , ELECTRO-THERAPEUTICS.
There are very many varieties of the electrolytic interrupter,
numerous modifications of the Wehuelt, bearing various names.
Caldicrfl and Simon.— In 1899 Mr. E. \V. Caldwell, of Xew York, and
Dr. H. T. Simon, of Berlin, simultaneously and independently of each
other, had published the description of a new type of electrolytic inter-
rupter, the principle involved being the production of interruptions by
the vaporization of the electrolyte at the aperture connecting the two
chambers. The apparatus consists of a glass jar containing dilute sulphu-
ric acid, with two plates of lead, one for the anode and the other for the
cathode. A partition of glass or porcelain, containing a hole, separates
these two plates and at the same time allows the communication of
the liquids in the two portions of the cell. The frequency of the inter
ruptions is dependent upon the strength of the current, the size of the
aperture, the resistance offered by the electrolyte, and to some extent
upon the inductance of the circuit. A pointed rod, non-conducting in
nature, regulates the number of interruptions by increasing or decreas-
ing the calibre of the aperture. The electrolytic action results in the
generation of bubbles of gas (steam), which break the circuit ; these
bubbles are almost instantaneously dissipated and then renewed, their
frequency being somewhat dependent upon the size of the aperture.
More recently the septum between the two containers has been made of
perforated porcelain disks, in order to prevent the damage incident to
the inner tube, from the unequal expansion of the glass of which it was
formerly made.
Dr. Simon claims that the advantage of his interrupter (Fig. 75)
over the Wehnelt is to be found in its being independent of the current
direction, working equally as well with the alternating as with the contin-
uous current ; because in the Caldwell-Simon interrupter, the wat'-rv
vapor is periodically evolved and followed each time by condensation,
and thus the current is alternately made and broken.
A useful electrolytic interrupter is shown in Fig. 76.
D. VARIETIES OF INDUCTION COIL.
(a) Variable Pi-iinani T ml net ion A///.S. — Walter, of Hamburg, con-
structed induction coils with a variable number of sections for the pri-
mary, in order to obtain the proper quality in the secondary discharge.
This he effected by arranging the windings of the primary coil in a num-
ber of sections, and passing the current through a greater or lesser number
of these divisions us he required more or less current. Each of the coil
windings can be connected in series, in two groups, or in parallel. These
windings end in wires to form eontaets at one side of the primary coil.
Upon these contacts a i •• plaeed pins which support plugs, and so arranged
as to effect the desired connection between the terminals of the coil
THE RONTGEN RAY APPARATUS. 179
endings. By connect ing the windings in series (for soft tubes), the self
induction of the primary coil is much augmented. By conned ing in
parallel (for hard tubes), or in two groups (for tubes of medium density),
self induction is materially decreased.
The primary coil is covered with an insulator of glass, ebonite, par-
affin, etc. This coil is frequently manufactured in a varying number
of sections or divisions, so that it can be replaced at pleasure within
the secondary coil, and be renewed, at any time, thus obviating the
unnecessary expense of providing for the cost of the entire coil.
The secondary circuit must be perfectly insulated ; lack of this most
important provision will result in discharges within the apparatus, fusing
the wire and destroying the coil. The insulating material used may be
paraffin, varnish, wax, or silk. Whatever substance be used, the several
layers of wires which are already of themselves well insulated must be
likewise insulated from one another.
A wise expedient in this connection has been the device of employ-
ing several short secondary coils in place of a single secondary coil. This
artifice insures better insulation, easy repair in the event of short-
circuiting, and the lessened cost incident to replacement.
Tfir Jumbo Coil. — This coil, owing to its mechanical arrangement, does
not throw more than a !)-inch spark (23cm.), thus making it necessary to
insulate only for the voltage equivalent for that spark length. This saxes
much valuable space, and it is therefore possible to use more iron in the
primary core, as well as heavier wire on both primary and secondary,
which are also brought into closer proximity to each other. In this way
the efficiency is so increased that when running on 110 volts direct current,
it will push 50 per cent, more energy through a tube backing up three
to four inches parallel spark-gap than any standard 20-inch (50-cm. )
coil. (See Fig. 101.)
By means of the variable inductance of the primary, the value of
which is changed by moving a switch, it is easy to adjust the voltage
delivered by the coil to suit the resistance of the tube being used, so as to
force the greatest amount of X-ray producing energy through it.
The switch -board is provided with a voltmeter and ammeter, a
switch for making connection for use of either the mechanical or electro-
lytic interrupter, a condenser-switch used in connection with the mechan-
ical interrupter, a reversing-switch to change the polarity of the dis-
charge, and a regulating rheostat.
The usual method of operation is to connect the tube to the coil, set
the inductance switch at point number 6, maximum inductance, connect
the interrupter desired, close the reversing-switch so as to allow the
current to pass into the primary, and adjust the current by means of the
regulating rheostat.
180
ELECTKO-T 1 1 K RAT K I 'TICS.
If the tube does not light up properly, the current is tin-own off, the
inductance switch changed, and the tube excited again. This adjustment
is very simple, and the proper inductance for any tube for skiagraphy or
for X-ray therapy is readily obtained.
(b) Tesla Coil. — The Tesla coil became universally known when
Routgeu's discovery was first verified throughout the civilized world.
The alternating currents resulting from, the action of this device are of
exceedingly high frequency (10 to 20 millions per second) as compared
with the Ruhmkorff coil with mechanical contact breakers ; whilst the
induced secondary electro-motive force of the Tesla coil is hundreds of
thousands of volts. Comparable to the rapidity of oscillations thus pro-
duced, is the discharge of a condenser or Ley den jar. These discharge
V
FIG. 77.— The Tesla oscillator.
FIG. 78.— Outer view of the same.
Currents are made to pass through the primary of an induction coil, devoid
of the usual iron core. The primary is made up of a very few turns of
thick wire ; the secondary has comparatively only a few turns of Mrire.
So great is the electro-motive force that the average non-conductor
would fail to effect insulation ; hence the necessity of immersing the whole
coil in an oil bath from which only the primary and secondary wires
protrude.
For charging the condenser, it becomes necessary to pass the alter-
nating current through a transformer, which raises its pressure to about
6000 volts. The existence of a bright, snappy spark, in the adjustable
spark-gap, indicates the discharge of the condenser.
The employment of the Leyden jar is fraught with much danger, if
care is not taken to make the primary circuit inaccessible. On the other
hand. sparks taken from the secondary of a Tesla coil are innocuous; but
the intense and continuous crackling produced by the primary spark-gap
is frequently terrifying to nervous patients and children.
Tesla Oscillator. (Figs. 77, 78.)— This device consists of three parts :
A vertical electro- magnet, well wound very many times with stout wire,
THE KOXT(Ji:X KAY APPARATUS. 181
possessing much self-induction. A condenser, which is charged by the
sell' induction of the electro-magnet on breaking the circuit which dis-
charges into the primary of the horizontal transformer. The latter is
composed of a single turn of copper ribbon, about six inches wide, and
its secondary consists of one layer of thick wire.
The working of the oscillator is as follows : The current from the
terminal, T2, magnetizes the electro-magnet, M, which, in attracting its
armature, breaks the circuit at B, and the high electro-motive force, due
to the magnet's self-induction, charges the condenser C. The discharge
being extremely rapid and oscillatory and flowing through the primary,
P. has its voltage increased in the secondary, S. The rate of vibration
should be tuned below one hundred per second. The oscillator is, for
some unknown reason, not put upon the market. In the laboratory it is
found to be inexpensive, compact, and very durable ; the absence of any
delicate wire and the general construction of the device aiford almost
indefinite immunity against any disturbance of its insulation ; but for
skiagraphic work, special tubes are demanded, because of the alternating
current generated by the oscillator.
(c) Kinraide Coil. — The Kinraide coil, the ingenious invention of
Mr. T. B. Kiuraide, of Boston, is a special modification of the Tesla coil
and possesses many features of merit.1 Among other things Mr. Kin-
raide remarks : "The coil I have succeeded in making was the result of
the repeated breaking down of the Ruhmkorff coils, ranging from six
to eighteen or twenty inches. I have succeeded very well in removing^
from the apparatus the danger of destruction so common to the ordinary
Ruhmkorflf coils, etc. My object was to remove the high -potential
region of the coil as far as possible from the primary. In my coil this
has been done, the low potential region of the single coil being the only
part it could come in contact with * * * * the moment the current
is broken, the lines of force collapse and fall inward in the direction of
the arrows. (Fig. 79.) In this way the highest potential is produced
in the outer terminal of a thin flat spiral secondary, if located in the
plane of the arrows, and the low potential at the centre. By that method
of winding, as the turns grow longer, the resistance per turn increases,
and the tendency of the discharge to pass from one turn to the other in-
creases. If a suitable primary were placed on the outside of this second-
ar\ . the reverse would be the case, and hence the tendency to break down
would be entirely removed in the section of the secondary. In my coil
this is the arrangement adopted, and the lines of force fall away from the
centre towards the primary in the direction of the arrows in Fig. 80, pro-
ducing a very high potential at the centre, and practically very little or
1 American Electro-Therapeutic Association, held at Buffalo, New York, Septem-
ber 24-26, 1901.
182
ELECTRO-TH ER APEUT I ( \S.
no potential at the outer turns, so that the centre discharges in (he
proportion of about six inches towards the earth wire whilst the outer
terminal discharges about three-fourths of an inch only. To remove all
tendency of discharge towards the primary, two of these coils were placed
FIG. 79.— Lines of force fall in the arrows in the older form of coil.
side by side (see Fig. 81). The two primaries are so arranged that a
high-potential positive and negative is obtained from the centre terminals
of the secondaries. There is practically no tendency whatever in this
form of coil to break down."
Fio. 80.— Shows the arrangement by which the lines of force fall away from the
centre towards the primary, as indicated by the arrows.
In order to present in a clear and terse manner the peculiarities and
advantages possessed by this recent invention, it is thought wise to
append tin- following abridged description.
The coil consists of two separate secondaries with their primaries
connected in series. Each secondary has a high ami low- potential
Till-: RONTGEN RAY AIM 'A II A 'ITS.
183
terminal, due to the position and the method of winding the primary.
The primary is located outside the secondary winding. The secondaries
arc wound in single flat disks and lie in the same plane as the primaries;
with this method of construction the discharge from the two terminals is
vastly different. The potential at the central terminal of the secondary
is extremely high, while that of the outer turns near the primary is very
low. By connecting the outer terminals of two such secondaries in series,
the potential of the outer turns entirely disappears, hence there is no
tendency to discharge into the primary.
There is absolutely no heating in the primary of the Kinraide coil,
as is the case with the Ruhmkorff, so that the insulation cannot be
melted, nor is there heat generated where it can in any way affect this
delicate part of the apparatus.
A valuable feature is the water-cooled spark-gap. The heat ordina-
rily developed in various parts of other coils is localized here, where it
can be cared for without trouble or risk. In other coils there is a single
FIG. 81. — Shows the arrangement of two coils side by side : A, A, secondary ; B, B, primary.
discharge from every interruption of the primary circuit. "With this
spark-gap we have a high-frequency apparatus giving many hundred dis-
charges, or surgings, in the secondary for every break or reversal in
the primary. This diminishes the time of exposure and increases the
steadiness of the illumination of the screen.
The interrupter is solid and durable, and with the spark-gap
embodies an entirely new principle, running at constant speed till the
motor is stopped. The alternating coil requires uo interrupter, but the
spark-gap is essential. The use of so little wire in the coil makes the
apparatus compact, strong, and portable. The current consumed is about
two hundred watts. It may be attached to any incandescent lamp socket,
either direct or alternating current.
184 ELECTRO-THERAPEUTICS.
(d) Trtiitxformrr icith Closed Magnetic Circuit, for X-rays and H'ujh-
rrx/Hi'iici/ ('iirnnfx. — Belot, iu his admirable work on Radiotherapy, thus
describes the above apparatus by Gaiffe & Co., of Paris:
"This new apparatus makes it possible to utilize an ordinary alter-
nating current, without au interrupter, either for the production of
X-rays or for high-frequency currents. It consists of an ordinary trans-
former, with a closed magnetic circuit, receiving an alternating current
of 110 volts, which it converts into one of 60,000 volts.
"The current should pass in one direction only. As the alternating
current produced by this transformer changes its polarity with each
oscillation, one series of waves must be absorbed before reaching the
tube. For this purpose two Villard valves are inserted in parallel with
the tube in a manner indicated by Villard himself.
"A commutator converts the continuous into an alternating current.
This installation is equally adapted for high-frequency work. It is only
necessary to remove the Villard valves and insert the spark-gap in order
to adjust it for this purpose."
I have seen Drs. B6clere in the St. Autoine and Chas. Infroit in the
Salpetriere Hospitals employing this apparatus with satisfactory results.
(e) Coil without Interrupter. — Max Levy read a paper before the
Rontgeu Congress in Berlin on a new form of apparatus in which a high-
tension alternating current is utilized without the interposition of any
interrupter or condenser. The current is made unidirectional by means
of a " strom -spalter," or current-sifter, — i. e., a pair of spark-gaps, by
means of which one phase of the alternating current is conducted to t he
earth while the other is used for driving the focus-tube. The author
expressed the opinion that within the next few years we shall see the
total abolition of interrupters for high-tension currents. I have seen
the Crookes tube well lighted up in his laboratory in Berlin.
Transformers. — Koch and Sterzel, of Dresden, exhibited before the
Berlin Rontgen Congress, a transformer, by means of which a constant
current is transformed into an alternating current through the agency of
a dynamo, which drives the secondary current- rectifier on the same
spindle, thus insuring synchronism. A step-up transformer with closed
magnetic circuit is used.
The Grisson Resonator. l — This is a device for dispensing with the use
of an interrupter, and thus doing away with the "make" current, which
is so destructive to the focus- tubes. A condenser of large capacity is
fitted with a commutator, and so arranged that it is charged alternately
to a positive and negative potential. This is connected to the primary
of an induction coil, whose self-induction is so adjusted to the capacity of
the condenser that resonance is obtained. When this is connected to a
1 Archives of the Rontgen Ray, April, 1906, p. 308.
THE BONTGEN RAY APPARATUS. 185
source of constant current, unidirectional impulses pass through the pri-
mary, and these are transformed in the secondary to the necessary tension
required for working the focus-tube.
Since at the end of each discharge the potential of the condenser falls
to zero, there will be no spark when the commutator is reversed. We
are therefore able to use a simple mechanical commutator, consisting of
a massive copper collector, with two rotating rings connecting its plates.
The current is conducted to these rings by means of contact brushes.
This commutator is rapidly rotated by an electro- motor. The primary of
the induction coil is introduced between the electric source and this com-
mutator. When the circuit is first closed there is a sudden rush of elec-
tricity through the coil, the current instantaneously attaining a maximum
value. As the condenser becomes charged, the intensity of the current
gradually decreases to zero. When this has occurred the commutator
will break the circuit without any sparking (since there is no current).
As the commutator makes contact again with the opposite plate of the
condenser, there will be another sudden rise to the maximum current,
followed by a gradual fall to zero, as this plate now becomes charged to
the potential of the source. The contact is again broken after the cur-
rent has fallen to zero. The primary of the induction coil is thus trav-
ersed by a series of undirectional impulses, each of which rapidly attains
a maximum value, and then very gradually falls to zero — the ideal form
of current for obtaining a practically unidirectional current in the sec-
ondary. A point of interest is that it is the "make" current which is
utilized in this apparatus, whilst the "break" is suppressed; whereas
in the ordinary coil our efforts have been directed to suppressing the
"make," and utilizing the "break" current.
II. Electrical Discharges in Partial Vacua and the Crookes
Vacuum Tube.
Before taking up a consideration of the Crookes vacuum tube, it is
Avell to observe that in a low-vacuum tube (Fig. 82) there is a column of
luminescence at the positive pole and extending toward the cathode
which is separated by a dark space (an interval in the illustration) desig-
nated 1he dark space of Faraday. In Fig. 83 the magnet, AB, shows
the deflection of the rays. As the pressure decreases, the luminosity in-
creases in volume, and as the pressure becomes still smaller, the lumin-
osity entirely disappears; on the other hand, as the vacuum increases,
there is a marked production of the cathode rays as shown in Fig. 84.
The deflection of the cathode rays is represented in Fig. 85. In Fig. 86,
the employment of one coneave i-athode in the presence of a number of
a mules is shown. As the vacuum is gradually increased, the base of the
cathodie cone becomes successively narrower as depicted in 2 and 3.
186
ELECTBO-THEKAPEUTICS.
y '
B
FIGS. 82, 83.— Discharge passing through low-vacuum tubes. (Bouchard. )
FIG. 84.— Cathode rays. The upper row are concave cathodes ; the lower rows are flat.
from left to right, is shown the progressive increase in the production of the cathode rays as the
pressure <s gradually decreased. (Bouchard.)
FIG. 85.— Deflection of the cathode rays. (Bouchard. )
THE RONTGEX BAY APPARATUS.
187
The rectilinear propagation of the cathode rays is represented in
Fig. 87, where the cathode C throws the shadow of the- mica cross A
ou the wall of the tube A'. Arouiid the shadow A' the tube shows a
pronounced phosphorescence.
A"
FIG. 8fi.— Illustrating the effect of one cathode and several anodes under different degrees of
vacuum. (Bouchard.)
A Crookes vacuum tube is an apparatus wherein electrical energy is
transformed into X-rays. These tubes present various shapes and modi-
fications, according to the requirements demanded. The essential in
FIG. 87. — Illustrating one of the phenomena in high vacua, — the rectilinear propagation of
the cathode rays. (Bouchard.)
the design of an X-ray tube includes a cathode of such shape as to focus
the cathode rays on a plate of dense metal, such as platinum, which either
is the anode or is placed near to it.
Fig. 88 is the illustration of such a tube. The cathode rays repre-
sented by the shaded area focus at a point on the anode, and at this point
l.ss
ELECTRO-THERAPEUTICS.
the X-rays originate, and from it radiate in every direction in straight
lines as light rays do from a source of light. They are represented by
broken lines. As platinum is not transparent to them, they are found
only on one side on the plane of the platinum and are practically of equal
intensity throughout that zone. If the platinum plate were absolutely
true and polished such would be strictly the case. As it is, in practice.
the rays are of equal intensity down to about ten degrees from the plane
of the platinum. In the majority of cases they are made of German soda-
flint glass, which presents an apple-green color, due to the fluorescence
produced by the X-rays under vacuum, this glass being extremely
transparent to the X-rays. Tubes
made of soft lead-glass give a pale
blue fluorescence, the lead acting as
a barrier to the passage of the rays,
hence this kind of glass is not so
desirable. Other varieties of glass
fluoresce in different colors.
The tube consists of a glass bulb
containing a single platinum- faced
target and one or more aluminium -
faced cathodes.
The anodes and cathodes are
connected to outside terminals by
means of platinum wires which are
encased by the extended glass stems,
the latter being fused during the pro-
cess of blowing. Oiten tubes are pro-
vided with an auxiliary anode, which
is invariably made of aluminium.
In order that the shadow-picture
may be sharply defined, the cathode
rays must converge or be focused to
a point, and to meet this requirement the aluminium cathode must pre-
sent a concave surface, varying in diameter from \ to 1 inch (.5-2.5 cm.).
The anode ( ant i- cathode) is made of platinum, and may have a varying
diameter, but it is usual to have its plane so adjusted as to form an
angle of 45 degrees to the cathode. Placed in this position the anode
behaves like a reflector, receiving and throwing off the rays emitted from
the cathode. Platinum has a high fusing point, and it is superior in
this respect to all ordinary metals; its use as the target for the cathode
lK>mbardment is because of its iufusibility. Very few other metals may
be used in its place. The most important of these substitutes is ind-
ium, which is another member of the platinum group and has a higher
Fio. 88.— Essential features of an X-ray tube.
THE RONTGEN BAY APPABATU& 189
fusion point than platinum itself. Osmium, which is also an infusible
metal of the same group, might be used.
Alloys of these metals, having varying percentages, are also used.
These infusible metals are to be backed up by ordinary metals such
as copper and iron, because the latter are less expensive and readily pro-
vide a large radiating surface and thermal capacity for the dissipation of
the heat produced at the focus-point.
The cathode is made of aluminium, because this metal disintegrates
least and causes the least discoloration on the walls of the tube. The
Crookes .tube contains a very high vacuum, — one millionth degree of
atmospheric pressure. In order to exhaust these tubes approximately
they are subjected to the action of mercury pumps. When a sufficient
vacuum has been obtained, the small glass tube that projects from, and
forms part of, the Crookes tube is removed from the pump receiver, by
melting it off and sealing it with the aid of the Bunseu burner.
A. THE VARIETIES OR TYPES OF VACUUM TUBES.
(a) Stationary Vacuum.
(b) SeJf -Regulating ttlld Regenerative.
(a) Stationary Vacuum. — A tube with a stationary vacuum is one
whose vacuum cannot be altered during its period of usefulness. This
marks the earliest type. The Crookes tube was originally pyriform
or cylindrical, and contained an aluminium cathode within a glass bulb.
The cathodal streams were projected on the extreme opposite side of the
tube, producing a peculiar fluorescence. In order to focus and subse-
quently reflect these rays Prof. Herbert Jackson, of King's College, Lon-
don, introduced the anode (anti-cathode) so as to reflect the cathode
rays.1 To this improved tube he applied the name " focus" tube.2
The priority of this modification is also claimed by Shalleuberger.3 As
the degree of vacuum in this type of tube is liable to vary either from use
or disuse, there is a constant danger of its permanent impairment. If
the tube be too hard (high vacuum), there is danger of puncture, and
impossibility of X-ray production. If the tube be too soft (low vacuum),
the rays will lack the required penetrability.
(b) Self-Regulating and Regenerative. — In this type of tube the degree
of vacuum is changed either automatically or by the operator, thus allow-
ing various modifications in the penetrability of the rays. This can be
effected by the action of gases derived from absorbent substances ; founded
on the principle that certain chemicals, — caustic potash, palladium,
1 Jackson was the first experimenter to employ a curved cathode.
2 Elect. Review, London, March 13, 1896 ; the Scientific American, April 4, 1896.
'Elect. World, New York, March 7, 1896.
190 KLK< TK( )-TH KK A PKl TI< S.
permanganate of potassium, etc.,- when placed in an auxiliary bulb
(low vacuum), liberate gases upon the application of beat and reabsorb
them upon cooling.
In 1S96, Mr. L. T. Sayen, of Philadelphia, devised a self- regulating
tube which has been placed on the market by Queen & Co. Its principles
are as follows : A small bulb, containing a chemical giving off vapor when
heated and reabsorbiug it when cool, is directly connected to the main
tube, and surrounded by an auxiliary tube, which is exhausted to a vacuum
of low resistance. In the auxiliary tube the cathode is opposite tin- al « >ve
mentioned bulb, so that any discharge through it will heat the bulb by
the bombardment of the cathode rays. The cathode is connected to an
adjustable spark point, the end of which may be swung to any desired
distance from the cathode (main) tube. The coil is connected as usual
to the main tube, which has been exhausted to a very high vacuum, and
consequently has a resistance equal to ten inches or more of air. When
it is put in operation the high vacuum of the main tube, and the conse-
quent high resistance, causes the current to take the path of least resist-
ance by the spark point and the auxiliary tube, and to heat the chemical
in the small bulb, thereby driving off the vapor which it contains into
the main tube. This will continue for a few seconds until a sufficient
amount of vapor has been driven into the main tube to permit the cur-
rent to go through it, which occurs when the vacuum has been reduced,
until the resistance of the main tube is equal to that of the spark-gap
plus the small resistance of the auxiliary bulb. After this only an
occasional spark will jump across the gap to counteract the tendency
of the chemical to reabsorb vapor and raise the resistance of the main
tube. The tube is thus maintained at a constant vacuum while running.
When the current is stopped, the tube returns to its starting condition of
high vacuum.
The construction of the tube should be understood before used, and
is as follows (Fig. 89): The large bulb "B" contains the main cathode
and platinum reflecting plate. The regulating bulb "D" is connected
with the main bulb "B." The cathode "C" in the main bulb is com-
posed of hammered aluminium, moulded to an exact curve of such ra-
dius that it focuses the cathode stream on the anode "A," which is
composed of platinum, and is the point of emission of the X-rays.
liull) " 15" is exhausted to a high vacuum, so that initially no elec-
trical discharge will pass through it. Bulb "D" is exhausted to a low
Crookes vacuum.
Within bulb "D" is a small pear-shaped bulb "X." in communica-
tion with bulb "B" and containing a chemical capable of giving off
\apor \vhen heated and reabsorbing it \\hencooled. A small cathode in
bulb "D" is arranged so that the discharge will heat this bulb "X."
THE RONTGE^ KAY APPARATUS.
191
Attached to this cathode is an adjusting spark-point "P," the end of
which may be swung to any desired distance from the terminal of the
cathode "C/'
When put in operation the high- potential secondary current will not
initially pass through the bulb u B" on account of its high vacuum, but
chooses a path from "K" to "P," through the bulb "D," heating the
chemical in the small bulb "X," causing vapor to be given off and re-
ducing the vacuum in the main bulb "B" until finally it becomes suffi-
ciently lowered so that the discharge passes through the bulb "B"
entirely, producing X-rays from the plate "A."
Let the spark-point "P" be separated about three (3) inches from
terminal "K." Start coil with small current flowing through primary
until sparks begin to jump vigorously between UP" and "K." Then
FIG. 89.— Queen's self-regulating tube.
open the primary circuit without changing its adjustment. Immediately
close again for a second or so, the spark passing from "P" to "K"
through and lighting up the small regulating bulb "D." Continue, alter-
nately, opening and closing the primary circuit, allowing the regulating
bulb "X'' to heat slowly until a green light begins to show in the main
bulb UB." Hold primary circuit open for a second or two, close, and
the bulb UB" will then automatically maintain its vacuum at the set
point, the primary current may be increased to the full capacity of the
tube, while only an occasional spark will pass between "P" and UK."
1C the bones appear in fluoroscope too black, make the gap between lt P'
and "K" greater. If not enough distinction between bones and flesh,
make less.
When tube is running properly, the main bulb will be filled with a
brilliant green light, with a sharp-cut zone through the plane of the
platinum plate, the upper section being more brilliant than the lower.
1!>L> ELECTRO-THERAPEUTICS.
Miiller, of Hoinburg, and E. Ducretet, of Paris, have brought forward
a tube, resembling in many respects the Sayeu tube, but differing from it
in that the regulating discharge passes directly into the auxiliary tube ;
the latter containing caustic potash. (Fig. 90.) When the vacuum in the
main tube becomes too high, and consequently the resistance too great.
the current passes into the auxiliary chamber, whereby the potash be-
comes heated aud emits vapor ; this vapor diffuses itself through the main
tube, thus lessening the too great resistance. Attached to the auxiliary
circuit is a lever that regulates the interval of the spark-gap ; the more
distant the lever from the cathode of the main tube, the higher the vac-
uum in that tube ; the nearer the cathode, the lower the vacuum.
Should the resistance in the main tube be in excess of that of the
spark-gap, the current takes the path of lesser resistance and passes
K—
Fro. 90.— Miiller's regulation tube.
through the side tube. The presence of sparks in the spark-gap shows
that the process is proceeding. Should the vacuum in the main tube be-
come too low (soft), disconnect the wire from the anode of the main tube
and attach it to the terminal of the electrode in the auxiliary chamber.
The discharge that passes under this adjustment causes metallic particles
to be driven against the sides of the tube and the generation of more gas
to be occluded on the electrode (auxiliary). Thus the vacuum of the
tube may be materially raised.
In order to clarify the alx>ve statements, it may be stated that the
auxiliary tube "B" contains an electrode, "C," of a substance which will
give off a certain quantity of gas by the electric discharge passing through
it. and will thus lower the vacuum. This is effected by approaching the
wire "E" to the cathode "K" aud thus permit! in- the spark to pass.
In case an even degree of hardness is to be maintained, the distance of the
TIN-: ROXT<;K.\ RAY APPAR.YTIS.
193
wire UE" from '• K" for hard rays t diagrams of the pelvis is 10-11 cm.,
for soft rays ('diagrams of the hand) 5-7 em., for treatment even less.
The working of the "Miiller regulation" maybe observed by the sparks
passing between ' • E " and
"K." As sooii as this
stops, the tube has the de-
sired degree of vacuum and
will maintain the same <m-
ioiiKificn//!/ by an occasional
spark jumping over and
reducing the vacuum, as
soon as the latter shows a
tendency to rise. In case
the automatic way of lower-
ing the vacuum should re-
quire too much time, it can
be hastened by either ap-
proaching the wire "E"
even closer to "K," or
finally connecting the nega-
tive pole to the loop "C."
In this latter event special
caution is recommended, as
tubes easily become too
soft and a hardening is
more difficult.
Hardening a tube is
effected by changing the
positive pole from 4<G" to
"J" and removing the
wire "E" far off from
"K." When the current
is now turned on, it will
scatter atoms of the metal
of the electrode UJ," thus
reabsorbing part of the gas
of the tube. This process
requires up to 5 minutes,
B
H
FIG. 91.— Monopol tube. The vacuum may be altered
during the process by the generation of air through the
disconnection of the movable conductor "Z," or by the ab-
sorption of air through the disconnection of the movable
conductor "H." The flexible wire "Z" is raised for some
seconds by means of an isolated rod until a spark leaps over
to the auxiliary cathode at "B," by means of which air is
generated and the resistance of the tul>e lowered. Tubes in
which the degree of generation has become excessive are
modified by raising the movable conductor " H " as shown in
the sketch. Air is generated by the disconnection of the
flexible conductor "Z" and the leaping over of sparks to
"B," and accordingly the degree of the vacuum in the tube
is lowered. Air is absorbed by disconnecting the flexible
conductor " H," and the resistance of the tube is increased.
according to the vacuum,
and may have to be repeated. It is not advisable to change the vacuum
of a tube too often. For different purposes different tubes should l>e em-
ployed. Tubes of varying construction have recently been brought forth1
1 Archives of Physiological Therapy, September and October, 1905.
IS
194 ELECTKO-THEBAPEUTICS.
that are worthy of brief mention. The Mouopol tube made by Hirsch-
niann of Berlin is especially devised for easy regulation of the vacuum
without interruption of the X-rays. (Fig 91.) Using a spintermeter
with ball terminals, he finds that each centimeter of spark equivalent
practically corresponds, with this tube, to the same number of the Benoist
scale of penetration. It is a biauodal tube, with a separate bulk at the
cathode end for lowering, and another at the anode end for raising the
vacuum, and either of these may be caused to operate by simply pulling
its movable arm with an insulated hook. This may be done while the
tube is in operation.
Heinz Bauer has made X-ray tubes in which the rapid raising of
the vacuum, due to the pulverization of the platinum anti-cathode is pre-
vented by causing the current to pass mostly to the anode. To this end,
the anode is pointed and contains quite a mass of metal ; besides this, a
regular small self-induction coil is placed between the external connec-
tion of the anode and that of the anti-cathode. Another of Bauer's t ulx-s
has a heavy corrugated copper stem for the auti -cathode, dissipating heat
inside the tube, and also externally, through a reentrant glass tube which
forms a part of it.
Method by Osmosis. (Fig. 92. ) — This method depends upon the prin-
ciple that heated platinum possesses the property of being penetrable
by hydrogen. A closed tube of platinum is sealed into the bulb of the
FIG. 92.— Osmosis regulating tube of Gundelach.
X-ray tube. When it is desired to lower the vacuum in the tube, the pro-
jecting platinum tip is heated to redness in a Bunsen flame. The heated
platinum permits the passage of gas through its pores into the tube, thus
lowering the vacuum. This process may be resorted to without inter-
fering with the working of the tube ; the degree of vacuum can thus be
gauged by the color of the fluorescence. A low vacuum is manifested
by a bluish tint, indicating that the heating of the platinum should
cease.
MecJuinical Regeneration. — This method allows of a variance in the
penetration value, by adjusting the distance between anode and cathode.
Its employment, however, is inapplicable, as it entails the sacrifice of
many tubes and requires an adept in manual dexterity.
PLATE I.
SELF-REGULATING X-RAY TUBE. OPERATING PROPERLY.
(FIG. 93.)
THE EOXTGEX EAY APPARATUS. 195
Electro-static Regeneration is founded on the principle that the dis-
charge passing through a focus tube is influenced by the charge general e<l
by electro-static induction on the outer surface of the tube. To accom-
plish this, the neck of the tube in the plane of the cathode edge is
covered with strips of tin-foil, and by connecting it by an adjustable
spark-gap with the ground or wire leading to the cathode. The method
gives some promise of usefulness, but the serious drawback is, the con-
stant danger of perforation of the tube.
Water-cooling tubes are those in which a stream of running water
passes around the anode, maintaining it in a cool condition, thus not
interfering with the degree of vacuum in the tube. In other tubes there
may !*> two anodes and two cathodes, which are adapted for the use of
the alternating current.
B. THE QUALITY OF THE X-RAYS.
The qualities of the X-rays depend largely upon the apparatus and
the degree of vacuum of the Crookes tube. Thus, while the quantity of
the electrical energy influences the intensity of the rays produced, the
condition of the tube is the predominating factor when a constant and
powerful supply of X-rays is required. Tubes are thus said to be
"soft," "hard," or "medium."
A tube is said to be "soft " when the degree of vacuum is low, thus
offering less resistance and allowing the current to pass easily, but with a
diminution in the intensity and likewise in the penetrability of the rays.
In a "hard" tube the degree of vacuum is high, resistance is there-
fore increased, and a greater obstacle is presented to the passage of the
discharge. The radiation gains thereby in intensity, as also does the
penetrative power.
The "medium" tube occupies a place intermediate between the
••hard" and the "soft."
J. M. Eder and E. Yaleuta1 observed that the effectiveness of a tube
varied with its degree of vacuum.
Porter2 thus classifies the rays:
Xrrays penetrate the soft parts easily, but the bones with difficulty.
X 2 -rays, those absorbed by the soft tissues.
X , rays, those readily penetrating both soft tissues and bone.
Albers-Schouberg* considers four degrees of vacuum :
1 , hard ( gra y ) . 3, soft ( deep-black) .
2, medium eoft (gray-black). 4, very soft.
1 Vers. n. d. Photo, niittel-st der Rdntgenstr. , Wien und Halle, 1896, p. 5, Anm.
2 Quoted by Valenta, Oest. Chemikerztg., I. Nr. I. 1898.
'Fortsrhr. a. d. Geb. d. ROntgenstr., I5<1. iii., H. 4, p. 143.
196 ELE( TK( )-THEEAPEUTI( \s.
The intensity of the shadows of the metaearpal bones on the fluor-
escent screen is taken as an index.
Kienboek recognizes a fifth grade, the "over-hard" tube.1
The success in skiagraphy most largely depends upon the quality of
the rays and the behavior of the focus-tube.
Until the present time, although the form, size, etc., of the tube
have steadily improved, the majority of operators will sustain me when I
assert that in order to make a good skiagram the knowledge of the decree.
of the penetration of the rays is most essential.
I have enumerated the various methods for ascertaining the approxi-
mate penetrability (quality and quantity) of the rays, but those methods
are as yet quite crude. This subject is fully treated of under Ilontgen
Ray Therapy.
The degree of the vacuum of the tube changes during or after
active work, so that the operator cannot predict exactly the degree of
penetrability of the rays; hence the time of exposure still remains
uncertain.
Testing the rays with the fluoroscope by the shadow of the bones
of the hand is most dangerous, and is virtually not employed to-day
except by some of the inexperienced and most careless. The osteoscope
of Carl Beck substitutes the skeleton hand for the human hand, but this
is injurious to the eye, no matter how well the latter is protected with
lead (flint) glasses.
Fluorescence of the tube is an inexact measure, and the degree of
redness of the anode is unreliable. Each tube behaves differently with
different types of interrupters, currents, and coils.
Spintermeter or Parallel Spark-gap. — The length of the spark-gap va-
ries with different voltages of current, the shape of the spark-gap, the
winding of the coil ; the degree of the vacuum of the tube or its resistance
cannot be ascertained because of the distance of the anode from cathode,
and the varying sizes of the latter may cause more or less resistance.
I have tubes that back up 4 to 5 inches (10 to 12.5 cm.) parallel
spark-gap, and yet produce cathode rays bluish in color and conical in
shape, which are useless for penetration ; therefore the resistance of the
tube does not always indicate the penetrability of the rays."
C. CARE OF THE TUBE.
Before using the tube see that it is absolutely free from dust particles
by employing some soft fabric as a wiper, exerting as little pressure on
main bulb as possible. The tube should always be perfectly dried by
allowing the heat from a gas jet to pass'around it.
1 Wiener klin. Woch., 1900, No. 50.
2 See Part III., Chapter IV.
PLATE II.
SELF-RK<;ri.ATlN(i X KAY 1TBK. CTRREXT RTXXIXG IX WRONG
DIRECTIOX.
(FiQ. M.)
THE RONTGKN RAY APPARATUS. 197
The leads from the terminals of the secondary coil should be per-
fectly insulated and sufficiently separated from one another through-
out their entire length to prevent any sparking between them. These
wires must not come in contact with any conducting material, which
would naturally permit of leakage of the current. The conducting wires
should be sufficiently distant from the surface of the tube to prevent
puncturing. Such a puncture is usually from a spark jumping through
the glass wall from the conducting wire to the electrode within the tube
of opposite polarity. Puncture of the tube renders it useless, in some
ruses presenting an immediate change of color. Sparking occurs between
the anode and cathode from the inrush of air ; in other cases the injured
tubes may be worked for two or three hours after the accident. If the
auxiliary bulb lights blue or red, the vacuum is low and a puncture or
leak may be suspected. (Fig. 07.)
In operating a tube see that the current is sent into it in the proper
direction, or blackening will soon occur on the inside, manifesting itself
by disintegrating platinum particles. Should the current conductors be
connected to the tube in reverse order, the error will be recognized by a
brilliant jumping fluorescence around and behind the platinum target.
With proper connections there is a steady fluorescence of the hemisphere
in front of the anode. As the X-ray apparatus is provided with a com-
mutator, the current can conveniently be reversed without altering the
connections and position of the tube. Figs. 93 and 94 illustrate the
proper and the wrong connection of the tube.
Blackening of the Tube. — As already mentioned, blackening of the
tube often results from the l ( inverse' ' current, but this can be avoided by
placing the spark-gaps in "series" of intervals of two or three inches
either in one or both ends of the terminals.
Lately I have seen the whole inner surface of the tube darkened by
an impure alkaline substance thrown off from the auxiliary bulb. The
tube was opened, and, by the aid of an acidulated solution, the substance
causing the discoloration was dissolved, showing that the blackening was
not due to disintegrated platinum particles, but to the impurities of the
potash in the auxiliary bulb. Had this blackening been caused by the
disintegration of the anode, the discoloration would have been manifested
only at the active hemisphere.
In place of the spark-gap in " series," Villard urges the employ-
ment of a veutril tube with a proper degree of vacuum for the current,
. instead of its passage through the air. (Fig. 95.) By employing the
ventril tube the current becomes unidirectional, the rays have a
greater penetrative power, blackening is minimized, and the " life " of the
tube is prolonged. I find the self-regulating veutril tube to be eminently
satisfactory.
198 ELECTKO-TH E I : A I ' 1 •: T T I ( 'S.
Puncture of the Anti-cathode. — This accident occurs only in tubes
with very thin and non-supported anodes : especially did puncture of
the anti-cathode happen when the Wehuelt interrupter first came into
use. This difficulty has been overcome by increasing the thickness of
the anode, and also by reinforcing it in back by means of copper ; like-
wise by making the converging cathode rays fall at a point a little in
advance of the anode.
Explosion of the Tube. — When a tube is accidentally broken, the
sudden inrush of air produces a report resembling that accompanying
the explosion of a firecracker. I believe the term '-explosion" is a
misnomer; the substitution of the term " collapse" would appear to me
FIG. 95.— Villard's ventril tube.
to be more correct, for the general breaking up is more likely the result
of external atmospheric pressure than due to any force created inter-
nally. In the experience of years I have never suffered the explosion of
a tube.
The "life" of the tube depends largely on the amount of its use,
and the care in manipulation bestowed upon it. The metallization of
the tube interferes in no manner with its working.
In regard to the consumption of tubes by the use of small and large
inductors the conclusions reached by Albers-Schonberg are of the greatest
practical importance. He has kept a complete record of the use of each
tube and the conditions under which it was used, and concludes that the
life of a tube used with an 80 cm. coil is more than three times as long
as when used with a 40 cm. coil. The small coil used in this instance
was the Dessauer instrument. At the same time he found that the work
done by the tube in connection with the large coil was more satisfactory.
In order to get the desired results with the small coil it was necessary to
use a ventril tube in series with the Kontgen tube, while with a large
coil none was used.
When the vacuum becomes so high or so low (Fig. 96) that it is
pii-uited for the operator's purpose, and his efforts to restore a proper
vacuum are unavailing, the only remedy is a repumping of the tube by
the manufacturer.
PLATE III.
SELF-REGULATING X-RAY TUBE. LOW VACUUM.
(FIG. 96.)
THE RONTGEN RAY APPARATUS. 199
III. The Fluoroscope and Accessories.
A. COXSTRrcTIOX OF THE FLUOROSCOPE.
The fluoroscope, also called cryptoseope and iristoscope, was devi>ed
and first described by Professor Salviui, of Rome.1 It cousistvS of a dark-
ened chamber, having the shape of a photographic camera. At the
larger end is fixed the fluorescent screen; at the smaller end is an opening
(fitting the examiner's forehead) through which the shadows on the
screen may be observed. With a fluoroscope a darkened room is unnec-
essary. The majority of fluoroscopes are provided with a handle for
holding the apparatus. More recent ones are so constructed as to permit
of the easy removal of the screen. (See Fig. 104. )
The fluorescent screen mentioned above consists of a coating of
platino-cyanide of barium, spread evenly upon a supporting sheet. A
layer of varnish is carefully applied, so as to prevent this fluoresciug
material from falling off, and likewise to keep it dry. As the fluores-
cence of the screen is not very brilliant, a dark room must be employed,
otherwise rays of ordinary light will interfere. The screen being adjusted
in the frame, the chemical surface further protected by isinglass, and
the light excluded from the tube by means of black paper, beautiful
shadows are portrayed by placing the object between the tube and the
screen. When not in use the screen should be kept free from dust and
moisture.
There are other chemical agents besides those mentioned which pos-
sess fluorescent properties and are adapted for screens. Thus Edison, who
examined 1800 chemicals,2 found that tuugstate of calcium fluoresced with
six times more intensity than platino-cyanide of barium; next in bril-
liancy was tungstate of strontium. Salicylate of ammonium (crystals)
fluoresces as much as double cyanide of potassium and barium; the
former's fluorescence, however, increases with the increase of the thick-
ness of the crystal layer. Other substances that fluoresce under the ac-
tion of the rays are mercurous chloride, caduiic iodide, calcium sulphide,
potassium iodide, potassium bromide, etc.
The only two of the many fluorescent salts employed in the manufac-
ture of screens are platiuo-cyanide of barium and calcium tuugstate. The
former affords a brilliant yellowish -green fluorescence, the latter a less
intense bluish-white. This bluish white fluorescence offers a greater
photo -chemical activity, and is therefore employed as an intensifying
screen in radiographic work. Under the name of "the collapsible
cryptoseope," H. W. Cox & Co., Ltd., of London, have placed upon the
1 Proceedings of the Accademia Medico-Chirurgica di Perugia, vol. Hi., No. 1-2 ;
also the Scientific American, March 28, 1896.
2 Elect. Review, New York, April 19, 1896.
200 ELECTRO-THERAPEUTN S.
market a fluoroscope, which apparatus is fitted with accordion folds,
that readily permit of easy adjustment. This cryptoscope has gi ven
satisfaction, but its exorbitant price makes us general employment
prohibitory.
B. SKIAGRAPHIC TABLE.
A skiagraphic table consists of a strong rectangular frame of wood
over which is stretched some fabric, or thin leather, which is radio-
scopically transparent. The frame, which is supported by four uprights
(one at each corner) 18 to 20 inches high, may be covered by a piece
of thin, strong board, in order to make it more steady. In making a
screen examination, the patient is placed upon the couch with the tube
under it, the rays penetrating from below upward. In taking a skiagram,
the sensitive plate is placed under the patient and the tube above, the
rays passing from above downward. Do not move the screen or the pa-
tient if a skiagram is to be taken after making a screen examination :
hence an adjustable plate-holder should be fitted to the couch. The tube
may be shifted and clamped in any position.
C. HOFFMAN'S MEASURING STAND AND EXAMINING FRAME.
This consists of two uprights firmly secured to a platform, and sup-
porting the square or rectangular shaped measuring frame which can be
shifted up and down or to the right or left, by turning a few thumb-screws.
The adjustable frame is subdivided into smaller squares. The dividing
cross-bars are so constructed as to permit of their being shifted into any
position and their exact location noted by reading the metric scales at
the sides. Accessory frames are placed at the outside of the uprights ;
one of these acting as a plate-receiver for a skiagram , another supports
the fluoroscopic screen for a visual examination.
Lately I devised a table that meets the requirements for skiagraphy,
stereo-skiagraphy, and X-ray treatment. (See Figs. 183 and 184.) It is
made of wood, and upon the two parallel horizontal metallic tubes, t\v<>
vertical metallic rods move to and fro, the latter supporting a horizontal
sliding bar of wood, from which is suspended the tube-holder. For skia-
graphy the tube can be placed under the table, over the table, or in any
position in relation to the patient's body. The table is provided with
an adjustable plate-holder. The device can be regulated so as to be
adapted to any sized plate ; it is attached to the vertical rods. This plate-
holder with the plate is placed over the part, with the tube beneath the
table, or in the sitting posture the plate is placed against the part, and
the tube behind the patient. In stereo-skiagraphy the plates can be
changed without employing the usual drawer. For treatment, the tube
is placed in a leaden lined wooden box, having an adjustable diaphragm
PLATE IV.
SELF REGULATING X-RAY TUBE. PUNCTURED OR CRACKED.
BULB PARTIALLY FILLED WITH AIR.
(Fro. 97.)
THE BONTGEN KAY A I'l'A I {ATI'S. 201
with any required sized opening, which is regulated by sliding the mov-
able pieces of wood composing it. The burs and tubings are scaled in
inches and centimeters to facilitate the ease of measurements required of
the operator.
D. TUBE-HOLDERS.
These are of various kiuds. For clinical purposes it is essential to
have a stand, in order that the tube may be adjusted to any desired height
from the floor, at the same time allowing it to project far enough to en-
able to operator to shift it at ease over the examining table or couch.
The base must be heavily weighted, to insure steadiness, and the project-
ing arm must be firmly clamped. The latter is made of wood or ebonite
to prevent any spark from the terminals passing into the metal and thus
perforating the tube. Loose clamping must be studiously guarded
against ; lack of this precaution will produce a blurred photograph, as
the swinging tube is made readily tremulous by the amplification of any
motion communicated to the stand and arm.
The majority of tube-holders slide on a horizontal bar, the latter
being supported by two vertical ones, or it may have independent sup-
port from a heavy iron tripod on the floor. The disadvantage of these
constructions is that the tube may move or shake if attached to the table,
it is clumsy to handle, occupies too much space, and stands in the way of
the operator. In offices a couch can be used as a table. It is soft and
convenient, and is useful for therapy and examinations. Above the
couch, attached to the wall, are two wooden rods grooved on their inner
surfaces. A square block of wood slides between the grooves of these two
rods, the whole being supported on brackets. Attached to this square of
wood, and at right angles to it, is screwed a movable rod, which by tight-
ening or loosening the screw can be adjusted to any angle. This last rod
has a small sliding transverse block of wood through which passes the
vertical metallic rod, holding the clainp. A similar metallic rod is
attached to a sliding rod for supporting a leaden screen, which protects
the operator.
Lately I devised a tube-holder in my office made up as follows : A
shelf, made of two horizontal bars grooved in their interior, is bracketed
upon the wall. Along these grooves slides a block of wood (the carriage).
To this carriage is attached a projecting bar of wood, whose angle may
be varied at pleasure by adjusting the thumb-screw maintaining its rela-
tion with the carriage. By means of an adjustable screw, a second block
of wood (transverse to the long axis of the projecting bar) is made to slide
to and fro at the will of the operator. Through this latter bar runs the
metallic rod. supporting the tube-holder. By means of this holder, free-
dom of movement is so obtained that the principles of the universal joint
202 KLE( TRO-THERAPKUTICS.
are faithfully portrayed. With this tube-holder the table is dispensed
with, and a couch or sofa is substituted upon which a board is placed it'
necessary, for supporting the sensitive plate. (See Fig. 200.)
E. BOX-COVER FOR X-EAY TUBE.
This consists of n wooden box covered ou its inner surface l»y a thick
coating of lead oxide. On one side of this box is a hole (4 to 5 cui. in
diameter) for the transmission of the rays. This circular aperture is
shielded by a wooden diaphragm of heavy sheet lead, having three differ-
ent sized apertures, and by adjustment the desired opening can be brought
in direct line with any part of the body. Luminous effects are excluded.
and the dangers of burning by the rays are reduced to a minimum. It
must be remembered that the diameter of the rays (cone-shaped
increases as the distance the tube is placed from the patient.
In some tube boxes, instead of the lead foil, several layers of lead
paint are used for coating the interior of the box. The size of the box
varies in different models. In some instances they are made so large as
to be an inconvenience, while in other cases they are too small to secure
perfect insulation.
F. DIAPHRAGM.
The diaphragm was formerly used for sharpening shadows ou sensi-
tive plates. It may be made of metal or glass, with an aperture in the
centre for the transmission of the rays. In the glass variety, the excess
of lead acts as an obstacle to their passage, the rays being almost wholly
transmitted through the aperture. If the diaphragm is metal, it should
preferably be grounded, to obviate the danger of puncturing the tube by
sparks jumping from it. The object of the diaphragm is to prevent the
passage of the rays to other parts than those examined.
Compression Diaphragm. — This appliance, devised by Albers-Schon-
berg, consists of a metallic tube, having one end applied against the part
to l>e skiagraphed, and the other end so adjusted as to receive the rays
emanating from the Crookes tul>e. By its use we secure immobility of
the part, mechanically lessen the thickness of the structures under exanii
nation, and totally exclude all the secondary rays. (Fig. 09.) In Fig.
98 is illustrated the ordinary diaphragm, wherein is depicted the passage
of the indirect rays, b b, affecting that portion of the plate indicated by
the slanting parallel lines; this is entirely obviated in the compression
diaphragm, where a a are the direct rays from the anode. (See also Figs.
192 and 193.)
Dr. Henry Hulst1 states that the use of this diaphragm is most valu-
able in the skiagraphy of renal, spinal, and pelvic conditions. Thus, in
•Transactions of the American Runt-gen Ray Society, September, 1905.
THE ROXTGEX KAY APPAR ATI'S.
203
cases of suspected renal calculi, the employment of the compression dia-
phragm materially lessens the number of diaphragmatic movements of
the patient, and as the kidney moves with each movement of the patieut's
diaphragm, the steadiness of the kidney is markedly increased, in conse-
quence of which, a skiagram of a renal calculus will not be blurred.
The serious disadvantage of the compression diaphragm is the fact
that only a very small area cau be skiagraphed at one time, while the
II
FIG. 9s— ordinary diaphragm.
FIG. 99.— Tubular or compression
diaphragm. (Donath.)
stone searched for may be located outside the part covered by the cylin-
der. This method prevents a negative being taken of both sides for the
sake of comparison ; a most necessary and invaluable guide.
Although largely used in Europe and America, I do not advocate
the employment of a compression diaphragm, as, with greater refinements
in the technic, the time of exposure has been so materially lessened that
there is a marked decrease of the secondary rays, and without the
diaphragm a large area is exposed for examination on the plate.
IV. The Selection and Installation of X-ray Apparatus.
A. SELECTION" OR CHOICK.
In equipping an X-ray laboratory several factors must be considered.
The scope of the work, the portability of the instrument, the necessary
expenditure that will be incurred, the requirements of the apparatus for
the office, the city or country hospital, and the fact whether the purchaser
is an X-ray specialist or a general praetitioiier.
By the scope of work to be accomplished we mean the extent of use-
fulness of an X-rav outfit. A small coil will suffice for the work that a
204 ELK< T IH >-T 1 1 K II A I ' KUTICS.
beginner may be required to do, but the purchase in the beginning of a
large coil, which will prove more lasting, is wisest because increase of
work will early demand this improvement in the apparatus.
Hospital (City or Country). — In the majority of city hospitals a 110-
volt current is supplied for working a coil. The coil that is installed
in the laboratory of a large city hospital should have a spark length of
from lii to 20 inches (30 to 50 cm.). It should be so constructed as to be
capable of conveyance to the various parts of the hospital. The coil
can be worked by attaching a connecting head to one of the electric light
sockets from which leads extend to the coil. If the hospital is not lighted
by electricity (110-volt current), it becomes necessary to prepare a place
on the main shelf of the carriage, or on the second shelf, for placing a stor-
age battery, by which means the coil then must be worked. When patients
can be conveyed from the bed to the laboratory, much labor is saved.
In country hospitals and sanitaria, where there is difficulty in obtain-
ing either continuous or alternating current, static machines are recom-
mended for exciting the Crookes tube, and also for therapeutic purposes.
For exciting a tube the use of a water motor or a small gasoline or gas
engine must be resorted to. If expense be a matter of moment, I then
recommend a coil worked by a secondary battery. The physician's or
surgeon's outfit should be portable. He should employ an 8- to 10-inch
(20-25 cm.) spark, worked by a storage battery. For examinations in
a private office the use of a static machine (run by an electric motor), in-
stead of a coil, is recommended. The expert should have in his posses-
sion an outfit capable of meeting all emergencies. It should consist of
two coils and a static machine. In his private office he should have a
stationary coil with a spark-producing power of from 18 to 22 inches
(45 to 55 cm. ), and a second coil so constructed and arranged as to allow
of its ready transportation, the latter to be capable of giving a spark
from 8 to 10 inches (20-25 cm.) long. This portable coil should be
worked with a storage battery.
Portable Outfits. — The necessity of moving an X-ray apparatus re-
quires the outfit to be as compact and light as possible. In the latest
forms of apparatus the coil and accessories are carefully fitted into a case
which makes it readily transportable. The cumbersome storage battery
must be conveyed separately with the coil, etc. The latter should be 8
to lo inches (20 to 25 cm.). The more recent accumulators are very light
and compact.
B. INSTALLATION.
It remains to give a brief resume" of the arrangement and manage-
ment of the different parts concerned in the production of a skiagraph.
The first essential is to determine the nature of the current available.
THE RONTGEN RAY APPARATUS.
205
The coil can be eiiergized by an accuiaulator or by the continuous or
alternating current from the street supply. In the latter instance the
transformer is necessary to reduce the enormous voltage. Some place the
coil upon the table ; my own preference is to rest it upon a shelf attached
to the wall, thus space is saved and the operator is kept away from the
S. Coil
FIG. 100.— AUTHOR'S TABLE AND TUBE-HOLDER.— The pulley moves the tube-holder to and fro.
The ventril tube is connected in series with the Crookes tube and lessens the " reverse current," whose
vacuum can be lowered, at pleasure, by the operator compressing, at a distance from the tube, a bulb,
which drives a blast of air into a gas flame, thus allowing the heating of the platinum in the ventril
tube.
magnetic field. The latter method is prevalent in Germany. The con-
trolling apparatus (the interrupter, rheostat, switch-board, etc.) should
be within easy reach. After installing the coil, the source of current ran
be connected with it by the use of the switch -board. The switch-board
is provided with several binding posts, the latter being connected with
206
ELECTBO-THEKAPEUTICS.
^-
THE EOXTGEX RAY APPARATUS.
207
tlie accumulator and likewise with the direct current. A double switch-
thrower connects the current with either the accumulator or the direct
current. Another switch can be made to connect the current with either
the mechanical interrupter or the Wehuelt break. For charging the
FIG. 102.— Author's office outfit.
accumulator a bank of lamps is provided ; the remainder of the switch-
board is made up of the fuses, the ammeter and the voltmeter. The
author's table and tube-holder and method of installation are illustrated
in Figs. 100, 101, and 102.
C. POLARITY AND CONNECTION OF TUBE.
Next to be considered is the connection of the terminals of the sec-
ondary coil to the tube. To do this properly it is necessary to ascertain
the polarity. The following methods may be applied :
(1) Dip the ends of the two wires into dilute sulphuric acid or
water. The negative wire shows a free development of gas; this does not
occur with the anode, which is colored black from the deposition of
copper oxide.
(2) Moisten the paper with potassium iodide, bring the poles in
contact with it; the presence of a black stain indicates the anode.
(3) By means of a small tube filled with a liquid into which plat-
inum wires project; the application of a negative pole is followed by the
liquid being dyed a red color.
(4) The polarity can also be determined by the peculiar color of
the spark on the terminal electrodes of the secondary coil ; the cathode
shows the presence of a thick, whitish spark, while the anode shows
several wiry lines of spark of a pink color. (Fig. 103.)
208 ELECTRO-THEKAPEUTICS.
The leading wires should be connected with the proper terminals of
the tube by thin, well- insulated copper wire. This connection to the
terminals should be provided, on each side, with at least one inch of
spark-gap. The wires should be separated at a distance from each ether,
from the tube, and also the patient, greater than the length of the parallel
spark-gap (where the wires are attached to the tube they are supported
by a non-conductor). The current must not be turned on before all con-
nections are completed, else there is danger of severe shock both to the
operator and the patient. "Wrong polarity can be easily determined by
the appearance of the tube, and corrected by the commutator.
After the polarity has been ascertained the ends of the tube may be
connected to the respective terminals. The connecting wires should l»e
thickly coated with gutta-percha to prevent leakage and also possible
puncture of tube. There should exist multiple spark-gaps in series, as
FIG. 103.— The polarity as determined by the appearance of the spark.
this device improves the quality of the rays and prevents or lessens the
" inverse " current within the tube. After the tube has been lit up, the
spark-gap between the ends of the tube and the brass balls should be
adjusted until the best results are obtained.
Advantages of the Static Machine. — The static machine requires little
attention and is nearly always ready to generate electrical energy, of a
high potential. The current is almost perfectly continuous through the
tube, and hence the illumination of the fluoroscope is steady. The radi-
ation and the penetration of the rays of the tube may be modified by
varying the interval of the spark-gap (in series). The static current
may also be used as a therapeutic agent.
Disadvantages of the Static Machine. — Should the beginner purchase a
coil or a static machine for X-ray work ? A definite answer cannot be
given unless the scope, kind, and the place of work be considered. I
employ both the static machine and the coil, the static for electro-thera-
peutic purposes, and the coil for X-ray work. I have stated the merits
and demerits of the static machine ; the converse of these assertions holds
THE ROXTGEX KAY APPARATUS. 209
good for the coil. If the leads are freely u brushing" the tube may be
seriously interfered with. These brush effects fill nervous patients with
fear; hence it is difficult to keep them steady for a sufficient length of
time required for the exposure. It must be remembered that a small am-
perage of static current does not produce the necessary penetration for
good skiagraphic or fluoroscopic effects of the deeper structures of the
body, nor is it adapted for short exposures ; this can be partially reme-
died by augmenting the number of plates or by increasing the speed.
If non-breakable plates are employed, the speed of revolution may be
increased manifold, without increasing the number of the plates, and
the deficiency is thus overcome in X-ray work. Other objections that
may be urged against these machines are their bulkiness and the sudden
and frequent changes in their polarity and failure to work in damp
weather.
14
CHAPTER II
THE PRINCIPLES OF TECHXIC.
I. Fluoroscopy.
briefly described the X-ray apparatus and the modes of its
manipulation, we shall now dwell upon the methods of its practical
application.
When conducting such examinations, it is essential, though not
absolutely necessary, to have the room darkened so as to exclude ordi-
nary light. Of course the rays are invisible. The means employed
for detecting the presence of the invisible Rontgen rays are (1) by its
physical effects, — i. e., the ability of these rays to produce a fluorescence
from certain substances ; (2) by the chemical effects taking place on the
sensitive plate.
For making fluoroscopic examinations we may employ either the
fluorescent screen or the closed fluoroscope. A cryptoscope has been
brought into the market which allows of the detachment of the screen
from the hood, Fig. 104, thus permitting of the use of the former
without the cumbersome attachment
A. METHODS OF EXAMINATION.
(a) Screen Examinations. — By daylight the fluorescence of the screen
is wholly imperceptible. Hence the necessity of excluding any light
that might fall upon the screen and the eyes of the examiner.
The brilliant fluorescence becomes manifest only in a darkened
room, and, therefore, as in Rontgen's original experiment, in order to
exclude this extra light the tube should be covered with some dark
material.
The examiner holds the open screen in his hands, shifting it to the
part desired, or it may be clasped to an adjustable rod attached to a frame
which rests upon the floor. When the open screen is used, it should l>e
brought as close as possible against the part under examination, so as to
bring out the shadows more distinctly.
Prior to covering the tube, it must be placed in its proper position,
preferably with the platinum anode pointing toward the operator; the
patient is then placed in front of the excited 1nlx>. (The cryptoscope is
used in a lighted room.) In order to make a thorough examination the
examiner's eyes must w\ accustomed to the darkened condition of the
interior of this apparatus. "When used on a sunny day, only the dark
contour of the part under examination is first seen, gradually giving way
to the more distinct details. Long and frequent examinations by this
210
THE PEINdPLBS OF TECHNIC.
211
means tire the eyes, often producing conjunctivitis among operators.
For superficial and preliminary examinations this appliance is indispen-
sable, but for deep examinations the open screen and dark room, with the
tube's phosphorescence shielded, are to l>e recommended.
FIG. 104.— Detachable fluoroscope and screen.
With a cryptoscope only one person is enabled to view the images
cast upon the screen. "When the screen alone is employed a group of
persons can see the existing conditions, hence, the latter7 s value for
demonstrative purposes.
(b) Preparation of IJtc Patient. — Always remove the clothing of the
patient from the part which is to be examined, permitting in some
instances the retention of the under garment, which should, however,
always be free from wrinkles. Pius, buttons, and any other metallic
structures which would cast shadows upon the screen must be removed,
to prevent an incorrect diagnosis.
In surgical cases where fine detail work is demanded, it is necessary
to remove all the garments from the part to be examined, also splints,
bandages, and powder dressings, as acetanilid, iodoform, boric acid, and
plaster of Paris, all of which produce shadows upon the screen. The
retention of wooden splints, though offering little or no obstruction to the
rays, interferes with a thorough examination of a part on account of the
immobilization of the joints, the ends of fractured bones, etc. These
splints act as stays and do not permit of any movement of the part or
of the close approximation of the screen.
I'll'
BLECTKO-THEKAPEUTICS.
(c) Position of the Tube. — The tube should be carefully clamped into
the notch of the holder so that the platinum anode points to the sen-en's
centre, causing it to fluoresce equally. The rays should pass in a straight
line and not obliquely from the tube to the object. AVhen examining the
FIG. 105.— A STUDY IN SHADOW DISTORTIONS ( FLUOROSCOPIC OR SK.IAGRAPHIC) WITH CORRE-
SPONDING DENSITY DIFFERENCE.— A, Anode parallel with the photographic plate. B, Axis of the tube
parallel with the plate. C, Tube midway between the above positions.
1, Either position of the object will throw the same shadow ; the darker portion indicates the
denser portion, whether the vertex is up or down. 2, Shadow smaller and denser. 3, Same object
slightly enlarged. 4, Cylinder or bone. Shadow denser at the extremities, because the rays must trav-
erse more substance at those positions. 5, Metallic cylinder. To ascertain the perpendicularity of the
rays, cross wires are placed upon both ends, when the shadows of the latter will superimpose on the
plate or fluoroscope. If these shadows do not superimpose, the rays are taking an oblique course.
6, Penny on its edge. The shadow line is dense, as the rays traverse much substance. 7, Stir:;;.
of the same. 8, Fracture of two bones. The shadows, being superimposed, cast a very dense shadow.
9, Rays traverse through less substance when the bones are longitudinally arranged, and cast less dense
and separate shadows.
thorax, for example, the tube should be so positioned as to cause the rays
to fall perpendicularly upon the screen. When examining a field near
the first, it is advisable to have the tube remain stationary, and to move
the patient as necessary.
Experience alone will guide the beginner as to the distance most suit-
able for producing the best images upon the screen. For fluoroscopic
PRINCIPLES OF TKCHXIC. 213
work the patient is usually brought closer to the tube than when a skia-
gram is taken. The shadows on the screen may often be sharply brought
out by a careful and systematic adjustment of the distance between the
patient and the tube.
(d) Position of Patient. — The patient may be examined by means of
the fluoroscope in the lying, sitting, or standing positions.
(e) Size, Shape, and Intensity of J//wv <>n the Screen. — The X-rays
diverge as they are projected from the anode. The shadow thrown on
the screen, therefore, will be larger than the object itself. If the object
is brought closer to the tube the distortion in size will be increased. The
further the 11 uoroscope is separated from the object, the larger but less
definite will be the shadow cast. If the rays do not fall perpendicularly,
the shadow on the screen will be distorted. This cau be well illustrated
by the following experiment. (Fig. 105.)
Take a lighted candle and hold it fifteen or twenty inches (38 or 51
cm. ) from a white surface ; between it and the candle place a coin. Upon
moving the coin toward the white surface, its shadow becomes smaller
and smaller as it is gradually made to approach that surface. The re-
verse occurs when the coin is moved from the white surface toward the
candle. Upon altering the plane of the coin a shadow of different shape
is produced. When the rays fall perpendicularly on the surface of the
coin, the shadow produced will be circular, but when tilted so that the
rays strike in an oblique direction, the shadow cast will be elliptical.
The change in size and shape of the shadow can be accomplished by al-
tering the position either of the source of light or of the object. These
principles are equally true in fluoroscopy and skiagraphy.
The intensity of the shadow on the screen, even of the same kind of
structure, will vary in different individuals. Thus the shadow of the
adult male thorax will be darker than that given by a child's thorax.
This difference in intensity depends upon the degree of penetrability of
the rays, the distance of the tube from the fluoroscope, and the relative
thickness of the part.
The operator should be thoroughly conversant with the normal ap-
pearance of the parts, so that he can use this knowledge as a standard of
comparison for the corresponding affected part in the same individual.
B. ADVANTAGES OF FLUOROSCOPY.
The method of using the fluoroscope is simple, inexpensive, and
rapid, and allows of immediate comparison with the corresponding nor-
mal part. The mobility brought about in the structure under examina-
tion permits of its study in different positions. In examining certain
parts that are in constant motion, as the heart, diaphragm, and thorax,
a study can be made of any abnormality in their movements.
214 ELECTRO-THERAPKr IK S.
C. DISADVANTAGES OF FLUOROSCOPY.
One of the limitations of this method is that the record is not perma-
nent, although "tracings" can be made. In prolonged exposures for
examinations the patient is liable to be " burnt," and the same injury
may befall the operator's hands and eyes ; for this reason, I at present
never employ the fluoroscope, having discarded its use five years ago.
Thicker parts, as the adult abdomen, the hip, and the skull, do not per-
mit of satisfactory examination by this method. The same is true of
certain fractures which present no displacement of the fragments (fissured
fractures), also in detecting and locating small foreign bodies. As the
soft structures present varying degrees of density, the presence of diseased
bone, tumors of muscles or of the brain, etc., cannot be differentiated,
owing to the affected tissue having only a slightly different density from
that of the surrounding normal parts. As the penetrability of the rays
cannot be controlled, and the varying degrees of density confuse the eye,
the differentiation by means of the fluoroscope becomes at once most
difficult and unsatisfactory.
II. Skiagraphy.
A. SYNONYMS, DEFINITION, AND NOMENCLATURE.
Skiagraphy (Rontography, Shadowgraphy, Ixography, Electro-
graphy, Skotography, Kathography, Fluorography, Actiuography, Radio-
graphy, Diagraphy, Skiography, Pyknoscopy, New Photography, and
Electro-Skiagraphy) is the art of photographing shadows on sensitive
plates by means of transmitted light. The Rontgeu Congress in Berlin
on May 2, 1905, adopted a uniform nomenclature for the use of the Con-
gress and for expression in writing. The following terms will be used
in the future: Rontgenology, Rontgenoscopy, Rontgenography, Rout-
genogram (Rontgeu negative, Routgen positive, Rontgen diapositive),
Ortho- Rontgenography, Rontgentherapy, Rontgenizing. I present this
new nomenclature, but I can hardly endorse it. I believe that the word
u skiagraph" and its modifications are more easily pronounced, more
general, and more euphonious.
The differentiation between an ordinary photograph and a skiagraph
is as follows: A photograph is an image produced on a sensitive plate
in a camera by ordinary light, reflected from the surface of the object,
converging and passing through a lens or pin-hole and then diverging
and falling, thus producing a reduced size of the image on the plate.
Therefore, a photograph is a " reflected" picture, and we see only that
part of the object that is near or toward the optical perimeter when the
object is opaque ; if transparent, the refraction obscures the clearness of
the farther side.
PHILADELPHIA HOSPITAL
RONTGEN RAY LABORATORY, RECORD OF DIAGNOSIS.
No.
1
NAME
\DDRESS Nativity Month Day fgo
Occupation
2
SEX Male -n^v
Color Weight ll>>. I >.-]iartment Referred by M.D.
Female Ma?ried
Height | Ward Address
3
Previous History
4
5
6
7
8
Date. Place,
Duration, Character, etc.,
of Injury or Disease.
Part or Organ Involved
at Physical
and
Clinical
Chemical and Microscopical
Examinations
9
REMARKS
„,,..,, j • r\- • Diagnosis made from Skiagram or Fluoroscope
Techmc Employed in Diagnosis. or Stereo-Skiagraph
I
IPPARITTJS
II III
POSITIONS OF THE TUBE QUALITIES OF THE RAYS,
AND PATIENT TIME OF EXPOSURE
A
\
I
Varieties and Make
Distance of Anwle Current going to the
from Plate Primary Coil
inch [ cm.
Volts Amp.
Revolving Plates
Numbec
Thickness of the Part
Secondary or Induced
Current
inch cm.
Inch cm .
POSITIONS OF PART
Parallel Spark-gap
Rev. per Minute
inch cm.
Length of Spark -gap
Anterc- posterior
No. of Benoist's Scale
inch | cm.
Lateral
Degree of Vacuum of
Tube: Low (soft).
Medium. High (hard)
B
Accumulator Volts
Flexion
Extension
Time of Exposure
SOURCK
OF CURRENTS
Ampere-hour
Dorsal Decubitus
sec. min.
Direct Current
Ventral Decubitus
Intensifying Screen
Altern. Current
Recumbent
Variety of the Plate
Transformer
C
Varieties
Semi-recumbent
Sizes Nos. Parts
Sitting
X A
gi
aj
Standing
X B
Length of Spark-gap
With or without
Bandage. Splint, Cast
X C
OPERATOR
inch cm.
Negatives •
D
Varieties
E v-
Over or under-exposed
or developed. Patient
moved
t>
x
8
No. of I nterrupiii >ns
*" Non-Regulating
S3
No. of Prints
Per Minute
g Self-Regulating
Duplicate
AUTOPSY
Mechanical
f§ Osmo-Regulat.
Mercury
Wehnelt
CkldweU
Simon
Diagnosis made by Director AI.D.
or Assistant M.D.
215
216 ELECTRO-THERAPEUTK S.
In skiagraphy the X-rays emanate from a small point (1 mm. anode),
diverge and pass through bodies opaque to ordinary light, throwing a
relative shadow of the object on a sensitive photographic plate, producing
merely an actual silhouette. The skiagraph, therefore, is produced by
transmitted light.
Before taking a skiagram, determine the best possible position that
can be secured, by first employing the fluoroscope, and then substituting
for it the sensitive photographic plate. On the latter the image east will
appear reversed, — i.e., the bones will appear white and the surround ing
soft structures darker, due to the fact that in the bones more rays will be
absorbed, fewer penetrate, and hence there will be decreased oxidation on
the photographic plate. When a photographic print is made from this
negative, the appearance will be identical with the fluoroscopic image.
(Hereafter the term xkia</r<tfth or skiagram will be used for the printed
positive, and the developed sensitive (photographic) plate will be termed
the negative.)
B. THE PATIENT.
History Taking. — It is advisable to take complete histories of all cases.
I employ the accompanying blank in book-form in the Philadelphia
Hospital and in private work. Its main features are, the history of the
case and the technic employed in each instance.
Preparation of the Patient. — Expose the part to be skiagraphed by
removing the clothing. If the part is an extremity, have it totally bared.
"When examining the chest or abdomen, should the patient be chilly or
complain of the unpleasant sensation caused by the plate, or be abashed
at the thought of completely disrobing, the wearing of an undergarment
may be permitted, or the part may be covered by a sheet of white linen,
care being taken to remove buttons and pins, and not permitting any
wrinkles or creases to exist in the field to be examined. If a part of the
forearm or leg is to be examined for fracture, dislocation, etc. , splints and
dressings of iodoform, boric acid, bismuth subuitrate, lead water and
laudanum, etc., must all be removed and the part skiagraphed in a bared
condition. If a compound fracture is examined, avoid infection by
covering with a thin sterilized gauze. In examining the abdomen, a
purgative should be administered ten or twelve hours prior to the exami-
nat ion. The patient must not be permitted to indulge in eating solid food
previous to the examinat ion. The urinary bladder should be emptied be-
fore being skiagraphed, for calculi, and a rectal enema given. The walls
of the stomach may be readily outlined by having the patient ingest large
doses of bismuth subnitrate for two weeks prior to the examination.
Position of I'alit'iit. —The patient should be placed in a comfortable
position. It is sometimes not possible to do this, hence the necessity of
THE PEIXCIPLES OF TErilNir. 217
conducting the examination rapidly, but without sacrificing the results
desired. In order to ascertain the necessary position for the patient to
occupy first examine with the fluoroscope.
The patient may assume various positions in skiagraphic work,
which will be dealt with under the various clinical conditions. They
arc- : the erect or sitting, anterior, posterior, or lateral, recumbent, dorsal
decubitus and ventral, named after the position or view of the part that
is in contact with the sensitive plate or fluoroscope.
Immobilization of the Part. — To obtain the sharpest outlines on the
plate, the patient must not be permitted to move while under examination,
or failure will be the inevitable result. Those that are timid should be
previously instructed to ignore noises, flashes, etc. , necessarily occurring
during the examination. It is better for the skiagrapher to have an
under-exposed plate rather than one that is blurred. This blurring may
be independent of the patient, and be caused by the shaking of the tube
or the table, or of both.
The part to be examined may be held in one position by firmly
strapping it to the table, although I seldom find this necessary. In cer-
tain cases, as in fractures, where there is movement of the part (the result
of muscular spasm), the annoying symptom may be met by steadying
the limb with sand- bags, etc. When it is found impossible to keep
children and the insane under control, resort must be had to hypodermic
injections, or to the administration of an anaesthetic.
C. PLATES, THEIR PREPARATION, SIZE, AND PROTECTION.
The plates as sent by the maker are not ready for use j hence it
becomes necessary to assort and arrange them in a dark room, so that
they may be conveniently handled by the examiner. Place the plate in
a black paper envelope, which in turn is covered by a heavy j-ellow one ;
this prevents injury by light, though it will be affected by the X-rays
with as great ease as desired. The size of the plate depends upon the
dimensions of the part to be skiagraphed ; those that I usually employ
are one size larger than is absolutely necessary. The plate should be
protected against breakage, damage from perspiration or other excretions
of the body, and from heat. To insure against breakage, it should be
placed over a smooth board, as I find that a plate-holder is objection-
able in preventing the approximation of the plate close enough to the
part to be examined, thus preventing sharp definition of shadows.
IJctweeii the patient and the plate I introduce a blotter or a sheet of
aluminium, oiled silk, or celluloid, which prevents injury from sweat,
urine, etc. For the sake of comparison, it is a wise provision to have the
plate large enough to take both sides of the body (hips, shoulders, etc. ).
For this purpose, place the tube in the median line of the body and take
218 ELECTRO-THERAPEUTICS.
both sides with one exposure. This obviates the error that would result
if the two sides were taken .separately, when in all probability the posi-
tions would be different. \Vhere the plate cannot be brought in contact
with the part, owing to a curvature of the latter, as on the flexor or
extensor surfaces of the elbow, or on the spine, in common with others,
I at times resort to the use of a film. The plate should be placed against
or under the part examined, with the gelatine side up. The part should
be as nearly centralized on the plate as possible, so as to get the import-
ant outlining shadows directly in the centre of the plate. Rays should
fall as nearly perpendicular as possible.
Data on the Negative. — It is always advisable that the plate should be
marked so as to guard against errors. The method of plate-marking
that I employ consists in placing lead letters and numbers in reverse type
in the corner of the plate, designating the part examined, the date,
the name of the operator, and also the name of the institution. The
letters and numbers employed for this purpose should be small, so as to
not occupy too much space on the plate. "When exposing a part I
usually indicate on the plate whether "right" (R) or "left" (L).
"When making more than one exposure of the same part, I usually
indicate the number of separate exposures consecutively by placing
on the plate the lead letters, A, B, and C. In medico-legal cases an
identifying mark is most important.
D. SELECTION AND USE OF THE CROOKES TUBE.
The Crookes tube must be selected according to the requirements of
the case. Thus, the "hard" tube, which produces a greater degree of
penetrability of the rays, is adapted for the thicker parts, in detecting
the larger foreign bodies, and in taking a negative of a fracture through
a plaster cast. In making skiagraphs of children, where their move-
ments would ordinarily blur the negative, the short exposure required by
this variety of tube is a marked advantage.
"When soft tissue differentiation is to be brought out, as in skia-
graphing a muscle tumor, a cyst, a small foreign body, or a tuberculous
focus in bone, resort must be made to " medium " or even " hard " tubes.
The consensus of opinion among the profession is that a soft tube is
desirable for skiagraphiug soft tissues in order to obtain a clear tissue
differentiation. But I have abundantly proved that with a hard tube, a
short exposure, and proper development, the same end may be attained.
The advantages of the latter method are : The time of exposure being
brief, the liability of movement of the patient is minimized and there is
less liability of penetration than with a soft tube of a longer exposure.
Position of the Tube. — Some investigators claim that no X-rays
are produced back of the anode, others assert that they do exist in this
THE PRINCIPLES OF TECHNIC. 219
position but possess very little penetrating power. As to whether the rays
are uniform in penetration in the active hemisphere, or if they possess a
point of maximum intensity, is another disputed question. Buguet and
Londe assert that the intensity of the rays varies at the active hemisphere
in different tubes, and in different kinds of the same tube. In some
tubes the most effective X-rays are evolved at right angles to the axis of
the tube ; in which case the latter must be placed parallel to the object
to be skiagraphed. In other tubes the zone of greatest intensity is at a
right angle to the plane of the anode, when the auodal surface should be
in the centre and parallel to the object under examination. I prefer a
position intermediate between these two. (See Fig. 105, C.)
M. Bordier1 says: "The direction of this principal axis, along
which the Routgen effects are at a maximum, must be determined sepa-
rately for each focus-tube, and it evidently lies in the median plane, — i. e.
in the plane passing through the centre of the cathode and perpendicular
to the auti- cathode."
He placed a series of pastilles in an arc, having for a centre the
focus of the anti-cathode ; the direction of the principal axis was given
by the pastille which was most discolored.
In experiments on three Miiller tubes tested in this way it was
found that the principal axis made an angle of 70° with the line passing
through the centres of the cathode and the anti-cathode.
.Form of the Ray-emitting Area of the Anti-cathode. — Gocht,2 in experi-
menting with a pin-hole camera, succeeded in photographing a luminous
area on the surface of the anti-cathode, the ray-emitting area having a
pyriform -ovoid shape. He asserts that the angle between the plate and
the anti-cathode at which the spot of light is most circular and there is
least penumbra is not 45°, but nearly 65°.
Direction of the Rays. — Rays emanating from Crookes tube should
fall perpendicularly. To prove this, place a metallic cylinder, 3 or 4
inches long, over the plate or on the screen. If the rays are perpen-
dicular the shadow cast will be circular ; if the rays are proceeding in
an oblique direction, the shadow will be elliptical or the shadows of two
cross wires on both the ends will not be superimposed. (See Fig. 105, 5.)
Distance of the Tube from the Plate. — The thicker the part and the
greater the extent in area to be skiagraphed, the greater should l>e the
distance between the tube and the object. This distance must be
measured from the anode to the plate, and is usually about 20-24 inches
(50 or 60 centimetres). Where any movement of the part is likely, it
is preferable to place the tube closer, in order to reduce the time of
exposure.
1 Archives of the Rontgen Ray, June, 1906, p. 7.
2 Ibid., April, 1906, p. 312.
220 ELECTKO-THERAPEUTICS.
E. FACTORS VARYING THE TIME OF EXPOSURE.
This is most important : no definite rule can be formulated relative
to the standardization, of any unit of time. The time of exposure varies
under the following conditions :
1. The capacity of the apparatus and the penetrability of the rays.
2. The peculiarity of the part to be examined.
Under the first heading we must consider the size and make of the
apparatus. If the static machine is used, we must take into account the
numl>er and size of the plates and the rapidity of the revolutions per
minute. In the use of the coil account must be taken of its size, and the
variety of the interrupter, with its frequency of interruptions, etc.
Under the secondary heading we consider the thickness of the part
and its texture. The thicker the part, the more prolonged must be the
exposure ; nevertheless, while the chest is as thick as the abdomen, the
latter requires a longer exposure, because the former is more easily pene-
trated by the rays, due to the contained air.
Quality of the Rays. — Rays of high degree of penetrability will require
a shorter time of exposure, and conversely with rays of medium and low
degrees of penetration. The sensitiveness and variety of the plate play
a minor part in the time of exposure. Xo plate has thus far been found
that is specially sensitive to the X-rays only.
Intensifying Screens. — Intensifying screens are intended to shorten the
time of exposure by placing in contact with the photographic plate a
screen of fluorescent substance, the latter acting like ordinary light on the
sensitive plate. It must be borne in mind, that the granularity of the
fluorescing surface reduces the definition of the skiagram, at the same
time omitting details of the smaller bony structures, and the necessity
of either using color-sensitive (ortho- chromatic) plates, or first color-
sensitizing ordinary plates, since the best screen (platiuo-cyanide of
barium) fluoresces with a yellowish-green light which does not greatly
affect ordinary dry plates.
I have conducted experiments that lead me to the belief that the ratio
of exposure necessary with an intensifying screen to the time required
wit In nit the screen is as 1 to 5 or 6. This screen will markedly assist in
the reduction of the time of exposure in fractures and the presence of
forei-n hoilics about the thicker structures, such as the hip, the pelvis,
and the abdomen. Of course by this procedure we sacrifice the fine de-
tails ..fthe softer structures, and for this reason I have abandoned its use.
1". l'K'i;\ i;\ 1 1,,\ OF SECONDARY OR SAGNAC RAYS.
When the Kont^eu rays penetrate bodies, the so-called secondary
rays of Sagnar are produced in the tissues. The rays being primary.
ra\s \\ill in turn produce rays railed the tertiary.
THE PRINCIPLES OF TECHXIC. 221
This diffusion or production of secondary and tertiary rays will be
increased when the time of exposure is increased and when the part ex-
amined is oi' considerable thickness. In order to prevent these useless
rays, which so often cause a foggy appearance on the negative, many
devices have been suggested, principal among which are the following :
The Lead Iris Diaphraym. — By the method of Albers-Schdnberg,
— /. <?., by means of the compression diaphragm (Fig. 99), — the pri-
mary rays are largely cut off, with a consequent lessening of the sec-
ondary rays. The irradiated area is diminished in size, and the
depth of the parts is likewise decreased, through the pressure exerted by
the compressing action of the diaphragm.
Robinson, in Holzknecht's laboratory, modifies the above by pressing
upon certain parts of the diaphragm with specially devised metallic rods,
in order to make the diaphragm conform to uneven surfaces, such as the
ankle, foot, knee, etc.
I have seen Coutreinoulius, of Paris, applying lead plates against
the flanks and chests of patients, to prevent the disappearance of the
shadows of soft tissues. He demonstrated the value of this method by
employing these plates on one side only. The development of the
negative showed in detail the shadows of the soft parts, while on that
side where no lead plate was applied the shadows of the soft parts were
invisible.
III. Photography.
The photographic processes involved in the production of a nega-
tive from a plate that has been exposed to the X-rays do not differ from
those involved in making ordinary photographic negatives. Experience
in this branch of X-ray diagnosis is absolutely necessary, hence steady
and continuous work is essential, in order to become familiar with the
many intricate points which so frequently arise.
Dark Room. — The dark room must be absolutely free from ordinary
light and so constructed as to allow of ready ventilation. Both of these
requirements may be met by utilizing a zig-zag entrance. The room
should contain trays, graduates, faucets (for hot and cold water), and a
suitable box or tank, encasing vertical grooves, for the purpose of "fix-
ing . " As the process of developing, which we shall presently describe,
produces a staining of the hands, and sometimes a dermatitis from the
action of metol, the use of rubber gloves is desirable. After employing
them for a short while, the operator becomes accustomed to them. When
the developing is completed, they should be thoroughly rinsed in water
and hung up to dry.
Light. — When developing, advantage may be taken of the ruby lan-
tern or incandescent lamp, properly shielded. Daylight, on account of
I . LECTKO-THEKAPEUTK s.
its variability, is nnsuited tor the purpose. In brief, the room should
be glazed with a sash composed of ground glass, a yellow and a ruby
glass, and a shade or curtain of a dark color.
N/ Hxitin- rhttf* <tn<l /-'/7//1.S-. —Skiagraphs are easily projected on photo-
graphic glass plates, papers, or films. Wet or collodion plates are only
slightly affected by the X-rays. Great advantage is secured by employ-
ing double emulsified plates, the depths and contrasts of the images being
brought out more thoroughly. Tire X-ray plate, which is always to be
preferred to the ordinary plate, should be employed.
Owing to their flexibility, celluloid films can be brought in contact
with any uneven part of the body. But if not handled with scrupulous
care, the emulsion is liable to crumble. Other objections are their cost,
their constantly varying sensitiveness, and the fact that they are not easy
to manipulate.
The double-coated celluloid films are coated singly on each side,
causing a reduction in time to the exposure of the rays ; but they offer
difficulties in development and by transmitted light present the blurred
effect of both films. Both paper and celluloid films inay be superim-
posed so that half a dozen or more may be simultaneously exposed to the
rays. Bromide paper can be examined only by reflected light. This
paper is cheap and does not necessitate first producing a negative ; its
use is not to be recommended, as a good picture never results thereby.
Care of the Plates. — Because of the extreme sensitiveness of the
plates, they should be stored in places that are absolutely free from
smoke, gases, excessive light, etc. The temperature of the room should be
constant, sudden changes being liable to cause a condensation of moist-
ure upon the coated side which in time results in " mildew fogging."
The plate packages or boxes should be placed on their edges, thus avoid-
ing undue pressure on the individual plates. As to the number of plates
to be kept on hand, I recommend not more than a mouth's supply, — the
operator, of course, must be governed by the amount of work he is doing.
The plates should not be unpacked from the maker's cases and placed in
the regular X-ray envelopes until needed, — this precaution guards against
fogging of the plate. If the plates are to be stored in the laboratory
where the X-ray apparatus is located, a wooden closet, carefully lined
with sheets of lead, should be built, to avoid the damaging effects of the
rays upon the plates. If stock plates are stored in an adjoining room,
they should be protected against the rays in exactly the same manner.
A. DEVELOPERS.
A developer consists of four parts, — (a) reducer, (6) preservative,
(c) accelerator, and (W) a restrainer.
:i i;«/i«-f>r8. — The best reducing agents are metol, pyrogallol,
THE PRINCIPLES OF TKCIIXH1. 223
eikouogen. hydroehinone, and rodinal. Tliey all undergo easy oxida-
tion; hence sodium sulphite is added as a (b) preservative. Combinations
of the above are usually preferred. Regulate the action of the developer
by the addition of an accelerator or a restrainer. If the reducer acts
tardily, add the accelerator (carbonate of sodium or potassium). Too
rapid developing with strong solutions is undesirable ; it means lack of
gradation, a forcing up of the high lights before the developer has had
time to act on the less exposed pails of the plate. Ready prepared de-
velopers will not be suitable for skiagraphic plates. It should be remem-
bered that the operator should adhere to one kind of developer and
become thoroughly acquainted with its action. The following are the
formula* that I daily employ in my laboratory :
Water 100 ounces (3000 c. c.)
Metol 120 grains (8 grams.)
Hydroehinone 100 grains (6.6 grams. )
s< >d. sulphite (crystals) 4 ounces. (120 grams.)
or
Water 64 oz. (1920 c. c.)
Eikonogen 1 oz. (30 grams.)
Hydroehinone J oz. (4 grams.)
Sod. sulphite (crystals) 2£ oz. (75 grams.)
(c) Accelerator. — With either of these reducing solutions, it is neces-
saiy to employ, in conjunction, an accelerating solution, made up as
follows :
Water 64 oz. (1920 c. c.)
Potass, carb. (crystals) 8 oz. (240 grams.)
Sod. sulphite (crystals) 2 oz. (60 grams.)
The dry or anhydrous chemicals are about twice as strong as the
crystals, and rii-c r/rwJ.
Combinations of hydrochinoue with metol when too old should not
be used, as they would cause the negative to present a "streaky" or
"blotchy" appearance.
The one solution developer of rodinal is convenient and effi-
cient, especially when employed for two-sided films or plates. This
agent keeps well as long as the containers are kept filled and tightly
corked.
With its use the image appears cpiiite rapidly, but development
must be continued until the film is so dense that no details are discern-
ible when viewed by transmitted light. The following formula may also
be employed :
Rodinal 1 part.
Water 20 to 40 parts.
224 ELECTRO-THERAPEUTICS.
An advantage of the ortol developer is that it may be repeatedly
used, keeping perfectly well as long as the stock solution is kept in
small bottles and tightly corked. Formula :
Water 60 oz. (1800 c. c.)
Ortol i oz. (20 grains. )
Potass, bromide 20 grains (1.3 grams.)
Sulphite of soda (crystals) 6 oz. (180 grams.)
Carbonate of soda (crystals) 5 oz. (150 grains.)
For use : Dilute one part of the above with two to four parts of
water, according to the density desired.
(d) Restraining Solution. — Ten per cent, solution of potassium bro-
mide kept in a tightly corked bottle. (Pipette and dropper are useful
adjuncts in the handling of this solution.)
Tropical Developer. — For hot climates where no ice is available.
"Water .50 ounces ( 1500 c. c. )
Sulphite of soda (crystals ) 2 ounces (60 grams. )
Bromide of potassium 20 grains (1 .3 grains. )
Citric acid 20 grains (1.3 grams. )
For use : To 4 oz. of the above solution add 10 grains of dry amidol.
Before developing place the plate in
Water 60 parts,
Formalin 1 part,
for about three minutes, rocking the tray occasionally, then rinse well
and place in the developer. '
B. MODUS OPEEANDI OF DEVELOPMENT.
After the plate has been properly exposed it is taken to the dark
room, the envelope opened, and the plate removed. (After having been
exposed, it should not be allowed to remain in the exposing room, if an-
other case is to be skiagraphed. ) Place the plate, gelatine side up, in a
tray of sufficient size, and pour on the developer. For development of
1 Henry Hulst (Transactions of the American Rontgen Ray Society, 1905) says:
"The developer which I use for exposures of one second or less in chest work, I use
for calculi as well. It is as follows :
Potassium carbonate, dry 12 dr. (48 gm.)
Sodium sulphite, dry 6 dr. (24 gm.)
Potassium bromide ( 10 per cent, sol.) 2 oz. (59.2 c. c.)
Hydrochinone 4 dr. (16 gm.)
Water.. 1 qt. (1 litre.)
" If the high lights begin to show before 40 seconds, from two to four ounces
more of the potassium bromide solution are added. Development should be complete
in four minutes."
THE PRINCIPLES OF TEC UNIT.
the plate, take four (4) parts of either reducing agent, above mentioned,
and about one-lialf Q) part of the accelerator solution. If the image
does not appear in half a minute, add another portion of the accelerator.
Thus cautiously add at very brief intervals small quantities of the accel-
erator, and the image will be better evolved than if an excess of the
alkali be added to the reducer at first. Start at one corner, and with a
.single sweep, pour on sufficient solution, rocking the tray to secure
thorough immersion and evenness. To splash the solution is to produce
air bubbles. a:id the latter will form spots on the negative. Should
air bubbles be detected, touch them lightly with a pledget of cotton.
For development of a special make of plate, follow the directions
on the box. Observe all changes going on in the plate. After the plate
has been developing for a minute or longer, lift it from the tray and ex-
amine it by transmitted light to see how far the process of development
has advanced. This is dependent upon the time the sensitive plate was
primarily exposed to the action of the rays, to the thickness of the part
under examination, the type of plate, and also upon the temperature of
the developer and the dark room. I always judge the density by trans-
mitted light, deeming this preferable to the reflected picture from the
sensitive side. Another method is the appearance of the picture on the
glass side or back, showing the reduced metallic silver deposited on the
glass. It will take a longer time to develop a plate of the lungs, pelvis,
abdomen, or the denser parts of the body than it does of the hand or foot.
For the former structures keep the plate in the developer until the whole
surface is uniformly blackened and very little light is transmitted. In the
fixing bath the proper degree of density will be produced. To strongly
contrast the bony and fleshy structures of a part, reduce the time of de-
velopment or dilute the developer; the result will be a "soft negative/'
The necessary density may be obtained later by intensification. For a
good negative, start with weak developers and gradually increase the
strength by adding stock solutions (the reducer). In order to bring out
the details with greater delicacy, some prefer to use first a suitable
hydrochiuone developer, to effect sufficient density, and then transfer the
plate in rodiual or metol developers. When the plate is sufficiently de-
veloped, put it in a trough of running water or under a stream from a
spigot, always seeing that the gelatine side is up, and that it is not liable
to get scratched by any contact with the spigot or other body. Continue
the washing for at least two minutes.
The denser the structure, the less will be the oxidation of the emul-
sions, and consequently the later the appearance of the part on the plate.
I f st ructures of different densities appear simultaneously on the plate, it
signifies over exposure : in that case, pour off the developer, and substi-
tute a fresh, weak developer. It should be remarked that the developer
15
•JIM; ELECTRO-THERAPEUTICS.
must imt )>•• diluted, as it makes development slow, and the negative will
be soft ; this is especially true of the thick parts : instead put iu less of
the accelerator (sodium carbonate). During the summer, put ice into
the developer, or put the developing pan into a tray of ice- water. Tem-
perature of the developer should be 65° or 70° F. (18° to 21° C.). Over
exposed plates should not be removed quickly from the tray, as the de-
veloper will not have time to penetrate sufficiently deep to affect the lower
layers of emulsion ; although the upper layer by its darkening may
deceive the operator.
If the image appears slowly, — i. e., within a minute or two, — it sig-
nifies under exposure; in this case tilt the solution to the corner of the
tray, and add some of the accelerator. If after this addition and suffi-
cient development, the desired density is not obtained, pour off and wash
the plate, and employ a fresh developer.
Of late years the "tank" or slow developing process, has been used
by some skiagraphers. The tank development is to be recommended for
plates which have not received full exposures and for the smaller size
plates. It is claimed that the length of time to which the plate is sub-
jected to comparatively weak developing solution (40 to 60 minutes), will
bring out much more detail than the application at once of a more vigor-
ous developer. However, for fully timed plates, I would prefer the
methods recommended above. The following is Mr. Cramer's formula :
STOCK SOLUTION.
Water 32 oz. (1000 c. c.)
Carbonate of soda (dry) 2 oz. (62 grams.)
Sulphite of soda (dry) according to desired
color of negative 1 to 1J oz. (32-48 grams. )
Bromide of ammonium 30 grains. (2 grams. )
Citric acid 30 grains. (2 grams.)
Hydrochinone 1 dram. (4 grams.)
<dycin 2 drams. (8 grams.)
Metol 2 drams. (8 grams. )
Pyro 4 drams. (16 grains. )
Dissolve the chemicals in given rotation.
To preserve the stock solution, we recommend filling small bottles
of the exact size to hold just enough for making the diluted solution
for tin- tank. The bottles should be quite full and tightly corked.
FOR USE :
Water 120 ounces.
Stock solution 6 ounces.
The developer should IM- used fresh, and its temperature kept Let \\een
60° and 05° F., until development is completed.
FIG. 106.— Envelo developer. (Lyon Camera Co.)
FIG. 107.— Automatic tray-rocker. (Rontgen Manufacturing Co.)
THE PRINCIPLES OF TECHXir. 227
It is necessary to observe the following rules in handling the developer:
Xo. 1. Immerse the plates in a tray of cool water before putting them
in a tank.
Xo. 2. Immediately after immersing the plates in the tank solution,
move the plates up and down with a quick motion, to prevent air-bells or
bubbles forming on the surface of the film.
Xo. .°>. After the plates have been in the tank from five to ten
minutes, lift each plate out of the tank and reverse its position, by plac-
ing that end of the plate which was at the top of the tank to the bottom.
This will prevent the appearance of streaks, which are sometimes found
in tank development.
Xo. 4. It is well to rock or shake the tank, at least once in every five
minutes, during development. This often prevents the appearance of
streaks or spots in the negatives.
The Envelo developer (Fig. 106) is an extremely simple device,
designed to develop two plates at one time, by the tank or stand method.
It is constructed of metal, heavily nickeled on the outside, and coated on
the inside with a liquid proof composition.
When the plates are large, and slow development is aimed at ; in
order to save time, resort may be made to the tray-rocker (Fig. 107}
which works automatically through the agency of an electric motor.
Fixing. — After development, the plate is washed in the tray with
running water, instead of the usual method of washing it, when removed
from the tray. This prevents breakage of the plate and likewise contact
with the developer, which would cause irritation to the fingers.
The process of fixing dissolves out all the silver bromide unacted
upon by the light or developer. Allow the plates to remain in the fixing
bath for three to five minutes, after the chemical agent has been com-
pletely removed ; this will insure permanency, freedom from stains, and
perfect hardening. After all ;' whiteness" has disappeared from the
glass side, bring ' ' the negative ' ' to the light. Leave it five minutes longer
in the solution, to allow for thorough fixing, as this plate has a thick
double coated emulsion.
The acid chrome Jlcing bath I largely employ, as it does not discolor
and keeps longer than the plain hypo fixing solution. It is made as
follows :
AVater 100 oz. (3000 c. c.)
Sulphuric acid 3 oz. (90 c. c.)
Sulphite of soda 4 oz. (120 grams.)
AVlu'ii dissolved, add —
Hyposulphite of soda 2 Ibe.
Dissolve, and add —
Chrome-alum, from one to two ounce?, previously dissolved in 20
ounces of water. Follow by adding water to make a total of 160 ounces.
ELECTRO-THERAPEUTICS.
In hospitals and large laboratories it is useful to employ two large
wooden boxes that act as tanks. (Fig. 108.) In the Philadelphia
Hospital I have these boxes divided into different sized compartments
to accommodate the various sized plates. Each compartment has six
vertical grooves, for holding six plates. One of these tanks contains
the acid hypo sufficient for six mouths' use. The other tank is similarly
Constructed, in which the water enters at the bottom and circulates
to the top, and then overflows into a discharging pipe.
Fro. 108.— Author's washing tank. The fixing tank is similar in construction.
Washing.— After fixing, washing must be quickly and thoroughly
done. One hour's washing with running water is sufficient ; if the sup-
ply be not so accessible, place the negative in a flat dish and constantly
rock for five or ten minutes. Change the water and repeat the process
for one-half to three-quarters of an hour. Remove the negative, a-ain
wash under the spigot, using a pledget of cotton to wipe off any foreign
particle adhering to the gelatine coating.
Drying. — Dry the negative in a room of moderate temperature, in
which a ventilator supplies plenty of air. Do not dry in the sun, as
THE PRINCIPLES OF TECHNIC. :."_'«»
sunlight produces softening and increases the density of the film. To
dry a negative hurriedly. — /. <"., in five or ten minutes, — lay it in a bath of
alcohol after washing thoroughly, or put before au electric fau.
The negative must be completely dried iu one room. To take it par-
tially dried into another room and there complete the process, will result
in the finished negative offering a difference in densities. During the
summer season the negative becomes denser than in winter.
Hardening. — After fixing the negative, wash and place it iu the
following :
Water 4 ounces (120 c. c.)
Formaldehyde 1 ounce (30 c. c. )
Keep in this solution from five to ten minutes, rocking the tray from
time to time. If the solution is made too strong the film may peel off.
If hardening is done before the fixing, then the fixing process should
require more than usual time. This will frequently be of necessity in hot
climates and during the hot seasons in temperate climates.
C. IMPKOVEMEXT OF THE NEGATIVE.
Intensification. — This process with proper exposure and development
is seldom required, except for special purposes, i. e., for under exposed
or under- developed plates. The negative is first well washed and then
placed in the following :
Mercuric bichloride 200 gr. (13.3 grams.)
Potassium bromide 120 gr. (8.0 grams.)
Water 6i oz. (200 c. c.)
Keep the plate in this solution a short time, when it will be observed
to be bleached uniformly white, assuming the appearance of a positive ;
the longer the negative is bleached, the denser it will become. It is
again thoroughly rinsed and washed under the spigot for at least a half
hour in running water, and then blackened in the following solution :
Sodium sulphite 1 oz. (30 grams.)
Water 4 oz. (120 c. c.)
or
Ammonia 20 min. (1 c. c.)
Water 1 oz. (30 c. c. )
It now being blackened, it is again washed, followed by drying.
The least yellowish east indicates that the negative has not been washed
sufficiently after the bleaching. The prints of such negatives show the
soft tissues very faintly, producing a great contrast, and on account
of their great density they print very slowly.
•_'.;<) ELECTKO-THKRAPKrTirs.
General n-ilnHnm is used when the negative is very dense, as a
result of over exposure, over development, or where there is an excessive
aim > ii MI of alkali present in the developer. To correct this nse the
following solution :
A.— Water ..................................... 16 oz. (500 c. c.)
Hyposulphite of soda ....................... 1 oz. (30 grains.)
B.— Water ...................................... 16 oz. (500 c. c.)
Potass, ferricyanide ......................... 1 oz. (30 grains. }
Mix 8 parts of solution "A" and one part of solution "B," ami u.<e in sulxlued
daylight.
The negative can be placed in this solution directly after fixing.
If a dry negative is to be reduced, it must be soaked in water for at least
half an hour, before applying the solution. To avoid streaks, always
rinse the negative before holding it up for examination. As soon as
sufficiently reduced, wash thoroughly. When not in use keep solution
"B" protected against the action of light.
A gradual uniform reduction will take place, its rapidity, of course,
depending upon the quantity of potassium ferricyanide added. When
sufficiently reduced, wash and thoroughly dry. To reduce locally, apply
carefully with a brush or cotton some of the solution on the wet nega-
tive, allowing it to remain until sufficiently reduced; follow by thor-
oughly washing and drying.
The other reducing agent consists of persulphate of ammonia in
water. One part to forty is strong enough for most purposes (J oz. to
10 ounces). This solution does not keep well, and should be made as
required. Its action on the plate must be carefully watched — it acts
slowly in the beginning, and then all of a sudden very rapidly. After
sufficient reduction, rinse thoroughly, and place in a 10 per cent, solution
of sulphite of soda. Wash well again and dry.
There is a great difference in the action of these two reducers.
Potassium ferricyanide, like most reducers, attacks the fine details
more readily than the denser parts, the negative becoming harder ami
thinner. The persulphate reducer, on the contrary, appears to reduce
the denser pails more in proportion, so that the negative becomes
slightly Hatter.
Local l!«Jiirtion. — This consists of bringing in contact with a certain
part of the negative some reducing agent, destroying contrast to some
extent. Let us suppose a negative having a printing effect of faintly
bringing out the fleshy |>art and deeply the osseous part : should we
dexire to bring out more heavily the fleshy part, we employ what is
termed the local reducer. To place this only on the k'tleshy" part of
the negative requires a great deal of skill — the effect being to further
THE PRINCIPLES OF TECHNIC. 231
reduce the silver salt, thus giving more chance for the rays of light to
penetrate the negative and printing the paper more heavily. The best
results in local reduction can only be obtained by constant practice. In
local reduction the plate must be previously wet, as otherwise a streaked
appearance will result.
Causes and Prevention of Faulty Negatives. Fogging. — A total black-
ening of the plate under development is distinguished from other
types of fogging in that the former remains clear at its edge. Fog
also results from a developer containing too much alkali, too high a
temperature, or exposure to other rays than those emanating from
the Crookes tube. Improper or too much light in the dark room also
causes fogging. General fogging cannot be remedied ; the negative,
however, may be sufficiently cleared by a reducer, followed by intensi-
fication.
Stains. — Deep yellow, orange, or brown stains appearing gradually
either in patches or all over the plate may result from imperfect fixing
or incomplete washing after fixing. Another cause for these stains is
decomposed hypo in the film by improper washing, or the use of alum
or acids. Over developing frequently causes greenish stains (excess of
reducing agent).
Spots. — Spots or pin-holes in negatives are usually due to air-
1 nibbles and decomposition of the films. Small clear spots generally
result from dust particles. Another type of transparent spot,
irregular in shape, results from the scum of the developer. This is only
seen on the surface of very old developers. Sediment, accumulating in
the trays, graduates, and solution bottles, may come in contact with
the film, thus interfering with the action of the developer, the result
being spots. Particles of uudissolved developer (pyrogallol) adhering
to the film produce irregular dark spots. Cleanliness in all the steps
of the developing process is the only preventive against the formation
of spots.
D. PRINTING (POSITIVE), TONING, AND MOUNTING.
The X-ray image of the negative may lie printed on paper as in
ordinary photography. All diagnoses, as far as practicable, should be
made from readings from the negative instead of from the print. There
are instances, however, where information may be gained from the print
which inadvertently had been overlooked in the interpretation of the
negative. Another advantage in using the print is that it may be passed
among a class of students for study, a procedure that might endanger a
valuable negative. A properly exposed and well developed negative
usually serves to produce a good print on almost any reliable paper. The
commonest printing-out paper used in this work is the ordinary
232 ELECTRO-THERAPEUTICS.
••albnma," the printing of which is conducted by sun-light. The
advantage of this paper is that the strength of printing process may be
easily controlled.
u Dodging"' is a method employed for reducing inequalities of a print
from a good negative. We can best understand this method by citing an
example. Let us take a negative of the hand ; it is placed in a regular
printing frame as already referred to. We are all aware of the fact that
the earpo-metacarpal part of the negative has been reduced by the devel-
oper to a less extent than the phalaugeal portion. Therefore in the print
the former portion would be shown more strongly than the latter, because
more rays can come in contact with the paper. In order to equalize the
print, we " dodge" the carpo-metacarpal portion of the hand by con-
stantly moving a piece of card-board above it, — L e., we shield it against
further action of the light rays. This permits of the phalaugeal portion
being printed to the extent desired. Were we to cover the carpo-meta-
carpal portion by laying card-board over it, without moving it, a divid-
ing line would be readily discernible, being exactly the opposite of what
we desire to achieve.
Ground- Glass Substitute. — The glass surface of the plate is cleaned of
all dust particles, finger marks, etc., and a solution of certain gum resins
in ether called ground-glass substitute is poured evenly over the surface,
precaution being exercised to prevent the liquid from coming in contact
with the film. The ether evaporates more rapidly, leaving behind an
even coating of gum resin, which, adhering firmly, gives a ground glass
appearance. The negative may now be " evened up" by daubing burnt
umber into the gum layer corresponding to those parts which are " thin."
To even up a negative requires skill, and in order to guard against any
errors I advise the use of a print from the negative before it has been
prepared, thus acting as a guide. If the negative is uneven, scrape the
ground-glass substitute from those parts that are too opaque to the rays,
thus allowing of the easy passage of the latter. Soft negatives should be
printed with tissue paper over the printing frame. With a little practice,
the inexperienced will rapidly learn the art of developing. It is better
that he do this work himself than to rely on the services of professional
photographers.
Developing Paper*. — Velox and bromide papers can only be printed
in dark rooms by artificial light, the sensitized surface of the paper being
placed against the gelatine side of the negative, and the printed image is
l.rnught out by a process of developing. The advantage of these papers is
tin- rapidity with which tin- printing is done without the aid of sunlight.
Tin- time of exposure to artificial light can be ascertained only by follow-
ing (fee directions and by experience. Velox and bromide paper should be
v!:-\Ho|x'd according to the "instructions" accompanying each package.
THE PRINCIPLES OF TECHXIC. 233
Toning Process. — Albuiua paper, after being printed, should be
trimmed, and then washed in running water until it ceases to be "milky."
The prints should now be placed face to back, one upon the other, and
introduced into the toning solution. The lowest print is then removed
and placed upon the uppermost, continuing this process for some time.
TONING SOLUTION.
Chloride of gold 20 gr. (1.25 grams. )
Acetate of soda 1 oz. (30 grams.)
Water 20 oz. (625 c. c. )
Keep slightly alkaline by frequently adding sodium bicarbonate.
Of the stock solution take an ounce, dilute it with ten ounces of clear
water ; it is then ready for use.
Put the prints into this solution; keep them moving, thus insuring
even toning. If the toning be too slow, a few drops of the stock solution
should be added to the diluted toning solution. On the other hand, if the
toning is too rapid, a small quantity of water should be added. Usually
from 15 to 20 minutes are required to bring out an even and proper
tone. After the toning process is completed, the prints are thoroughly
washed for some time in running water. The prints are next introduced
into a fixing bath which consists of
Hyposulphite of soda 2 oz. (60 grams.)
Water 20 oz. (600 c. c.)
In this solution they should be allowed to remain for at least 15 or
20 minutes, keeping them in motion. All these processes should be
conducted in a dimly lighted room.
Mounting. — After the prints have been thoroughly fixed, they are
again wrashed for several hours in running water. They are next placed
separately on a plate of glass (face downward) before drying, and all the
wrinkles are rolled out by blotting paper. The back of each print is now
painted with photographic paste and mounted on stiff card-board. Blot-
ting paper is placed on the face of each print, and a roller used before the
print has dried, to remove any wrinkles.
/'o.s/7/Yr.s. — Another method of printing consists in placing the X-ray
negative into a regular printing frame, and a sensitive plate behind it.
Kverythiug being in total darkness, light a match and expose the plate
for 5 or 8 counts. Develop the plate in the usual manner, the result be-
ing a ^pnxiflrc." These positives are the exact size of the negative
(contact print), while transparencies and lantern slides are reduced in
si/.e. It' prints are made from these positives, the bones will appear
white, i he fleshy ] tarts dark, etc., similar to the appearance of the original
negative.
234 ELECTRO-THERAPEITK s.
<ni>l Lantern Slides or />/V//;o,sv7//r.s. — The reduced trans
parencies appear with fuller detail and are easily handled and convenient
for exhibiting purposes. The reduced transparency can be obtained by
putting the original negative in a camera or window, the negative being
transilluininated and focused over a 4 x5 inch (10x12.5 cm.) sensitive
contrast plate and developed. If a smaller sized plate be used, 3^ x 4
inches (8.2 x 10 cm.), we obtain a lantern slide for projection. In
making prints from these negatives, the bones, for example, will appear
white, a circumstance that will often prove useful.
Batelli and Garbasso were the first to suggest the wisdom of obtain-
ing reduced photographs, from images observed on the fluoroscopic
screen, the advantage being that small-sized plates may be readily em-
ployed. But certain disadvantages of the method at once present them-
selves. The image on the screen must be steady, and there is required
an ortho-chromatic plate, with a long exposure, as the image formed is
yellow in color. The process is not well developed as yet, but when it
is, an additional precaution will be the protection of the camera from
the rays.
IV. Interpretation of X-ray Negatives.
This is more difficult than making the negative, because of the
superimposition of shadows of varying densities. The trained eye of
the X-ray specialist alone, can indisputably interpret the negative with
any degree of correctness.
The negative should be a satisfactory one of the special structures
under examination. If it is found to be unsatisfactory, a duplicate should
be made ; if this is not easily procurable, the negative can be improved
by the process that I have mentioned in the chapter devoted to pho-
tography. In those cases where difficulty is encountered in arriving at
a positive diagnosis it is imperative that a duplicate be made in order
to confirm the earlier diagnosis.
A blurred negative cannot be remedied and is in every way inferior
to an under- or an over-exposed plate.
The skiagrapher should keep full data of the technie when making
tin- negative. He should always endeavor to interpret it correctly and
to compare it with a negative of the corresponding part in the same
individual; he should study each part and its anatomy, and make him-
self thoroughly informed upon every subject that comes to him for
diagnosis and opinion.
///;;/' to View thr \ff/(itive. — It is of prime importance to know the
exact relations of tiie lube and the position of the part to the plate.
'I'll.- X-rays emanate from a small point on the anode, diverge, and
then traverse the object, casting enlarged shadows on the fluoroscope or
THE PRINCIPLES OF TBCHNIC. 235
plate. The collect ions of silhouettes are therefore superimposed — /. c.,
there is a composite of the shadows of the object near the tube ami those
near the plate, "When a negative is dry and ready to be examined, the
eye of the skiagrapher or observer should take the place of the anode of
the Crookes tube, the film or gelatine side facing the interpreter's eye,
equal to the distance of the tul>e from the plate.
Suppose that the right palm is in contact with the sensitive side of
the plate, when examining the negative, it follows that the negative will
be seen when the gelatine side is toward the observer's eye ; but if the
observer's eye corresponds to the Crookes tube, then the dorsum of the
hand will be brought into view. On the contrary, with the glass side
toward his eye, the observer views the dorsum of the left hand or palmar
view of the right hand, which is equal to the fluoroscopic view or a
print. For instance, a patient is in the dorsal position, the plate placed
against the back and the tube over the sternum, with the gelatine side
(film) toward the observer's eye and the eye corresponding to the
Crookes tube ; then this negative will show as though the observer were
looking through the anterior wall of the thorax ; the left side of the
patient will be his right side and vice versa.
If you examine this negative with the glass side towards your eye
(which is equal to placing the fluoroscope to the back, or looking at a
print) the right side of the patient will be your right side, etc.
If a ventral or anterior view is taken, place the plate in front of the
chest and the tube posterior ; when this negative is examined (film side
towards the eye), the patient is viewed through the back, his right side
will be your right side, etc. , but if you look at the glass side of the neg-
ative, then this will be equal to the fluoroscopic view or a print, i. e., the
patient's right side will be your left side, etc.
I prefer to make the examination or interpretation directly from the
negative and not from the prints, because prints reverse the views. If
we look at prints of the anterior view of the thorax, our eyes do not
correspond to the anode of the Crookes tube, but we are looking at the
front of the chest and rays are coming through the back of the patient ;
we call this the ventral view, etc., — /. e., the view or part that is next to
the gelatine side of the plate, the fluoroscope, or print, or its equivalent
to the negative glass side toward our eyes. The negatives should be
placed or held with the gelatine side toward the examiner's eyes, because
in this position, we look through the object and see its shadows more
correctly and truer in their relation to each other. There will likewise
be no reflection of light from the film, as there will be from the glass
side. The negative can be held by the examiner who manipulates it, by
viewing it from different angles, or an assistant holds the plate and the
operator examines it from different distances and angles.
236
ELECTRO-THERAPEUTICS.
A better plan is to place the negative in a window, lower the cur-
tain, and allow the light to come through the negative. I often prefer
to place the negative iu the window of the dark room and examine it
cither alone or by a similar negative of the corresponding part of the
same person; if this be not possible, I employ the negative of sonic
other person and then compare them side by side. Another easy method
is to place the negative in a photographer's retouching desk, which is so
very convenient for small negatives.
I have devised a viewing box (Fig. 109) which I employ at the
Philadelphia Hospital. This box accommodates any sized negative and is
capable of rotation, and thus without any displacement the negative can
be viewed at any angle and also in the vertical or horizontal position.
FIG. 109.— Author's ncriitive-viewinff box.
This box contains three series of eight c. p. lights behind the ground
glass. When a dim or weak light is desired for less dense negatives, one
series of lamps is lighted ; if strong light is desired, the ~No. 2 switch is
turned on and greater illumination is produced. This box contains per-
forations and is lined with asbestos. The preferable light for the exam-
ination of negatives is white (day) light or the electric light. The
intensity of the light can be regulated by the interposition of either
ground glass or a rheostat, as necessity requires.
A. FOKKI<;\ UODIKS.
In interpreting a negative for a foreign Ixxly, exclude all possible
errors, such as white spots produced by air bubbles during development,
Till-] PRINCIPLES OF TECHXIC. 237
the presence of iodoform, lead water and laudannni. etc.. that may In- on
the bandage or dressing. Metallic foreign bodies will eclipse all other
shadows. When semi-opaque bodies east their shadows on those of the
bones the contrast may be only very slight, especially so. when the plates
are undeveloped. Small bodies in the deeper portions of the body (as
for instance in the abdomen and in bony cavities, as the eye) may defy
detection if the time of exposure is prolonged and secondary rays produce
fogging on the plate. This occurs especially when the foreign body is
non-metallic, — i. e., a fragment of stone, etc.
B. FRACTURES AND DISLOCATIONS.
Green -stick fractures and impacted fractures are often difficult to
recognize. If the rays do not penetrate the separated fragments, the
shadows will be superimposed, and the characteristic dark Hue on the
negative will not be visible ; in impacted fractures instead of this dark
line there will appear an increased white shadow. Epiphyseal lines
should not be lost sight of. The elbow-joint in children should lie
compared with the corresponding normal side.
Fractures of th<> Hip-Joint. — In these fractures note the changes oc-
curring, even if the dark line ou the negative is not visible ; and also look
for any change in the continuity of the periosteum, the shape and relation
of the femoral neck to the trochauter, etc. Compare the normal hip-joint
with the affected one, and take a skiagraph of both hips on one large
plate, being careful to observe the position of the feet.
Dislocations. — This condition can be discerned easily. The relations
of the heads of the bones may often be disturbed or changed either by a
peculiar position that the part may assume, or by a faulty relationship
in the position of the tube to the plate ; this frequently occurs in the
shoulder-joint, in the acromio-clavicular articulation, etc. Intra- articular
cartilages are transparent to the rays and may thus be mistaken for a
dislocation.
The ventral and dorsal positions of the shoulder-joint present differ-
ent appearances on the negative.
C. DISEASES AND TUMORS OF THE BONES.
It is important to determine if the growth is osseous or of muscular
origin. Whenever possible the shadow should be cast in the light field,
and note should be made whether the shadow is attached to the perios-
teum or to the central portion of the bone. Do not diagnose the bony
normal ridges, grooves, or projections as irregularities of the compact
portion of the bone. The early stages of any special bone disease are dif-
ferent iated with difficulty from other osseous diseases by the appearance
238 KLKITIH >-TII KK'AI'KUTICS.
offered on the negative, as nearly all bone affections produce an increase
in shadow density. Such a negative may assist the physician as to the
origin and the exact location of the disease, and as the disease advances
the characteriMic appearance of that particular disease of the bone on the
negative will be noticed.
Callus. — The appearance of callus can be diagnosed from periostitis,
or other diseases, by the deformity produced and because the shadows
are fusiform and encircle the ends of the fragments.
Diseases of Joints. — Endeavor to obtain an mtra-articular space as
wide as possible. Bandages and dressings should always be removed.
Ordinary arthritis is differentiated with difficulty from the other arth-
ritic affect ions in their early stages. Pus and fluid, whether serous or
purulent, cannot be easily differentiated, although serum casts a denser
shadow than pus.
Intra-articular inflammation with exudation, can be differentiated
from a periarticular inflammation, because the intra-articular space of the
former is increased on account of the tension exerted.
False and true aukylosis should be carefully differentiated. Bony
ankylosis may be excluded by the absence of dense shadows, or by the
obliterated intra-articular space, which is absent in false ankylosis. In
advanced cases deposits of tophi are demonstrable, and one can observe
with certainty whether the disease is mtra-articular or periarticular in
origin.
In hip-joint disease or in any other disease of the bone or joint, the
true conditions or si£e of the bone may be altered, diminished, or increased,
either by being nearer to the plate (as the result of atrophy of the muscle
from disease), by disuse, or by other causes that may exaggerate the
normal size of the bone on the negative.
D. DISEASES OF THE SOFT STRUCTURES.
It is very difficult in these conditions to skiagraph or to obtain a
clear shadow on the negative, and even when once obtained it cannot be
differentiated from similar conditions, as lipoma, sarcoma, cyst, etc. A
soft negative, full of details, is most desirable, and may be easily obtained
by slightly under-developed and properly exposed plates.
Brain tumors are very difficult to diagnose. Thickness of hair,
especially in female subjects, should not be mistaken for a neoplasm.
E. DISEASES OF THE THORACIC ORGANS.
Negatives of the thorax should be examined in a viewing box. The
skiagniphcr should be familiar with the fluoroscopic appearance of the
normal and of the pathological lung. The physical examination should
always pre<-..<lr th,- skiagraphic examination. When the plate is placed
THE PRINCIPLES OF TECHNIC. 239
over the anterior wall of the thorax, the negative will reveal the cage-like
appearance of the thorax ; the anterior portions of the ribs will appear
sharp and distinct, and will form ail angle with the posterior portion.
If the negative has been exposed in contact with the back of the pa-
tient, then the posterior portion of the ribs will be more distinct than the
anterior portion, the latter being further from the plate. If the time
of exposure is prolonged, these anterior portions of the ribs will be
indistinct and widely separated. The shadow of the diaphragm will be
more distinct on the aifected side, being less mobile during the exposure.
In comparing the transparencies of the apices of both lungs in right-
handed persons, the right side may appear lighter on the negative.
In viewing the anterior wall of the chest examine the intercostal
spaces; do not mistake the shadows of the anterior portion of the first
rib (often cast between the 2d and 3d intercostal spaces), or the sternal
end of the clavicle (which may show an increased shadow), for consoli-
dation. The shadows of the sternum require most careful observation and
the shadows of the scapula will often be cast outside of the thorax. The
female mammary glands throw pronounced shadows.
In the incipient stage of tuberculosis, the apices of the lungs must
be studied with great care, as a slight degree of congestion or infiltration
will throw a shadow on the affected side. If one apex is diseased, the
diagnosis will be arrived at with less difficulty, because an opportunity is
afforded for comparison with the normal apex. Do not compare the
transparency of one apex with other portions of the lung, but apex with
apex, etc. ; for as the thickness of the thoracic wall differs in different
parts, so does the transparency vary in the same person.
Bronchial or lymphatic glands when calcified (and which are tuber-
culous), can often be observed without difficulty ; small areas of consoli-
dations will appear as irregular scattered light patches. Longitudinal
streaks on each side of the heart are supposed to be due to the foldings
of the pleurae, when the latter are viewed edge- wise. Upon the nega-
tive the posterior view shows the ribs very clearly and distinctly, and
likewise the vertebra. The anterior portions of the ribs, however,
are blurred, because the posterior ribs are nearer to the plate and are
immobilized.
Abscesses and empyema do not cast shadows so dense as does consoli-
dation ; neither do the former obscure the shadows of the ribs. Pleural
thickening is differentiated from effusion in that the latter casts a uniform
and more dense shadow ; the level of the shadow will change with the
position of the patient and is best viewed in the erect or sitting posture.
In thickening of the pleura an irregular outline is discernible.
In contioti<l<ttion the shadows are larger, more irregular, and denser
than those cast by the ribs, and especially noticeable in advanced cases
240 ELECTRO-THERAPEUTIC 'S.
of tuberculosis. The apex alone may be affected, but in other instances
the entire lung is attacked. It is thus that consolidation is differentiated
from effusion.
Gavitations are characterized by dark areas surrounded by a light
field; this is due to a lessened amount of tissue for penetration by the
rays. If the cavity is partly filled with fluid while the patient is in the
recumbent posture, the fluid gravitates, and the dark area is obliterated;
but in the erector sitting posture the level of the fluid will be visible
when it is of considerable size.
Prior to a paroxysm of severe coughing, if a fluoroscopic or skia-
graphic examination be made with the patient in a recumbent position,
and another examination taken subsequent to the paroxysm, the cavity
will be noticeable, because the fluid, pus, etc., will be evacuated.
Emphysema is manifested by excessive darkness on the negative, due
to the presence of air in the lung, as is also observed in cases of pneumo-
thorax, etc.
The shadows of the ventricles, the auricles, and the aorta, are easily
recognized ; for a detailed account, the reader is referred to the chapter
devoted to the Circulatory System.
I have made stereoscopic skiagraphs of the thorax which are very
useful in differential studies in pulmonary and cardiac affections.
F. ALIMENTARY SYSTEM.
Stricture of the oasophagus, whether due to a growth within or exter-
nal to and compressing the oesophagus, is difficult and often impossible to
differentiate by the skiagraphic appearance; but if the growth is within
the oesophagus and the latter cannot be dilated, it becomes necessary to in-
troduce an oesophageal bougie ; on the other hand, if the growth is external,
the sound can be introduced by displacing the growth to one side.
The Stomach. — The reader is referred to Chapter V., Alimentary
System.
G. GENITOURINARY SYSTEM.
Only in emaciated individuals are the shadows of the kidneys easy
of demonstration. In the normal individual, shadows of the kidneys as
seen on the negative are very unsatisfactory.
Renal calculi should not be mistaken for biliary calculi, intestinal
concretions, enteroliths, tuberculous foci, or abscesses. Scars and accu-
mulations of sand in the pelvis of a kidney may in some cases cause an
erroneous diagnosis to be made. I once mistook an undissolved capsule
of bismuth for a calculus, but a second negative showed the change in the
position that the capsule assumed, and the operation was postponed.
THE PRINCIPLES OF TECHXIC. L>41
Dr. Heiiry Hultz1 reported a case in which fracture of the transverse
process of a vertebra would have been mistaken for a calculus had he not
made a stereo -skiagraph of the condition. Whether a calculus is in the
lower part of the ureter or in the bladder, is often a difficult matter to
decide.
There are three methods for ascertaining the exact location of a
calculus. 1. By inflating the bladder, when the shadow cast will be
darker on the negative. 2. By injecting water, when the shadow will
be seen to be lighter than the surrounding structure. 3. By introduc-
ing a catheter, when the presence of a (small) stone in the ureter will be
noticed by its position, and relation to the end of the catheter. By the
first and second methods the relation of the calculus to the bladder will be
observed.
Several small round white spots often mistaken for calculi may be
noticed along the left line of the ureter. They are frequently situated in
a curved line and are more frequent on the left side than on the right, or
sometimes on both sides of the same patient. They commonly occur after
the thirtieth year. Their true nature is a disputed matter. Some believe
them due to the presence of sesamoid bones in one of the obturator
tendons.2 Russell H. Boggs is of the same opinion ; others incline to the
belief that they are calcified glands.
Dr. Joseph F. Smith,1 of Chicago, believes that in 25 per cent, of his
cases negatives of the pelvis contained from one to six small round
shadows, sometimes on one side, sometimes on both sides, in the vicin-
ity of the ischiuui. He found, by dissections of cadavers, that these
shadows are caused by small bony deposits that occur in the pelvic liga-
ments, especially in those attached to the spiuous process of the ischiuni.
I concur with those who believe that these spots are phleboliths. Among
the latter may be mentioned Chas. L. Leonard, Henry K. Pancoast, and
Max Reichman.4 These shadows can be differentiated from those of
ureteral calculi by passing a metallic bougie and by skiagraphiug in situ.
If these shadows are outside the shadow of the catheter, they are evidently
not ureteral. The autopsy of one of my cases showed the presence of a
phlebolith.
TV.s/coZ Calculi. — The shadows of the sacrum and coccyx may be
superimposed by the shadow of a small calculus, hence the shadow of the
latter may fail of differentiation. This is also true of the shadow of
impacted fecal matter in the rectum. The bladder should be evacuated
just prior to the X-ray examination, as water offers a barrier to the
1 Transactions of the American Rontgen Ray Society, 1906, page 158.
1 E. W. Caldwell, Medical News, April 22, 1905.
3 Transactions of the American Rontgen Ray Society, 1906, p. 157.
4Fortschritte a. d. Gebiete der Rontgenstrahlen, Feb. 22, 1906.
16
LMi> ELECTRO-THERAPEUTICS.
I»;i-»age of rays. I have frequent ly seen the outline shadows of the
bladder, which are so valuable in determining whether the calculus is
uretenil or vesical, or if the appearance is due to an interfering shadow.
In stricture of the urethra, by the introduction of a bismuth solution
we are enabled to ascertain the location of the stricture, its calibre, etc.
A report of the X-ray negative should be written or oral and should
be most carefully executed. The report should be made as intelligible
as possible, by making some tracing, marking, etc.
There are numerous shadows on the negative that defy all efforts at
interpretation and are as little understood to-day as they were when
skiagraphy was first presented to the notice of the medical profession.
V. Stereo-Fluoroscopy and Skiagraphy.
A. HISTORY AND PRINCIPLES.
The application of the principles of stereoscopy to skiagraphy was
first employed in this country by Professor Elihu Thomson l and subse-
quently used abroad.
Ch. Bouchard2 claims priority of the discovery for Imbert and Bertin,
of Montpellier, France, but this is erroneous, as the latter first made
known their studies in Comptes-Rendus, March 30, 1896.
Dr. Mackenzie Davidson was perhaps the first investigator to pro-
duce and interpret X-ray photographs by this method, publishing an
article in the Britixli Medical Journal in 1898.
Professor G. P. Girdwood, of McGill University. Montreal, Canada.
made extensive use of this method in studying foreign objects. The
leading scientific journals of Germany have published many articles on
this subject, describing the methods, the apparatus, and detailing advan-
tages gained by its employment.
In October, 1901, Dr. Louis Weigel, of Rochester, exhibited a stereo-
scopic outfit before the members of the New York Medical Society, and
Dr. A. B. Johnson, of New York City, published an article on this snl>
ject in the Xew York Medical Record, September, 1900.
In order to produce a stereoscopic picture, it is necessary to arrange
a pair of tubes so that when worked simultaneously they will present on
the fluorescent screen a double set of outlines fused into one. To bring
out this effect we must alternate the use of the tubes, and so choose ihe
intervals that the continuity of vision may accomplish the fusion of the
two images. (Figs. 110, 111.)
The anodes ;nv placed about 6 cm. distant from each other. They
are alternately excited by a single coil, but preferably by individual
Electrical Engineering, March 11, 18%.
* Trait£ Radiologie M^dicale, p. 661.
THE PRINCIPLES OF TErHXIO.
243
coils. The terminals of the secondary c'oil are connected to the tubes
alternately, by means of a commutator or switch worked automatically.
It is also necessary to have a revolving opaque disk containing two
apertures on directly opposite sides, and set apart from each other at a
distance corresponding to the space between the examiner's eyes.
If the sector disk and the automatic switch rotate synchronously,
and are so adjusted that the tube on the left side becomes luminous
simultaneously with the passing of the aperture for the eye of that side,
FIG. 110.— Principles of Brewster's refracting
stereoscope.
FIG. 111.— Principles of Wheatstone's reflecting
stereoscope.
there may l>e observed a sharp image on the fluorescent screen between
the left tube and the perforated disk ; this is suddenly followed by an
obscuration of the vision of the left eye. In this instance the tube is
suddenly thrown into illumination and the image of the part is thrown
upon the screen. Dr. Davidson l constructed such an apparatus.
B. STEREO-FLUOROSCOPY.
Briefly, this stereoscopic fluoroscope consists of a fluorescent screen
illuminated by two tubes which spark alternately. A rotating disk with
appropriately placed slots eclipses each eye alternately and works syn-
chronously with the sparking of the tubes. Each eye sees the shadow
1 Dr. Mackenzie Davidson described the mechanism of his invention, together
with the application of its principles, before the Rontgen Ray Society of London, on
December 6, 1900.
244 ELECTRO-THERAPEUTICS.
cast from erne tube. A stereoscopic image i.s thus seen, the movements
of the shutter, etc., being sufficiently rapid to give a continuous
illumination of the screen.
E. W. Caldwell1 uses a large Crookes tube of the double focus
variety (two anodes) at a distance of three inches. The fluoroscope is
provided with a shutter which permits only oiie eye at a time to view the
fluorescent screen. In other respects the apparatus is very similar to
Davidson's device.
C. TECHNIC OF STEREO-SKIAGRAPHY.
In brief, the technic consists of obtaining two separate skiagraphs
of the same part, or of employing two different sensitive plates without
changing the position of the parts, but in alternating the position of the
Crookes tube two and a half to two and three quarters inches (6 cm.),
corresponding to the distance between the pupils. (Fig. 112.) Subse-
quently these two negatives or skiagrams should be examined with a
special instrument. It is important to observe that the part on which
the stereoscope is to be used should first be fluoroscoped or skiagraphed
in order to locate accurately the seat of the injury.
For use in stereoscopic work, a plate-changing box (Fig. 113), witli
a top of thin wood or hard fibre and measuring from 14 to 17 inches (35
to 45 cm.), is employed. The size of the plates is marked upon its top,
in order to correspond with the dimensions on the drawer of the box.
Over this box are placed cross-wires, which facilitate the accuracy of
superposition. It is advisable to have a horizontal bar scaled in inches
and centimetres. The skiagrapher should first centre the object and then
move the tube to the right, corresponding to the vision of the right eye,
one and one-quarter inches, or 3 cm., and procure a picture. Place
another plate in the drawer of the box without moving the object, and
adjust the tube to the left, corresponding to the view of the left eye, and
again take a picture. The plates should be marked " right" and "left,"
to obviate confusion after photographing the part.
Some operators use two Crookes tubes at a distance (the anodes) of
seven or eight centimetres, not moving the tube at each exposure. The
objection to this method is, that the two tubes will have different de-
grees of vacuum.
A. B. Johnson, of New York, and P. Czermak prefer to shift the
box two and one-half inches instead of sliding the tul>e.
Another method of taking stereoscopic pictures2 is to have a plate-
holder so constructed that, by a heavy sheet of metal, one-half the < «>n
tained photographic plate is shielded from the action of the rays. After
'Electrical Review, November 16, 1901.
J A. B. Johnson, Annals of Surgery, April, 1902.
FIG. 112.
246
EaJSCTEO-THEBAPBUTICS.
exposing one-half the plate, the other halt' is brought beneath the part.
the latter having been previously shielded by a lead screen. The tnl>e
is moved a suitable distance, and a second exposure is made. The
FIG. 113.— Author's plate-changing box.
two pictures thus lie side by side upon the same plate, and may be
copied in a reduced size, and viewed as positives on glass or paper in a
refracting stereoscope. This method is suited for the extremities, l»ut
not for the chest, abdomen, etc.
Marie and Ribaut1 have derived the following formulae and table,
which they assert will give the most relief and perspective view without
fatiguing the operator's eyes. They arrived at these deduced results by
a series of experiments founded upon mathematical proofs:
A Maximum = The maximum displacement of focus tube.
1) The distance of the tube from the surface of the object.
P — The thickness of the object.
P (D + P)
Max.
50 P
'Archives d'c-lectricite medicale experimentales et cliniques, viii., July 15, 1905,
and Trait*'- Radiologie Medicale by Bouchard, pp. "><;"> ami 5t;i;.
THE PRIXCIPLES OF TI-riINK .
247
When the actual size ("dimension ' is desired, then i> equal to 6.6
cm. — viz., the distance between two pupils.
6.6 cm.
P (D 4- P)
,50 P
Marie and Rlbauf s Table, showing the varying relationships between
the thickness of the part examined and the displacement of the Crookes
tube, and also the change in the distance of the tube from the surface
of the object. For example, if the part, such as the wrist, is 6 cm. in
thickness and the distance of the tube is 40 cm., then the displacement
of the tube will be equal to 6.1 cm.
P = THICKNESS
UK THE OBJECT.
\> DISTANCE OF THE TI'BE FROM THE SURFACE OF THE OBJECT.
Inch.
Cm.
8 20
Inch. Cm.
12
Inch.
30
Cm.
Inch
40
Cm.
Inch.
50
Cm.
23f
Inch.
60
Cm.
MAXIMTM
DISPLACEMENT OF CuoOKES Tl'BE.
}
•2
1!
4.4
3i
9.6
6A
16.2
1
-
it
'I
•2.4
1.7
1.2
11
1
5.4
3.6
2.8
ill
8.8
6.1
4.1
6A
III
13.5
9.3
7.3
4
10
H
2.4
4.0
6.0
6
15
1
1.8
i U
2.9
IT!
4.3
2|
6.0
71
20
IS
1.5
H
2.4
1 ,•;,
3.5
l|
4.8
9|
llf
25
30
j
1.3
1.2
H
2.1
1.9
5ft
3.0
2.7
4.0
3.6
I have; devised a special table and an adjustable plate-holder, which
I believe possess many advantages.
The table is so constructed that the tube can be made to slide
on a rod with great ease, whether on the top, bottom, or side, without
discomfort to the patient.
Usually in skiagraphing for either simple or stereoscopic purposes
the part is placed over the table or plate -changing box, and the weight
of the patient rests upon the plate, thus changing the original position of
the foreign body. "With the above device, the part maybe placed in a
natural position, without the plate-changing frame touching it at any
point.
To produce two negatives of "equal density" the degree of penetra-
tion of the rays should be as nearly uniform as possible, and great care
should be exercised in development.
IMS
ELECTBO-THEB A I » K r TI ( 'S.
Xo two tubes have exactly the some degree of vacuniu, the same
tube changing its vacuum during the exposure. The operator should
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POSITIONS OK THK
NEGATIVES.
1m side toward
the reflecting
mirrors; similar
to fluoroscopic
view or skiagram.
1m side toward
the reflecting
mirrors; similar
to fluoroscopic
view or skiagram.
lass side toward
the mirrors (skia-
grams) , eyes cor-
responding to the
Crookes tube.
ass side toward
the mirrors (skia-
grams) .
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judge the time of exposure of the second plate by experience. A self-
regulating tube is pivfcralilc. I usually give a little longer time for the
second exposure than for the first, as the tube runs down a little and the
penetration lessens. Short exposures are most desirable.
THE PRINCIPLES OF TECHNH1. 240
Lately I have been developing for the same duration of time two ex-
posed plates in one tray, but I have discarded this method, because the
handling of large plates is difficult and the plates differ in density, but
now I develop them separately, and by carefully mixing the developer
before and during the progress of development, I alter it as the plate
requires, to secure equal densities. Soft negatives are preferable.
D. METHODS OF VIEWING STEREO-SKIAGRAMS.
Reflecting Method. — This instrument, devised in 1838,
consists of two vertical mirrors accurately set at a right angle (the ver-
tex of the angle facing the middle line of the observer's forehead), this
arrangement of mirrors slides forward and backward, and is placed over
a long board, upon which is a vertical frame parallel with the reflecting
plane, forming an angle of 45°. These frames and mirrors are so con-
structed that the observer can easily superimpose the two pictures.
(Fig. 114.)
The pictures must be so placed in the frame as to hold the same
position as that occupied by the Crookes tube during exposure. For
instance, the picture marked ''right'' should be placed in the frame to
the right of the observer in order to get an anterior view of the part. If
placed in the left-hand frame, a posterior view will be obtained. When
prints are examined with reflected light, by turning the prints end for
end, without changing the UR" or UL'' positions, posterior and anterior
views may be obtained ; this is known as pseudo-stereoscopy.
The advantages of Wheatstoue's reflecting method are that : Any
sized negative, even before a print is made, can be viewed. When nega-
tives are used without prints, the picture is seen more in detail ; nega-
tives can be examined while wet. I bore two holes in a block of wood
which is placed between the reflecting mirrors, where the same reflecting
light used for negatives can be set for the illumination of prints.
Brewster's refracting or lenticular stereoscope is founded on the prin-
ciple that two pictures can be produced, by causing a displacement of the
tube, two and one half inches (6.5 cm. ), with the pictures side by side,
and viewed with two prisms (18°) for each eye. (Fig. 110.)
These pictures will be superimposed according to the laws of refrac-
tion. One disadvantage of the Brewster refracting stereoscope is the
jireat degree of the convergence of the axis of vision required, and the
necessity of reducing the size of the pictures for use in this refractor.
This has been overcome by Walter, of Germany, who places the original
si/,- negative in the frame and views it with different prisms. (Fig. 115.)
There is yet another method of viewing these stereoscopic transpar-
encies or prints. The reduced pictures mounted in frames are placed on
an endless chain, and are viewed by the operator who looks through the
250
ELECTEO-THEEAPEUTICS.
prisms. The advantages of this method are : That the number of pic-
tures is practically unlimited, unnecessary light is excluded, and that
prints as well as transparencies may be employed.
Lately I have made some plastographic views from these stereo-
scopic negatives. The plastographic method consists in superimposing
one print in green over another in crimson, which offers a ha/.incss to the
naked eye, but when viewed through eye-glasses (one of a green color
and the other of crimson), a very beautiful picture with marked relief
Fio. 115.— Prism stereoscope of Walter.
details is afforded. I believe this process will be useful for stereo
scopically illustrating medical journals and scientific books. There is
another method of combining stereoscopic pictures without an instru-
ment, which can easily be acquired by crossing the visual axes. Place
the skiagraph in front, hold up the index finger in the middle line
between the eyes and the skiagrams, and while looking at the top of
the finger, a third picture will appear in the centre, offering a most
iM'autiful stereoscopic effect.
E. ADVANTAGES OF STEREO-SKI ALL- \IMIV.
An ordinary skiagraph is composed of superimposed shadows of
dilferent densities, which appear Hat on the negative or print, and in ad-
dition contains many shadows appearing indistinct and weak, but in
the stereoscopic pictures the supcrimposition will be more distinct
and visible. Two plates exposed at different angles are used, and any
deficiency in one is easily compensated tor in the other. Another
FIG. 114.— Wheatstone's reflecting stereoscope, as modified by Weigel.
FIG. 116.— Stereo-skiagram of Colles's fracture, palmar view taken through the splint, and should be viewed
with prism stereoscope.
THE PRINCIPLES OF TEC1IXH . •_>.-> l
advantage is that the anterior and tin- posterior views are discernible.
In passing, we will very briefly note a few of the many applications
of siereo-skiagraphy.
Anatomy. — For demonstrating the structure of the bones. In the
long and short bones the trabecuhe are seen, and in the long bones we
may observe the lamella? in the shafts and in the cancellous tissue.
The spiral arrangement of the lamelhe is distinctly shown, especially
in the humerus and femur, also its change in direction near the articular
surfaces.
In examining the skull, the grooves for the meniugeal arteries are
seen, the concave appearance of the cranial processes, the frontal sinuses,
the antrum of Highmore, the turbinated bones, etc.
In studying the mechanism of the joints, these pictures give a per-
spective of the relations of the articular surfaces of the bones, their actual
depths, and the relation of the processes, to the observer.
Arteries, veins, bronchi, and excretory ducts, wheu injected with
opaque materials, such as lead or mercury, show their exact relations
(their depths) to the bones, the muscles, etc.
Surgery. — Of the numerous methods of locating foreign bodies stereo-
skiagraphy is the most satisfactory, because it offers a definite view of
the foreign body, and thus enables the surgeon to operate with cer-
tainty. The negatives should be soft and full of details, in order to show
shadows of different tissues, especially cystic and soft tumor tissue.
When two negatives of this kind are superimposed, the intensity of
the shadow is doubled. I am and have been using this method in
the Philadelphia Hospital in a series of experiments for detecting and
locating brain tumors, etc.
The foregoing statement is also true in regard to fractures. (Fig.
116.) By this method we may procure definite views of the injuries, the
exact position of the fragments, the amount of overlapping, the separa-
tion, the degree of apposition in deformities, etc. The ordinary skiagraph
does not show the variety and character of dislocations. The stereo-skia-
graph overcomes this difficulty, and enables one to differentiate between
an anterior and a posterior dislocation. We may view the thorax either
from an anterior or posterior aspect. The heart and the aorta with their
various relations are interesting and fascinating from a practical and
scientific standpoint. In the study of normal and morbid conditions,
I invariably resort to the employment of stereo-skiagraphy at the
Philadelphia Hospital.
CHAPTER III
THE CLINICAL APPLICATIONS OF THE KOXTGEX KAYS.
INTRODUCTION.
I. The Uses of the X-rays in Anatomy and Physiology.
MUCH has been written about the uses of the X-rays in investigating
anatomical structures and in studying the functions of organs. Undoubt-
edly the knowledge gained by dissection and vivisection through many
years of laborious research has been greatly altered and modified through
the application of the X-rays.
A. BLOOD-VESSELS AND RESPIRATORY TRACT.
I have studied the blood-vessels of infants and adults by injecting
into them a substance opaque to the X-rays. The substance used is a
concentrated emulsion of bismuth subnitrate, a strong solution of litharge
(red oxide of lead), or metallic mercury. In order to demonstrate
sharply the arterial tree, the injection must be done carefully and slowly.
By some it is deemed advisable first to empty the arterial system of all
its blood, and then to inject a solution of zinc chloride, so as to get rid of
any existing clots. This solution should be removed by washing, or by
forcing water into the arterial system, followed by an injection of metallic
mercury, by a force pump connected to the external carotid artery.
The kidney, heart, brain, spleen, liver, stomach, etc., may have
their arterial systems demonstrated by first removing them from the
cadaver, and then injecting into them some opaque substance, preferably
lead oxide. In experiments performed two years ago, I showed the
arterial and venous systems of a kidney by employing substances of
different densities. Thus metallic mercury was used for the renal artery
and its branches, and a weak solution of red oxide of lead for the renal
vein and its tributaries.
The brachial, radial, and popliteal arteries have been observed in
the living subject, especially in the aged where sclerosis was present.
I have traced the respiratory tract from the larynx to the small
bronchioles, by introducing into the upper opening of the larynx a solu-
tion of red oxide of lead and allowing it to expand the air-vesicles.
The larynx, the trachea with its bifurcation, and the bronchi, with a few
of its branches, can be beaut i fully demonstrated skiagraphically. 1 nstead
of the red oxide of lead, I have used small shot, which travel only to the
smaller bronchioles, and not into the respiratory passages and air-cells.
252
THE CLINICAL APPLICATIONS.
253
B. BOXES AND JOINTS.
So far as the subject of anatomy is concerned, the X-rays have been
most useful in studying the osseous system, \\~heu the entire foetal
skeletal system is mapped out in cartilage, the X-rays cast no shadows
of these structures. As soon as ossification of the cartilaginous tissues
begins and advances, every step involved in the process may be shown
by X-ray skiagrams. The cartilage, being transparent to the rays, casts
no shadow.
The rays are of great value in estimating and detecting delayed
union of the epiphyses. All X-ray specialists should be thoroughly
familiar with the normal appearance of an epiphysis and the time of
union. Mr. Poland, F.R.C.S.,1 London, states, that epiphyseal separa-
tion is much more common in males, owing to their rougher forms of
amusement, heavier work, etc., and also that the injury is frequently
started in intra-uterine life or during awkward, difficult, and instru-
mental labors. The larger number of injuries are produced during
childhood, between the ages of five and ten and even up to the sixteenth
year of life.
The most frequent seats of epiphyseal lesions occur in the upper
epiphysis of the humerus, lower epiphysis of the femur, lower epiphysis
of the radius, and in the phalangeal and metacarpal and metatarsal
epiphyses. The times of union of the various epiphyses to the corre-
sponding diaphyses of long bones are as follows:
UPPEK EXTREMITY.
Radius
Radius
Ulna
Ulna
Hurnerus
Humerus
Humerus
Motacarpal
Phalanges (fingers)
Clavicle
LOWER EXTREMITY.
Tibia
Tibia
Fibula
Fibula
Femur
Femur
Femur
(upper end)
(lower end)
(end of olecranon)
(lower end)
(lower end)
(upper end)
(end of epicondyle)
(upper end)
( lower end )
(upper end)
(lower end)
(lesser trochanter)
(greater trochanter)
(head)
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
Between
15 and 17.
17 and 19.
15 and 17.
18 and 21.
16 and 17.
18 and 22.
17 and 18.
19 and 21.
18 and 20.
22 and 26.
21 and 22.
18 and 19.
20 and 22.
19 and 22.
17 and 19.
18 and 19.
18 and 20.
1 " Traumatic Separation of the Epiphyses.'
Smith, Elder & Co., London, 1898.
A monograph published by
\-AA-A T IK >-T 1 1 1 : i ; A i • 1-: i'T i ( \s.
LO\VKK EXTREMITY. — ' nntin<i"l.
(lower end) Between L'O and 24.
Mftatarsal lietween 19 and 21.
Phalanges (toes) Between 17 and 1M.
( Ilium Between 7 and 10.
Isrhium Between 7 and 12.
] Pul.is Between .i and 15.
( (Uniting at 25)
As an epiphysis consists of rapidly developing cartilage, it is readily
penetrable by the rays, while a skiagram casts a light shadow of the
epiphyseal band, which on the negative appeal's as a dark band. It is
essential to diagnose correctly an epiphyseal injury, as it often results in
severe deformity. Both sides must be taken for comparison.
The joints and their mechanism have been carefully studied by Dr.
Ernest A. Codmau,1 of Boston. He says : "This has been undertaken
in two ways, — first, by skiagraphiug the normal joints in their extreme
positions (extreme flexion, extension, adduction, etc.) ; secondly. l>y
watching the movements with the fluoroscope. As the parts of the object
near the plate show best, it is necessary to take each position from
both sides. One thing which will arrest attention is the great distance
that apparently intervenes between the bones. This is in part due to
the fact that the articular cartilages, being easily traversed by the
rays, do not cast a shadow. The wrist -joint has proved most interest-
ing in this study, and the points brought out will be found in the fol-
lowing description. For convenience we may consider the wrist-joint to
lie made up of four immobile and two mobile elements. (1) Immobile
(/. <"., those made up of simple bones or of a group of bones, the com-
ponents of which cannot change relative positions). These are : (a)
metacarpal of thumb, (6) metacarpal of ring-finger, (c) metacarpal of
index and middle finger, with trapezium, trapezoid, os magnum, audunci-
form. This last group is so firmly attached to one another that they move
as a whole, practically as one bone. No doubt, however, their li-a
mentous attachments allow of more or less spring in strained positions of
the hand brought about by external force.
"2. Mobile (the components of which change relative positions).
(«) The intermediate row of carpal bones composed of scaphoid, semi-
lunar. cuneiform, and pisiform. (6) Radius and ulna. From skiagraphs
it is found that the carpus and metacarpus are, in any of the extreme
positions, in practically the same relation to the radius, no matter what
the relation of the radius to the ulna, whether prouation or supination.
This is due to the more or less flexible fibro- cartilage, which in any posi-
tion completes the cups of the radial joint. The question of mechanism,
then, is further simplified by leaving out the ulna, which really does not
1 Archives of the Koiitgen Ray, AiijruM.
THE CLINICAL A PPLK 'ATIOXS. 255
enter into the construction of the joint except as a pivot. The pisiform
also does not enter the mechanism, serving only as a sesamoid for the
nlnar tendons.
•• Proceeding to eliminate other accessory elements, \ve can disregard
the metaearpal of the thumb, ring and index fingers, each of which
moves independently on the large fixed elements composed of the os mag-
num, etc. The thumb forms a typical saddle joint with the trapezium,
with the pommels of the saddle so low that motion is allowed iu a small
circle, either as rotation within the circumference or straight motions on
any of the radii. The metaearpal of the ring finger is allowed a slight
antero-posterior motion of a few degrees; that of the little finger the
same, but of slightly greater extent, with possibly a degree of adduction.
This leaves us with : (a) The large compound fixed element of the os
magnum, etc. (6) The radius with fibro-cartilage. (c) The intermediate
element of the scaphoid, semilunar, and cuneiform. These constitute the
real wrist -joint.
"By injecting a solution of paraffin in alcohol containing substances
opaque to the rays, we may bring out the normal anatomical relations of
certain of the internal organs. Thus, by injecting this charged solution
into the urethra, bladder and ureters, vagina, Fallopian tubes, rectum,
and the intestines, we may be able to produce exact skiagrams. To bring
out the normal topography of the large intestines, inject with water,
and allow it to escape from the small intestines through an incision previ-
ously made ; this will remove the fecal matter, permitting the opaque
solution to fill all crevices or depressions between the rugae. As has been
previously stated, we may by the X-rays determine the movements of the
heart in the living. The heaving of the diaphragm, together with the
relationship this organ bears to the movements of the pulsating heart,
may be illustrated by careful fluorescent screen examinations."
M. Bouchard1 reports that he observed a marked dilatation of the
left auricle when the intra-thoracic blood pressure was raised during a
deep and prolonged inspiration. The same condition exists when the
inspirations of a whooping-cough paroxysm are most violent. In two
cases examined with the fluorescent screen I was enabled to observe the
same condition. During forced inspiration a clear space between the
diaphragm and the heart may readily be demonstrated that does not exist
during ordinary inspiration.
C. PHYSIOLOGY OF PHONATION.
The physiology of phonation as seen by careful screen examinations
is very interesting. Max Scheier2 was the first to investigate this subject.
1 Lancet, September 10, 1898.
- Fortechritte a. <1. Geb. d. Rf.ntgenstr. , B. i., 1897-1898.
256 ELBCTBO-THEEAPEUTIC8.
In examining the parts involved during phonation. the X-rays should
penetrate the head laterally, the screen showing clear shadows of the
upper part of the pharynx and the naso-pharyngeal space. If the person
under examination utters a vowel sound, the screen shows the velum to
be raised, taking a position in the naso-pharyngeal space, the position vary
ing with the sound that is uttered. During the rendition of the vowel
letter a, we may observe the velum to rise a little and become more and
more elevated as the other vowels (in the order of e, o, u, and i) are suc-
cessively uttered. In high tones the velum rises more than when low
ones are uttered.
If consonants (except resonauts and semi-vowels) are pronounced,
the velum is raised higher than when the sound i is uttered. If the sounds
of the letters m, u, and ing are uttered, the velum rises only a very little
and in many cases not at all. The movements and positions of the tongue,
lips, and the inferior maxillary bone can also be easily interpreted on the
screen. The movements of the larynx, velum, and other associated parts
can easily be seen during deglutition, breathing, hawking, and sneezing.
II. Diagnostic Value in Fractures, Dislocations, and Callus
Formation.
The employment of the X-rays in surgery has found a fertile field iu
the study of fractures, their frequency, character, and varieties. Only of
late empirical knowledge has given way to scientific deductions, whilst
improved and modified forms of treatment have followed in the wake of
this recent achievement.
The deformity associated with a fracture is often deceptive. It may
be due to swelling of the neighboring tissues, occurring at the time of
or subsequent to the accident. The diagnosis of a fracture is not pre-
cluded by employing certain bony landmarks as guides in the diagnosis.
Again, shortening does not occur in green-stick fractures, in those which
are impacted, or in the iutra-articular or in the longitudinal fractures of
small bones, such as the carpal or tarsal.
Preternatural mobility is a sign of doubtful value. It often defies
recognition in incomplete, iutra-articular, and fissured fractures. In
fractures near a joint it is often impossible to declare positively if the
mobility proceed from the joint or from the supposed seat of fracture.
Difficulty may be experienced in grasping the fragments, and rough
manipulat ion exposes the patient to the danger of having a simple fracture
converted into a compound one.
Crepitus is likewise an unreliable guide in the diagnosis of fracture.
Interposition between the fragments of muscle tissue, fascia, or granula-
tions will ma.sk the true condition. In incomplete, fissured, or impacted
fractures of the neck of the femur and humerus, the nature and seat of the
THE CLINICAL APPLICATIONS. 257
injury may fail to elicit this sign : again this difficulty may be encountered
where muscular action maintains displacement and separation of the
fragments, as iu transverse fracture of the patella. «>lecran»»n. coracoid
and acroinion processes of the scapula, etc. Lastly, tenosynovitis. move-
ment of a rheumatic joint, and inflammation of a sheath or tendon may
closely simulate crepitus.
Movement of a broken bone or pressure at the seat of fracture elicits
pain, but its presence is not positively diagnostic. Loss of function is
another negative proof, as arthritis and painful joints will often cause
this condition.
A. THE ADVANTAGES OF THE BONTGEN RAY METHOD IN THE DIFFER-
ENTIAL DIAGNOSIS OF COMPLICATED FRACTURES.
The foregoing signs and symptoms are established facts based on
clinical knowledge. They, however, do not manifest themselves in any
given order, and are not typical, as they do not exist in all cases. They
always require an observant eye, a trained ear, and an experienced touch.
This method is supplemented by the X-rays, which for accuracy and
reliability are far superior to it, and possess the following additional
advantages :
1. As a method of diagnosis it is painless. It entails no waiting for
the diminution of the swelling nor necessity for the removal of bandages.
2. It allows a positive diagnosis to be made, at the same time reveal-
ing the exact nature of the injury.
The variety of fracture, whether oblique, transverse, comminuted or
fissured.
Its exact seat and extent, whether of the anatomical or surgical
neck or shaft, whether intra- or extra-capsular, simple, complete, or
incomplete, green-stick or intra-articular, etc.
The number of fragments, their size, shape, position or location.
The overlapping of the fragments, the exact amount and direction
of displacement, and whether the fragments are in apposition or not,
can only be ascertained before or after the reduction of the fracture.
3. It allows of its differential diagnosis from the following condi-
tions : dislocation, epiphyseal separation and displacement ; diseases of
bones and joints.
The differentiation of a fracture from a dislocation is often difficult,
because the great effusion or swelling around the joint will quickly
produce marked deformity. Because immediate reduction is necessary,
an early diagnosis is an important matter.
When an injury occurs in the vicinity of a joint, especially in chil-
dren, the epiphyseal condition will at once attract attention. The
epiphyseal separation or displacement is most important, but is easily
258 ELECTKO-THEKAPKI'TICS.
by the skiagraph. lu differentiating epiphyseal separation from
tincture, the patient's age must be considered, tlie average date of union
varying in each individual.
Fractures of the epiphyses and their displacements can also be
differentiated from fractures of other portions of the bone. Fragments
of the epiphyses may float in the joint and simulate fracture or dislo-
cation.
B. DISEASES OF BONES AND JOINTS.
The normal bone appears on the skiagram with its characteristic
texture. When any alteration, as increased density, is shown, it is due
either to an increased blood supply (as in osteitis or periostitis) or to
hypertrophy of the osseous structure, and the beginning of an inflamma-
tory process. Later, when the caseation or absorption takes place,
the bone will appear more translucent than normal. This shadow can
readily be differentiated from that of a fracture.
Osteiti* <in<l periostitis are differentiated from fracture and callus with
great facility.
Tumors of bones can be differentiated from suspected fractures or
formations of callus, especially in cases of impacted fractures of the neck
of the femur; for the latter, being undiaguosed, and exuberant callus
forming, may be mistaken for a tumor.
Exostoses of bones, which may occur either after fracture or in-
jury to the epiphyses, can be differentiated from a displaced fragment
of fractured bone. Exostoses, however, may be congenital, when not
infrequently they are found to be multiple.
The differentiation between coxa vara, fracture of the neck of the
femur, coxalgia, and arthritis of the hip-joint, is of great value to the
surgeon.
Diseases of Joints. — In cases of synovitis, tenosynovitis, arthralgia,
rheumatic conditions, bursitis, epiphysitis, and tuberculous arthritis
following injuries, the X-rays will prove most valuable in clearing up the
diagnosis by differentiating between fractures and diseases or injuries
of the soft tissues.
By means of the X-rays we are enabled to show clearly the bones, the
muscles, and tendons (such as tendo Achillis, and ligament um patelke,
tendo-qitadrioeps, etc.) ; but often we experience much difficulty in de-
tect ing with the aid of the X-rays the injuries to these soft structures in
all parts of the human body. In children the X-rays show the capsule
and hamstring tendons in the knee-joints, etc.
Sprain.* <ni(l drain* caused by a twisting of the joint, which result in
a rupture of some or all of the ligaments or tendons, are conditions always
difficult to diagnose. In those suspected cases when the part is examined
THE CLINICAL APPLICATIONS.
with the X-rays it is noticed that there is no fracture, and by exclusion
we are justified in saying that a sprain exists. If the periosteum is torn
off by a ligament or tendon, it will be observed under certain favor-
able conditions. (See Figs. 133 and 145.)
In many instances I have been able to see on the negative the ten-
dons and ligaments in the ankle-joint, and in the lateral view also those
of the knee-joint, etc., especially when a soft negative was obtained. In
children the negative should be "soft" and full of details ; a short
exposure with a high-vacuum tube should be the rule.
C. VALUE IN THE TREATMENT OF FRACTURES.
The X-ray diagnosis during and after the treatment of fractures is
invaluable, assisting the surgeon in approximating the fragments, which
can be accomplished by observing the process with a fluoroscope ; thus a
cast can be applied at once without disturbing the reduced fragments.
After the permanent dressing or cast has been applied, another fluoro-
scopic or skiagraphic examination will reassure him of the correctness of
the position of the fragments.
As a fracture is readily diagnosed by the X-rays, it is no longer
necessary to delay treatment until the swelling and effusion subside, thus
endangering the integrity of the joint.
The frequency of deformities following fractures has been steadily
decreasing since the introduction of the X-rays.
In suturing or wiring the great advantage gained from the rays is
that the operator is informed whether or not the suturing material is
remaining intact.
D. CALLUS FORMATION.
In the first stage of callus formation the X-rays reveal nothing.
About the twelfth or fifteenth day, it manifests itself as a cloudy mass at
the ends of the fragments, and, as calcareous salts are deposited, the X-rays
show the presence of a dauker substance. The time required to produce
this phenomenon depends upon the variety of fracture, the age of the
individual suffering from the accident, etc.
Duration of Callus Formation. — This is variable, in small bones the
time required is brief; thus the metatarsal bones manifest a cloudy
appearance about the end of the second week. About the second month
the rays show the callus formation to be firm and definite. It is fre-
quently difficult to see the shadow of callus ; because the latter is liable to-
be superimposed by the shadow of the bones. The shape of the callus is
fusiform and encircles the ends of the fragments.
The Varieties of Callm. — In many cases the bones are united firmly
and strongly several months after the accident, nevertheless the X-rays
may fail to reveal these conditions. On the contrary, callus may be
260 ELECTRO-THERAPEUTICS.
thrown out and yet the parts may not !>•' firmly united, as in an oblique
fracture of the tibia and fibula. This may arise from the callus being
too deficient in quantity to give a shadow on the plate.
I'' T feet Apposition. — If there is good apposition at the ends of the
fragments, especially of the long bones, the callus is not easily discovered,
being overlapped by the shadow of the bones ; but a careful examination
will divulge the callus, encircling and forming a faint fusiform shadow,
in addition to the compact osseous tissue.
Slight Overlapping. — In cases of displacement or slight overlapping,
the space between the fragments will be a light area, but as callus
is deposited the space will become gradually lighter on the negative,
depending upon the thickness of the callus thrown out.
False Joint. — If callus does not fill the space between the fragments,
the bone at the seat of fracture remains movable and the condition of a
false joint is produced. This is the result of a fibrous and not of a bony
union. It is of great importance to be able to differentiate true from false
union.
Fractures icith Extensive Displacements. — When the displacement is
so extensive (2-3 cm.) that the ends of the fragments do not come in
apposition, lateral union occurs, which requires several years for its com-
pletion and at best does not result in a very strong coaptation of the
fragments.
Age. — Because of the vitality of the osseous system and the perios-
teum, the formation of callus in children and the adolescent is more rapid
than in the adult and the aged. This ready deposit of callus must not
be mistaken for periostitis the result of the traumatism.
Structure of Callus. — When the fracture is old and vicious union
has occurred, the X-rays may reveal a partial or complete absence of the
bony structure, the texture and trabeculse having suffered a complete
change. Care should be exercised not to confound this osseous change
with osteo-myelitis or some other bone disease.
III. Fractures and Dislocations of the Upper Extremity.
THE HAND.
Fluoroscopic Examination. — The fluoroscopic examination of the hand
is satisfactory only when no skiagraph can be taken.
In the examination for fracture, the patient should be seated and all
bandages and splints removed. In the presence of a wound, avoid all
danger of sepsis by covering it with aseptic gauze. Extend the hand,
place it against the screen, 20 inches from the Crookes tube, the rays arc
to fall perpendicularly. The right hand of the operator grasps the handle
of the fluoroscope, with his left he manipulates the hand of the patient,
gently pressing and rotating the suspected parts in order to view at
all angles the injured part. This pressure in cases of green-stick and
THE CLINICAL APPLICATIONS. 261
impacted fracture is especially necessary, in order to produce marked
separation of the fi auinents, so as to be able to view the disturbance of
texture and the irregular contour of the periosteum.
In order to determine the direction of the displacement in disloca-
tion, the phalanges, carpals, and metacarpals must be examined in the
lateral, antero-posterior, and oblique positions. The backward disloca-
tion of the first phalanx of the thumb is of special interest, because there
is usually some difficulty in its reduction. (Fig. 117.) Of course the
normal hand must first be studied. (Fig. 118.)
Skiagraphic Examination. — Secure a sensitive plate of sufficient size
to include the entire hand. The arm and elbow should rest upon the
table, to obviate any possible movement or tremor. Place a sheet of
blotting paper or celluloid between the hand and the plate, to prevent
moisture affecting the gelatine coat of the latter. The tube should
now be placed 20 inches (50 cm.) above the hand, directly over the
middle of the third metacarpal bone. Expose the plate from 3 to 5
seconds. In skiagraphing the phalanges, it is necessary to take both a
lateral and an antero-posterior view. Fracture of the scaphoid is shown
in Fig. 119.
Lateral and oblique fractures of any of the phalanges may be readily
skiagraphed by placing the fingers separately in a lateral position upon
the plate. Unfortunately carpal and metacarpal bones cannot be skia-
graphed separately. The fluoroscope usually suffices in the examina-
tion of the phalanges, but for the carpal and metacarpal bones more
satisfactory results are obtained with the skiagraph. If there is much
swelling of the palmar surface of the hand, place that member in the
dorsal position upon the plate, when the shadow of the bone will appear
much clearer.
THE WRIST- JOINT.
Fluoroscopic Examination. — In examining the wrist-joint, follow the
directions given for the hand ; manipulate the part gently, so as not to
aggravate the injury. This examination should be conducted before
splints or casts are applied. Much assistance can be rendered the
surgeon if the process of reduction is watched through a fluoroscope.
Skiagraphie Examination. — The wrist -joint should be skiagraphed in
the supine, prone, and the lateral positions both before and after reduc-
tion and also before removing the cast. Place both the hands upon the
plate for comparison. A small weight is placed upon the hand, or the
arm is strapped to a board, to prevent tremors. In the lateral position
the tremor can be avoided by the patient grasping a book or other small
object.
Lower End of the Rmlhix <tn<l Utna.—Au epiphyseal separation at the
lower end of the radius may be mistaken for a Colics' s fracture. (Fig. 124. )
262 ELECTRO-THERAPEUTICS.
It must he home in mind that tbe epipbysis commences to ossify about
the end of the second year of life, and unites with the shaft at about
the nineteenth or twentieth. Vertical fracture of tbe epiphysis is ran-.
The difficulty in detecting this fracture is due to a wrong position of
the tube, in consequence of which its rays not falling perpendicularly do
not traverse between the fragments ; or the shadows of the fragments may
superimpose, and thus obliterate the dark line on the negative.
Though dislocations at the wrist-joint were regarded by the older
writers as of infrequent occurrence, the advancements made in diagnosis
and tbe discovery of the X-rays prove them to be of much greater fre-
quency than was formerly supposed. These dislocations may be back-
ward, forward, or lateral, and may occur independently of fracture of
the radius or ulna.
THE FOREARM.
A fluoroscopic examination of the forearm is conducted in the same
manner as for the wrist -joint.
A skiagraphic examination can be taken while the arm is in either
the supine, prone, or lateral position. The plate should be 8 x 10 inches
(20x25 cm.), the time of exposure from 5 to 10 seconds.
Fractures of the middle third of the radius and ulna in children are
discerned with difficulty by the fluoroscope, being usually the so-called
green-stick fractures. A skiagraph is preferable. (Fig. 125.)
In fractures of the radius and ulna, if the two lines of injury are
near each other, the subsequent callus formation may bring these
bones together, thus producing a synostosis, which will interfere writh
rotation of the arm. The X-rays will indicate the amount of callus
thrown out.
In Colles's fracture a skiagraph taken in the antero-posterior posi-
tion may not show the fracture, or should the fracture appear the degree
of displacement of the lower fragment may not show at all. This will
necessitate a skiagraph taken in the lateral positions ; — i. e., the ulnar or
radial sides being in contact with the plate. (Figs. 120, 121.)
In the oblique type of Colles's fracture the line of dissolution often
includes a chipping off of the styloid process of the radius.
Fracture of the styloid process of the radius may be found inde-
pendent of (Figs. 122, 123), or in connection with, Colles's fracture.
Often the anterior border of the radius is fractured, producing subluxa-
tiou of the wrist.
Multiple fracture, especially that form known as the Y-fracture, is
more common than is usually supposed.
The supine or prone position of the wrist may show in the skiagram
either lateral displacement, transverse, oblique, or Y-fracture, and fissure
or fracture of the styloid process of the radius.
FIG. 117.— Inward dislocation of the first phalanx of the thumb. (Case of Dr. G. E. Shoemaker.)
1
Fio. 118.— The normal hand, taken with high-vacuum tube.
FIG. 119.— Fracture of the scaphoid, 1, 1.
FIG. 120. FIG. 121.
COLLES'S FRACTURE.
(Antero-posteriorview.) (Lateral view.)
Left picture, taken in the prone position, shows, at F >• and F, a transverse fracture of the
radius and a green-stick fracture of the ulna. E »• and E >- are the ununited epiphyses. The
right-hand picture is the same, taken in a lateral position. (Case of Dr. Franklin Brady.)
FIG. 122.— Fracture of styloid process of the FIG. 123.— The same, in the prone position,
ulna (supine position, hand slightly abducted). which does not show the fracture (arrow 5).
FIG. 124. — TvprcAi, COLLES'S FRACTURE. — The bones appear white, as seen on the negative:
1, scaphoid ; 2, semilunar ; 3, cuneiform ; 4, pisiform ; 5, unciform ; 6, os magnum ; 7, trapezoid ;
8, trapezium.
THE CLINICAL APPLICATIONS. 263
Occasionally the styloid process carries with it when fractured a
part of the dorsal border of the radius ; this is known as Barton's frac-
ture. Colics' s fracture is frequently associated with fractures of the
styloid process of the ulna accompanied by rupture of the triangular
fibro-cartilage.
THE ELBOW-JOINT.
F 1 noroscopic Examination. — It is very unsatisfactory to examine the
elbow in the antero- posterior position with the ordinary fluoroscope, as
the curvature of the part prevents a close approximation of the screen.
To meet this difficulty it is necessary to employ a small tubular fluoro-
scope which fits snugly the anterior surface of the joint. A disadvan-
tage of this fluoroscope is the small area brought into view. To obviate
this the author has devised a flexible fluoroscope which, when properly
used, will bring all the parts into view.
The lateral position is by far the most convenient one in which to
examine injuries of the elbow-joint with the fluoroscope. The joint
should be viewed from the internal, external, and lateral positions.
tikiagraphic Examination of the Elbow.— Skiagraph the elbow either
in the anterior, posterior, or antero-posterior position. The forearm
should be well extended and placed in the supine position. The sensi-
tive plate 8x10 inches, (20x25 cm.) is placed under the olecrauon
process of the ulna, with the tube held at a distance of from 12 to 16
inches (30 to 40 cm.) above the joint.
The elbow-joint is best shown in two views, the antero-posterior and
the lateral.
To skiagraph the elbow in the postero-anterior position, place the
patient in the ventral recumbent posture, with the arm extended by his
side. Place a small plate under the joint, remembering that it should be
as near the bones as possible.
A sensitive film can be placed in the flexure of the elbow -joint and
the tube beneath the table ; a convex block of wood, also conforming
to the contour of the flexure of the joint, will hold the film in position.
In the lateral position the plate should be placed either under the
internal surface of the elbow with the tube above the joint, or over the
external surface with the tube beneath the table, the former being prefer-
able. In both of the above methods, the elbow should be flexed and
brought on a level with the shoulder of that side.
To properly interpret the shadows, a normal corresponding joint in
the same individual must first be carefully studied; especially is this
the case with children. In the antero-posterior position, we notice the
shadow of the olecranou process clearly visible and superimposed upon
the shadow of the sigmoid fossa. Light shadows are seen between the
articulating surfaces of the huinerus and ulna.
264 E LECTRO-TH E 11 A I ' E UTICS.
A skiagram of the elbow in the antero-posterior position always
shows a light horizontal shadow between the internal condyle of the hu-
merus and the coronoid process of the ulna, which has often deceived the
inexperienced into diagnosing a fracture of the olecranou. Fig. 120 shows
the lighter portion extending inward between 10 and 7, toward 11. This
shadow is in reality that of the olecranon process of the ulna, and is
deceptive, because it is bounded by heavier shadows, which are cast by
the humerus and olecranon on one side, and by the coronoid and the
olecranon processes on the other.
Fractures of the head or neck of the radius are of rare occurrence.
(Fig. 126.)
Separation of the epiphyses is extremely rare. (Fig. 127.) It is
convenient to know that ossification begins about the sixth year, and
union with the diaphysis occurs about the sixteenth or seventeenth year.
Fractures of the upper third of ulna, with dislocation of the head of
the radius, are skiagraphed by lateral exposure. (Fig. 128.)
In longitudinal fracture of the upper end of the ulna, the lateral
position will not reveal the fracture, but it must be skiagraphed in the
antero-posterior position.
In order to separate the fragments, when the fracture is in close
proximity to the insertion of the brachialis anticus, the arm should be
well extended during the examination.
Dislocation of the Elbow-Joint. — For dislocations of the elbow-joint a
lateral view should be taken with fluoroscopic and skiagraphic examina-
tions. In children, this dislocation may simulate epiphyseal separation.
Supra-condyloid fracture, partial fracture of the internal epicondyle, and
partial detachment of the external coudyle of the humerus, are well
shown in Figs. 129, 130, 131, and 132. Detachment of the supinator
longus muscle, simulating a fracture of the humerus and epiphysitis of
the humeral head, at first thought to be a fracture, are depicted in Figs.
133, 134, and 135.
THE MIDDLE THIRD OF THE HUMERUS.
Fluoroscopic and skiagraphic examinations readily reveal, from all
sides, fractures of the middle third of the humerus.
THE SHOULDER-JOINT AND ITS VICINITY.
On account of the immediate swelling of the part, examination is
often rendered very difficult.
Fluoroscopic Examination. — If the patient is a child or a thin person,
this method of examination will !><> satisfactory.
Should one suspect fracture with dislocation, it is preferable to
take a skiagram, as it requires less disturbance of the parts. The
examination is made in the antero-posterior position.
THE CLINICAL APPLICATIONS. 265
Fractures of the surgical neck of the humerus are quite common
(Fig. 136), while fractures of the anatomical neck are very rare.
In skiagraphing the shoulder-joint, in order to avoid erroneous inter-
pretations, the operator should always bear in mind that the epiphysis
and diaphysis do not unite until the twentieth year.
Skiagraphic Elimination. — The patient is placed in the dorsal recum-
bent posture, the head being supported by a low pillow, and the uu-
bandaged arm is extended to an angle of 35°, and is*immobilized by
employing a sand-bag or small weight.
In corpulent individuals the head of the humerus may be too distant
from the sensitive plate. This may be remedied by simply tilting the
patient to that side, or by raising the uninjured shoulder on a pillow.
The rays should be directed over the lower border of the glenoid cavity.
In viewing from the anterior position, the patient may lie either on
his abdomen or on his back. When the patient assumes the former
position, the tube is placed over the spiuous process of the scapula, and
the plate rests on the table, under the joint. In the dorsal recumbent
position the tube is placed under the table, and the patient may rest
either in the dorsal decubitus or semi-recumbent position. I put the
plate in an adjustable plate-holder, which prevents it from coming in con-
tact with the patient. The rays should be applied only during the period
in which the patient holds his breath, after a full inspiration or expira-
tion. These intermittent exposures should be repeated 4 or 5 times.
This method prevents the blurred effects which one sees occasionally.
Dislocations or Subhixatiotis of the Shoulder. — In these classes of cases
there is likelihood of wrong interpretation of the skiagraphed part, as
different positions of the tube and arm will give varying relations of the
humeral head to the glenoid cavity. In order to guard against this error,
a, large plate should be used on both shoulders, and the parts skiagraphed
simultaneously, by placing the tube on the median line, and maintaining
both shoulders and arms in precisely the same position. Instead of
using one large plate, we may employ two plates placed together.
The acromio-clavicular space, being cartilaginous, appears as though
a fracture or separation existed. Sometimes this light area is exaggerated
on account of the faulty or oblique position of the shoulder or part.
The oblique ridge separating the head from the anatomical neck
often shows a white line on the negative. A depression where the
spinatus muscle is attached may also be seen on the plate. Fig. 137
shows a fracture of the acromion process.
THE CLAVICLE.
Fractures of the clavicle occur mostly in children, yet they may
happen at any age. (Fig. 138.) Skiagraphic examinations are best
obtained by taking either anterior or posterior views. Dislocation of
the scapular end and other varieties can be readily discerned.
•_v,r, ELECTEO-THERAPEUTICS.
THE SCAPULA.
Fracture of the scapula is best skiagraphed in the dorsal recumbent
posture. The coracoid process is best skiagraphed with the patient on
his abdomen ; the better method is to place the tube in such a position
that the rays will pass through the axillary space, the plate being
fastened over the clavicle, the coracoid, and acromial processes.
Always endeavor to throw the shadow of the process under the clear
space of the clavicle, and not over the neck of scapula.
FRACTURES OF THE SKULL.
Many difficulties are met in skiagraphing fractures of the skull,
owing to the superimposition of the shadows of the bony Avails surround-
ing the part under examination, and the difficulty in bringing the plate in
proper apposition to the curved outline of the skull cap. Fluoroscopic
examinations are satisfactory in the thin skulls of young children. Skia-
graphs can be taken in the lateral, the fronto-occipital, and the occipto.
frontal positions, but the lateral view affords greater detail of structure
and offers a clearer field.
Fissured fracture of the base defies detection, because the line of
fracture is inaccessible in any position in which the tube may be placed.
Any change in the contour of the inner or outer tables of the skull or the
presence of the formation of callus, can be brought out by placing the
tube and plate in exactly the right position, which can be determined only
by constant practice.
IV. Fractures and Dislocations of the Lower Extremity.
THE FOOT.
Fractures. — Fractures of the phalanges of the foot are of the com-
minuted or splintered type.
Fractures of the metatarsal bones, which were formerly thought to be
extremely rare, have been shown by the X-rays to be of common occur-
rence. (Figs. 139 and 140.) The so-called "swelling" of the feet is
often due to fracture of one or more metatarsal bones. The first and fifth
of these bones are most frequently broken, the resulting fracture being of
the compound type.
Fractures of the astragalus and os calcis are not infrequent, the force
travelling through the body or neck. This injury is often associated with
a separation or a dislocation of one or the other fragment. Fracture of
the os calcis may involve the body of the bone or one of its processes, and
is frequently comminuted. Fractures of the astragalus and os calcis can
readily be seen on the screen if there is sufficient separation of the
fragments. The lateral view is always preferable.
Fractures of the phalanges and metatarsal bones may be disclosed by
a fluoroscopic examination. Skiagrams of these fractures may be made
Fin. 125.— Green-stick fracture of the ulna, B, with a transverse fracture of the radius, D.
A and C are the epiphyses.
Fro. 1-26.— Fracture of the neck of the radius, 8.
FIG. 127.— EPIPHYSEAL SEPARATION ASD DISPLACEMENT OF THE LOWER Kxi> OF TIIE Hrvri:r>.
The eondylesS, 4, remain at their normal positions, the diaphysis having suffered a lateral
inent. The dotted line indicates the normal position that the diaphysis should occupy.
Fio. 128.— Fracture of the ulna and displacement of the head of the radius, 8.
FIG. 129.— Supracondyloid fracture of the humerus.
FIG. 130.— Fracture of part of the internal epicondyle after forcible reduction for dislocation.
.
Fio. 131.— Detachment of a portion of the external condyle of the humerus, antero-posterior view.
Fio. 132.— The same, lateral view. 3, inner condyle ; 4, olecranon fossa ; 5, external condyle ;
6, olecranon process ; 7, coronoid process of the ulna ; 8, centre of ossification of the head of the
radius. (Case of Dr. Franklin Brady.)
FIG. 133.— DETACHMENT OF THE SUPINATOR Losers MrscLE, ISDICATED BY THE ARROW.— The injury
was thought to be a fracture prior to X-ray examination. (Case of Dr. H. C. Kellner.)
FIG. 134.— EPIPHYSITJS OF THE HUMERAL HEAD.
FIG. 135.— THE CORRESPONDISG NORMAL SIDE.
Epiphysitis of the head of the humerus, diagnosed as a fracture. 3, internal epicondyle ;
4, olecranon fossa ; 5, external epicondyle ; 6, olecranon process ; 7, coronoid process of the ulna ;
8, head of the radius ; 9, tuberosity of the radius ; 10-11, trocblea ; 11, centre of ossification of the
capi tell urn.
'
Fio. 136.— Subluzation of the shoulder-joint, L -
surgical neck.
F >• is a fracture of the
FIG. 137.— Fracture of the acromion process, >• F. (Case of Dr. C. H. Burr.)
FIG. 138.— Fracture of the acromial end of the clavicle. (Case of Dr. W. L. Rodman. )
FIG. 139.— Fractures of the 1st, 2d, 3d. and 4th metatarsal bones and of the 1st phalanx
of the great toe.
THE CLINICAL APPLICATIONS. l't;7
in a number of positions. In the anterior-posterior position the patient
occupies a high stool with a back rest, which affords greater comfort and
lessens the possibility of movement. The foot should be placed oil a
small supporting bench which may serve as a holder for the sensitive
plate as well.
The foot is extended by gradually moving the bench from the stool,
the patient in the meantime being instructed to keep the sole of the foot
evenly upon its top. In skiagraphing a "partial" lateral view the
rays from the tube should fall more or less obliquely, thus preventing a
snperimposition of the metatarsal shadows.
Skiagraphy of the tarsal bones is more difficult. The astragalus may
be successfully skiagraphed in an antero-posterior view, by placing the
tube anteriorly at the upper angle of the foot and the sensitive plate
posteriorly, plantar or dorsal. Put both feet close together upon two
separate 8 x 10 inch (20 x 25 cm.) plates, with the tube in the centre. The
tarsal articulation can be best skiagraphed by placing the plate against
the dorsum of the foot and allowing the rays to penetrate through the
plantar surface.
Dislocations. — Phalangeal dislocations of the foot closely correspond
to those of the hand, but are of much less frequent occurrence.
Dislocation of the metatarsal bones at the tarso- metatarsal articula-
tion, usually occurs as a complete displacement involving several or all of
the metatarsal bones on the dorsuui of the foot. Plantar dislocations are
very rare.
The technic in dislocations is practically the same as has been
discussed under fractures.
THE ANKLE-JOINT AXD CONTIGUOUS STRUCTURES.
Fractures. — Fractures of the ankle-joint involve the tibia, fibula, and
tarsal bones, either alone or in combination. For all practical purposes
they should be divided into two groups, dislocation-fracture and sprain-
fracture.
A suprarnalleolar fracture of the tibia and fibula is best skiagraphed
autero-posteriorly. Skiagrams of typical Pott's fracture show a trans-
verse or oblique line of injury in the lower third of the fibula, with frac-
ture of the malleolar processes of the tibia, (Fig. 141.) A skiagram is
best made by placing the patient in a recumbent or semi-recumbent posi-
tion. The sensitive plate, 8x10 inches (20x25 cm.), should be placed
directly under the seat of the injury, as low as the os calcis, the leg being
slightly rotated inward to prevent superimposition of the shadows of the
tibia and fibula. The tube should be about 20 inches (50 cm.) distant
from the plate. The time of exposure varies between 10 and 20 seconds.
"NVhen the fracture is longitudinal, without displacement, the antero-pos-
terior view may fail to reveal the presence of fracture; in such a case, it
268 ELECTRO-THERAPEUTICS.
is imperative that a lateral view should be taken, with the suspected
side next to the plate. A fracture box should be employed to secure
immobilization.
Epiphyseal separation and malleolar and supramalleolar fractures
must not be confounded with Pott's fracture.
Dislocations of the ankle present nothing characteristic and there-
fore require no special technic. They should be examined in both
positions.
THE LEG (MIDDLE THIRD). (Figs. 142, 143.)
Fractures. — When making antero- posterior and lateral skiagrams in
this region, prevent the shadow of the tibia superimposing upon that of
the fibula, or vice versa.
THE KNEE-JOINT.
Fractures. — Complete transverse fracture of the tibia in its upper
third, fracture of the tuberosity, and traumatic epiphyseal separation of
the upper end of the tibia, are readily discerned by the X-rays.
The knee-joint should be examined from two views, either the antero-
posterior or the lateral. A fluoroscopic examination of the knee-joint is
rather unsatisfactory except in ankylosis. Gliding movements of the
various ligaments and patella may be studied, and severed ligaments can
often be detected. In osseous ankylosis the articular plane of the knee is
obliterated, while in the fibrous form there is usually no such obliteration.
In making antero- posterior skiagrams, have the patient on his
back, with the head and chest elevated, the extremity of the foot fixed
resting upon an extension of the operating table, or tied to fracture box.
A sensitive plate 8 x 10 inches (20 x 25 cm.) is placed against the posterior
aspect of the knee-joint, with the tube directly over the patella. The
shadow of the patella is usually very faintly superimposed upon that pro-
duced by the lower end of the femur. The patellar shadow is increased
in density if the plate is placed in front of the patella and close to it, the
rays being allowed to penetrate from behind. In making lateral skia-
grams the patient should lie upon the injured side with the fractured
joint slightly flexed, the other leg should be extended or fully flexed so as
not to interfere with passage of the rays. Detachment of the tubercle of
the tibia is shown in Fig. 145.
Fractures of the Patella (Fig. 144). — In transverse fracture of the pa-
tella, the lateral fluoroscopic view shows the separation of the fragments.
Stellate and fissured fractures can only be shown by a skiagraph taken in
the postero-anterior position. The patient should lie face down, with the
tube behind the joint and the plate under the patella. The sesamoid
bones give distinct shadows and float ing or loose bodies are often detected.
Detached cartilages are very difficult (and often impossible) to skiagraph.
THE CLINICAL APPLICATIONS. 269
THE FEMUR (MIDDLE AND LOWER THIRDS).
Fracture*. — Fractures of the shaft of the femur are common. In
children the injury is usually transverse with little or no displacement,
while in adults it is usually oblique with much displacement. In making
skiagrams of the shaft, two plates, in exactly opposite directions, should
be taken. Fractures of the lower third of the femur are easily diagnosed
by the X-rays.
THE HIP-JOINT.
Fractures. — Fractures of the upper end of the femur are divided as
follows : (1) intra-capsular, (2) epiphyseal separation, (3) extra-capsular,
(4) fracture of the trochanters, (5) isolated fracture of the trochanter
major, and (6) fracture of the upper portion of the shaft immediately
below the trochanters.
Fluoroscopic examination of the hip-joint in children is usually
satisfactory, but the thickness of the tissues makes it unsuited for adults.
At best, skiagraphy of the adult hip-joint is troublesome, especially if the
subject is very corpulent and the part painful.
The technic is as follows : Have the patient fully extend the
leg of the injured side. If this is impossible, place a pillow under the
partially flexed knee. Place two superimposed plates, 10 x 12 inches
(25 x 30 cm.) or 11 x 14 inches (28 x 35 cm.), under the hip, which
should extend from the iliac crest and project two inches from the outer
aspect of the leg. The tube should be placed directly over the head
of the femur, and from 20 to 25 inches (50-63 cm.) from the plate. If
the foot is inverted or everted from the injury, do not correct it. Guard
against tremors by the use of a pillow, sand-bags, bandages, or
suspended weights.
It is often valuable to take both hip-joints at the same time for com-
parison. For this employ either a large plate that will include the
shadows of both hips or two smaller plates touching side by side. Adjust
the tube to the median line at a distance of more than 20 or 25 inches
(50-63 cm.), the anode pointing to the pubic symphysis, remembering
that this position will require a longer exposure. It must never be for-
gotten that certain positions of the foot will cause the neck of the femur
to assume varying angles, shapes, and lengths to the acetabular cavity, and
that the shape, distance, and position of the lesser trochanter will change
its relation to the descending ramns of the pubis. To convince others
of the correct interpretation of the negative, employ as a confirmatory
measure a simultaneous skiagraph of both hip-joints, previously securely
binding the feet and ankles in the vertical position, thus placing the
necks of the femora in identical positions, or take another without tying
the feet, and let the feet occupy their actual positions in order to show
the difference. As very fine detail work — i. e., the structural texture of
270 ELECTRO-THERAPEUTICS.
the femur — must especially be brought out, it is apparent that, if this
sharpness of definition is lacking, an impacted or fissured fracture might
easily escape detection.
In doubtful and obscure cases, advantage is gained by making another
skiagram in the ventral position ; because of the thickness of this region,
the time of exposure is lessened by using the intensifying screen, which
sacrifices, however, the fine details. I therefore do not recommend it.
A ntero- posterior fractures of the acetabuluin can readily be skia-
graphed, but stellate fracture is extremely difficult to determine. Skia-
grams of impacted fractures of the neck of the femur do not present the
usual light lines. The fracture can, however, be diagnosed by the short-
ening, and the slight irregularity in the size, shape, and angle of the neck
of the femur.
The osseous ridge running between (intertrochanteric ridge) the tro-
chanters posteriorly, usually gives a light line on the negative, which must
not be mistaken for fracture. In the fracture at the base of the neck,
the angle diminishes from the normal to 90° or less. An incomplete,
intertrochanteric fracture is well shown in Fig. 146.
Chemical intensification of a negative defines the osseous tissue more
clearly, but as the detail of the soft structure is thereby diminished, a
second exposure is preferable, if possible.
A satisfactory negative should clearly differentiate the head and
neck of the femur and the hip bones. If not sufficiently dense, the
lines and shadows indicative of fracture will not be visible. The
tendency in making these negatives is to over expose, but better results
are obtained by using a tube of high penetrability, with an electrolytic
interrupter.
Dislocations. — Congenital dislocation of the hip in children (Figs. 147
and 148) can be well demonstrated by skiagrams, showing the presence or
absence of the ring of the acetabular cavity, the depth of the acetabulum^
the position, shape, and situation of the head of the femur. I have made
studies of a series of cases, before reduction, after reduction through the
cast, and after removal of the cast, in the service of Professor Adolf
Lorenz during his recent visit to this country, and they proved to be very
suitable and interesting from a stereo-skiagraph ic stand-point.
Pathological dislocations (Figs. 149 and 150) the result of tuber-
culosis, osteo-arthritis, Charcot's disease, etc., are easily skiagraphed in
the manner outlined under fractures. In pathological dislocations 11m
head and neck of the bone are absent, as in cases of epiphysitis.
Tin ()s INNOMINATA, SACRUM, AND COCCYX.
l-'mctures. — The clinical diagnosis of fracture of the pelvis can only
be made when the separation of the bones is marked or when displace-
ment is considerable. When only slight separation exists, the X-rays
FIG. 110.— FRACTURE OF THE MIDDLE OF THE FOURTH METATARSAL BONE.— I, II, III are the meta-
tarsal bones; A, 1st internal cuneiform; B, 2d middle cuneiform; C, 3d external cuneiform; D,
cuboid bone ; E, scaphoid ; F, astragalus ; G, anterior process of the os calcis ; 1, 2, sesamoid bones.
FIG. 141.— POTT'S FRACTURE.— F *-, F »•, fractures of both malleoli ; I) >• shows the in-
ward dislocation of the tibia. The internal malleolus, at 2, should be in the dotted area, having
become detached and left in the position marked 2 (white).
FIG. 142.— FRACTURE op THE TIBIA AND
FIBULA, TAKEN AT AN ANGLE BETWEEN THE
ANTERO-POSTERIOR AND LATERAL POSI-
TIONS.—This skiagram fails to show any
overlapping of the fragments of the fibula,
but exhibits the presence of callus.
FIG. 143.— Lateral view of the same, reveal-
ing a pronounced overlapping of the fragments.
(Case of Dr. W. L. Rodman.)
FIG. 144.— Fracture of the anterior portion of the patella.
Fio. 145.— Detachment of the tubercle of the tibia, result of a kick in a game of foot-ball,
(Case of Dr. Carlos M. Desvernine.)
FIG. 140.— Incomplete intertrochanteric fracture. (Case of Dr. W. L. Rodman.)
FlG. 147.— COXGEMTAL DISLOCATION OF THE HEAD OP THE LEFT FEMUR.— 1, ICSSCf tfOChanter ; 2,
greater trochanter ; 3, heart ; 4, neck ; 5, acetabulum. (Case of Dr. H. Augustus Wilson.)
FIG. 148.— CONGENITAL DISLOCATION OF BOTH HIPS.— This skiagraph was taken by me after
reduction by Dr. Adolf Lorenz of Vienna.
FIG. 149.— PATHOLOGICAL DISLOCATION OF LEFT HIP IN A CHILD OF Six YEARS.— When one year
old an abscess developed, which was incised and drained, and extension applied. Five years later the
skiagraph, as shown above, revealed absorption of the femoral neck. On the normal side, N indicates
the neck ; this is wanting on the affected side (X )• 1, lesser trochanter ; 2, greater trochanter ; 3, head
of the femur; X, neck of the femur; 4 >-, epiphyseal line; 5, acetabulum ; 7, iliac fossa ; 8, epiph-
ysis between the ilium and ischium ; 9, pubic bone; 10, obturator foramen; 11, ischium; 12, pubic
arch; 14, ilio-pectineal line; 16 >- 16, sacro-iliae synchondrosis ; 17, crest of the ilium; 18, trans-
verse process of the 5th lumbar vertebra ; 19, fecal matter surrounded by light area (gas) ; C, coccyx.
(Case of Dr. James K. Young.)
Fio. IJSO.— A CASE OF PROBABLE INFANTILE PALSY.— The patient's left femur (right side in the
photograph) shows an absence of the neck, and also a transparent area at the dotted portion indicated
at X. (Case of Dr. James K. Young. )
THE CLINICAL APPLICATIONS. 271
are of great diagnostic aid, as the contour of these bones is very irregular
and the rays must traverse great density of structure. Fractures of the
pelvic bones are divided into those in which the individual parts are
fractured and those in which the pelvic rim is broken.
In skiagraphing the pelvis the patient must assume the ventral and
dorsal decubitus positions. In a skiagraph of the sacro-coccygeal region
the tube should be placed over the umbilicus so that the shadow of the
pubic symphysis will not overlap the shadow of the sacrum or coccyx.
The rectum should be emptied by an enema prior to the examination.
The ilium, ischium, and the pubes can be skiagraphed in the above
manner, with slight modifications in the relation of the tube, the part,
and the plate.
THE SPINAL COLUMN.
For the sake of conveniently studying the spinal column, it is divided
into the ccrrical, dorsal, and lumbar regions.
The cervical region is best skiagraphed in lateral view. Complete
fracture of the cervical vertebne can easily be shown in skiagrams, but
incomplete fracture is detected with great difficulty. In my experience
I have found the fifth and sixth cervical vertebne are most frequently
fractured. To demonstrate a fracture or dislocation, skiagrams should be
taken in the lateral and the autero-posterior position. Recently I had
two cases of old fracture-dislocations of the fifth cervical vertebra, and
the patients are still alive. I have had four cases of fracture of the
cervical vertebrae.
Skiagrams of the dorsal region are somewhat indistinct, due to the
super-imposition of shadows cast by the liver, heart, sternum, and ribs.
I have had four fractures of the second and eleventh dorsal vertebrae.
The best definition is obtained from the young and those of slender build.
In thin persons autero-posterior dislocations may be shown by taking the
skiagram in the lateral view. Of course distortion will be exaggerated
on account of the distance between the plate and the vertebra.
Experience proves that the obstacles encountered in making skiagrams
of the vertebral column are numerous. Thus, the peculiar anatomical ar-
rangement in this locality, the projecting and irregular processes from each
vertebra, and the impossibility of obtaining the desired relations between
the tube, the part, and the plate, make this procedure a most difficult one.
The dorsal decubitus should be selected for examining all regions of
the spine ; but the tube should be placed at varying positions, and in
this way the shadow of the sternum will be lessened in the dorsal region.
This technic answers for the dorsal vertebrae, but the upper six cervical
should be taken in the lateral view. Only one region of the spine
can be skiagraphed at a time. In order to obtain the intra-articular
spaces clear and distinct, it must not be forgotten that the alimentary
272 ELECTRO-THERAPEUTICS.
canal should be well cleansed previously. The negative must be suffi-
ciently dense to bring out strongly and sharply the shadow of each verte-
bra with its processes. If this cannot be obtained, resort must be made
to chemical intensification.
The technic employed for the lumbar region is in every way identical
with the techuic employed in renal skiagraphy (vide).
THE RIBS AND STERNUM.
Fractures of the sternum are best examined by skiagraphing in the
ventral position. The ribs can be examined by the fluoroscope in differ-
ent directions. The dorsal and ventral views will reveal the fractures
and even slight fissures, but difficulty is encountered at the angles of the
ribs, because of the difficulty in approximating the plate, and the neces-
sity of the rays traversing diagonally the thickness of the body, and
because of the respiratory movements.
The negative clearly reveals the presence of displacement. A slight
fissured fracture may often escape detection. Care should be taken not to
confuse the costo-sternal and costo-vertebral articulations with fractures.
It must not be forgotten, in this connection, that the cartilages are trans-
parent to the rays. Fracture of the ends of the floating ribs may be de-
tected. The exposure must be short, and made preferably at the end of
a prolonged inspiration, the patient holding his breath for five or ten
seconds. Zinc-oxide adhesive plaster, if uniformly applied over the en-
tire chest, immobilizes the part and aids the skiagrapher, but a few strips
applied for this purpose may confuse the picture on the negative by
casting shadows, in conjunction with those of the ribs.
Do not mistake the various grooves or prominences in the ribs for a
fracture.
V. Diseases of the Osseous System.
As the osseous system is largely composed of mineral matter (cal-
cium phosphate), the X-rays in their passage must suffer a marked
absorption and their progress meet with great obstruction, causing
decreased oxidation on the plate, and offering white shadows on the
negative, thus greatly facilitating its study. Some think that the rays
throw merely a shadow or silhouette of the bone on the plate, but the
fallacy of this view is apparent. In studying the photograph of the
humerus, for example, we see the superimposition of various strata of
different densities ; the compact portion appears denser than the medul-
lary, because the rays in the former must traverse more osseous structure.
In the medullary portion the negative gives a darker appearance, because
the rays are only compelled to pass through two layers of bone, the
medullary canal intervening. Ridges appear whiter, and fossae darker,
than the medullary portion, due to increased density ; foranrin* show
THE CLINICAL APPLICATIONS. L'7.5
as dark spots, while bony canals offer dark lines on the negative. Articu-
lar cartilages being transparent to the rays, and likewise the epiphyses,
the shadows cast will be dark.
A. PATHOLOGICAL CONDITIONS.
Any pathological condition either in the organic or inorganic con-
stituents will offer a corresponding change in the shadow thrown ; the
diseased portion of bone will cast a shadow lighter or darker than the
surrounding healthy osseous tissue, and likewise of the same bone of the
opposite side. In skiagraphing osseous tissue, care should be taken to
ascertain the presence of diseased conditions of surrounding soft parts,
such as an effusion, cyst, tumor, etc., as their presence might produce a
dense shadow that could be interpreted as belonging to the bone. To
corroborate the diagnosis, a skiagram of the corresponding part should
be taken, with exactly the same technic, as difference in the position of
the plate, the tube, and the part might cause a difference in the definition,
shape, and size of the shadow produced. When possible, expose both
parts simultaneously.
Arifff ami ('/ironic Periostitis and Osteomyelitis. — Periostitis is charac-
terized by the presence of a fusiform thickening of the periosteum.
This must not be mistaken for bony irregularities.
Osteitis (osteo- myelitis) is marked by an increase in shadow density.
(Figs. 151, 152.) Eight or ten days after the injury suppuration occurs,
and about the twelfth day disintegration of bone takes place, resulting
in the production of a lighter shadow. Later, the skiagraph of a
sequestrum will be revealed.
Tuberculosis of Bone. — This affection is characterized by numerous
white irregular spots which have a natural tendency to coalesce. The
shadow cast will be lighter than that of the normal bone, because the
rays traverse less density, due to caseatiou and fibrous tissue formation.
(Fig. 153.)
Si/philix of Bone. — In syphilis of the bone, two conditions are en-
countered,— the occurrence of rarefaction or an absorption of the com-
pact bony structure, and a sclerosis, with an increase in density of the
bone affected. The infected gummatous portions of the bone cast a
lighter shadow than does the normal bone. When eburnation occurs the
shadow cast will be darker, but the density of the shadow will not be
uniform, an irregular thickening encroaching upon the medullary canal
being evidenced. In the adult this condition is differentiated with
difficulty from the thickening resulting from a chronic osteitis and
periostitis. (Fig. 154.)
Hi/pert rophic <]< forming osteitis (Paget's disease) presents a hyper-
trophy of the compact tissue, manifesting a very dense shadow.
Leprosy. — Among the various bone lesions, transparency of the
is
L>; i ELECTBO-TH BRAPEUTIG8.
digital phalanges is most frequent. This transparency is very pro-
nounced in the distal phalanges, though it may be equally so in the
others.
AcromegaJy. — This affection may be more thoroughly understood by
a careful investigation into the bony peculiarities of the skull. A great
prominence of the external occipital protuberance, an irregular thick-
ening of the cranial parietes, the over-development of the frontal sinuses
and mental eminence, as well as the marked hypertrophy of the sella
turcica, make this means of diagnosis of incalculable benefit. The
shadows of the phalanges show the epiphyses to undergo an enormous
hypertrophy and deformity, and to offer no obstruction to the rays.
Rickets. — In this disease the bone appears shorter than normal, the
diaphysis slender, the epiphyses enlarged, and the line of calcification
presents an irregular appearance. The delay in the process of ossification
can be accurately determined.
Cretinism. — In this affection there is supposed to be a premature
union of theepiphysis and the diaphysis, resulting in an arrested growth
of the bone.
Langhans and von Wyss1 found that there is no hint of premature os-
sification in cretins and cretinoids, but a late development of the centres of
ossification occurs, and consequently at or after the age of development.
the epiphyses show a delayed union ; this delay in the process of ossifica-
tion, as compared with the normal individual, is of a few years only. The
bones of the hand are the last to ossify. Hoffineister, in treating a cretin,
observed skiagraphically that when the child was treated with thyroid
extract, the bones under examination grew 4 cm. in four mouths, equiv-
alent to 12cm. in a year, in comparison with the normal growth of
6 cm. annually.
Osteomalacia. — In osteomalacia the shadows of the bones will be
transparent, and as the disease progresses there will be a complete ab-
sence of these shadows.
Necrosis and caries are characterized by transparent shadows, and irreg-
ularity in the contour and texture of the bone. (Fig. 155.) Far advanced
cases will not cast a shadow. Skiagraphy of the sequestra is of marked
service to the surgeon, informing him of their location, number, and re-
lations to the bone itself and whether they are still adherent or exfoliated.
Avoid the superimposition of their shadows with those of the bones.
B. TTMMKS CF BONES.
Skiagraphy enables us to determine if a neoplasm is connected with
the compact or cancellons portion of the bone, or if it is connected with
the bone at all. Thus, the growth might be a cyst or a myoma that
closely simulates an osteoma, an osteo-sarcoma, etc.
1 Fortechritte a. d. Geb. d. Rontgenstr., I1., iii.. lsw-1900.
FIG. 151.— Chronic osteitis with eburnation, as indicated by the arrows. (Case of Dr. M. P. Dickeson.)
FIG. 1V2.— OSTEITIS OF THE INDEX FINGER — F.B., foreign body which produced the condition ;
A •+ was the point of entrance of the foreign body. (Case of Dr. Prendergast. )
FIG. 153.— TUBERCULOUS OSTEITIS.— The dotted area on the fourth metacarpal bone shows tuber-
culous invasion of the bone.
FIG. 154.— Syphilitic osteitis of the radius.
FIG. 155. — NECKOSIS OF THE Os CALCIS. — Right-hand picture shows part of the foot of a patient
who complained of intense pain in the heel, supposedly due to an ill-fitting shoe ; but the X-rays
revealed a necrosis of the os calcis, with partial absorption, indicated by 1. The left-hand picture
shows the normal heel. 4 >-, centre of ossification of the epiphysis of the tuberosity of the cal-
caneum ; A, astragalus ; 3 O.C., os calcis : 5, fat (dark on the negative) ; 6, tendo Achillis ; 7, muscles ;
s, sinus of the tarsus ; P, plantar arch ; C, cuboid ; S, scaphoid ; V, fifth metatarsal. (Patient under
care of Prof. II. A. Wilson, service of Philadelphia Hospital.)
FIG. 156.— Supernumerary thumb. ( Case of Dr. George M. Boyd.)
< :
.--
FIG. 157.— Congenital absence of the ulna and two fingers. (Case of Dr. W. Frank Hnehnlen.)
FIG. 158.— Congenital multiple exostoses. (Cnse of Dr. J. P. Mann.)
THE CLINICAL APPLICATIONS. L'",
Osteo-sarcoma, like all osseous growths, may be of the periostea! or
medullary variety.
In periosteal sarcoma, the growth may be observed to start laterally,
but later to completely encircle the bone.
In the early stage the medullary form may be easily confused with
syphilitic osteitis ; in the latter the tendency is to be formation of clear
spots, that later become multiple, while osteo-sarcoma begins with a
single clear spot, becoming gradually enlarged ; it is never multiple.
Metastatic carcinoma has been shown by Benedict1 to affect osseous as
well as the softer tissues. A patient under his care suffered from cancer
of the kidney, and later had it removed. Four years subsequently,
intense pain was diagnosed as sciatica, but the X-rays revealed a meta-
static carcinoma of the last lumbar vertebra, which was later confirmed
at post-mortem. Bone cysts can also be detected.
C. DEFORMITIES OF BONES.
Among the more common deformities of congenital origin are super-
numerary fingers, or the absence of one or all of the digits. (Figs. 156,
157. ) There is usually either a second little finger (the most frequent)
or a second but smaller thumb. We determine if the additional digit is
simply tagged on by the skin, or if a distinct and completely developed
articulation exists. In cases of supposed giant finger, the X-rays will
indicate whether the bone or the surrounding tissue has undergone
hypertrophy. In cases of syndactylisin the skiagrapher can often deter-
mine whether bone itself partakes in the union. Hammer-fingers are of
interest in that the joint itself is not diseased, there being only a con-
traction of the ligaments and tendons, as may be demonstrated by the
fluorescent screen.
Exostoses show the normal compact and cancellous structures. (Fig.
l.")S. j There is an overgrowth of the normal bone, the epiphyseal line
presents a darker color, and from its margins spring peculiar, hook-like
o-seous projections.
These changes produce an alteration in the curvature of the bone,
with atrophy of the epiphysis and arrest of the development of the dia-
pliysis. Frequently a union of the bones (synostosis) occurs, but the
growth is usually partially inhibited iu one of them, resulting in a pecu-
liar twisting, readily diagnosed and differentiated from rhachitis and
other bone diseases.
Deformities of the pelvis and pelviinetry will be treated of in the
article on Obstetrics.
Two interesting cases, studied by Dr. Charles W. Burr,2 of congenital
deformities were presumably due to intra-uterine disease of the spinal
1 Wiener klin. Wochenschrift, June, 1899.
2 Journal of the American Medical Association, June 11, 1904.
276 ELBCTBO-THEBA PKl'TICS.
cord. (Fig. l.">9. » The first cast- was a male, fifty-five years of age, four
feet tall ; head and skin normal, no anaesthesia, sensation preserved all
over the body ; the reflexes were present. The legs and arms Mere de-
formed, and locomotion was prevented by weakness of the muscles. The
epiphyses of the bones were distinctly abnormal, and the skiagraph
showed marked absence of lime salts in the bones of the hands. The
other case was that of a man, aged twenty-three years, in whom the
shoulders, arms, and forearms had never developed, or there was a retro-
gression of development. The biceps jerk was absent ; there was no
disease of the bones ; there was very slight wasting in the left leg, only
detectable by measurement. Several theories had been advanced as to
the cause of the condition, among others, bilateral brachial palsy from
birth, malposition in utero, etc. ; but the author was inclined to believe
that possibly the patient had disease of the anterior horns of the spinal
cord in utero.
Diseases and Deformities of the Spinal Column. — The more common
pathological spinal curvatures are scoliosis, kyphosis, and lordosis.
In scoliosis the patient should assume the dorsal decubitus posi-
tion. A skiagram of the kyphotic patient is difficult, because the
plate cannot be properly approximated upon the part, necessitating a
lateral view with the patient on his side. This, however, will not
afford a very sharp definition of the shadow, as the plate is too distant
from the part.
The same difficulty is encountered in lordosis ; consequently in these
cases the lateral view must likewise be employed.
Torticollis. — "When the deeper muscles are diseased, it not infre-
quently happens that caries of the cervical vertebra coexists. Its pres-
ence may be verified by a skiagram in both the antero-posterior and
lateral views.
Pott's Disease. — It is difficult to differentiate the early stages of Pott's
disease from intercostal neuralgia, renal disease, empyenia with sulxlia-
phragmatic abscess, etc. ; but the skiagram will show the bodies of the
vertebra) and the interarticular spaces to possess a denser shadow than
normal. In advanced cases the disintegrated osseous tissue will present a
dark, dense, irregular shadow. Place the patient in the dorsal decubitus
position, have him flex the knees so as to straighten the spine as far as
possible and thus bring it in closer relation with the plate. The above
description applies to any region of the spine. Dark shadows in the
right iliac fossa, often due to the accumulation of gases in the colon,
must not be mistaken for necrosis of bone.
Amputation Stumps. — The process of healing can be systematically
followed in cases of amputation stumps, by noting the existence or ab-
sence of a fine layer of compact bony tissue, covering the medullary canal,
and thus the presence of a sequestrum, interfering with the healing, can
likewise be detected.
FIG. 159.— DELAYED OSSIFICATION OF THE EPIPHYSES.— Patient 55 years of age. Every bone deformed.
Unable to walk since childhood and had been in the hospital more than 30 years. No history of syphilis, and
Dr. Burr of the Philadelphia Hospital believes the deformities to be congenital and due to disease of the spinal
cord which developed during foetal life. The epiphyseal ends of the femora, tibiae, and fibulae look spongy from
lack of ossification. Articular surfaces irregular, bones bent and pervious to the rays. The epiphyseal lines
appeared darker because of excessive ossification.
THE CLINICAL APPLICATIONS. L>77
Resection of Joint*. — Before resecting a joint, the rays will determine
the exact character of the affection, and their application after the wound
has been dressed will inform the operator if the bones are in the best
possible position.
Regeneration of Bone. — After removal of a portion of bone, the peri-
osteum being left intact, the formation of new bone may be carefully
observed, and the surgeon can often determine if the proper amount of
osseous-forming structure has been deposited.
VI. Diseases and Tumors of the Soft Tissues.
Tumors of the soft tissues, being only slightly opaque to the X-rays,
art- skiagraphed with great difficulty, owing to the surrounding struct-
ures having very nearly the same density. For this purpose we employ
a hard tube with a short exposure, avoiding over-exposure and super-
imposition of the shadow of the bone. This may also be accomplished
by diluting the developer and producing a soft negative full of details,
or by an under-developed negative. The detection of the presence of a
tumor by a skiagraph will be dependent largely upon the location, size,
and consistency, and the technic employed.
In the order of the density of shadows cast, tumors may be arranged
as follows :
Hsematomata and Abscesses,
Myomata,
Ench< mdromata,
Lipomata,
Fibromata,
Sarcomata,
Carcinomata.
Hazmatomata.— The blood contained in a hreinatorna is more opaque to
the rays than the surrounding tissue ; hence the shadow cast will be
darker. ELematomata may be differentiated from abscesses by the fact
that the former present a greater density, especially when the blood is
coagulated.
Abscesses cast dark shadows on the negative, but not to so great a
degree as do the hoematomata. In the extremities they are easily diag-
nosed, but in the abdominal cavity or cranium they are differentiated
from other growths with great difficulty. Thus, during the past year I
encountered many obstacles in skiagraphiug a condition at the Phila-
delphia Hospital that resembled appendicitis, subphrenic and hepatic
abscess. The negative revealed a diffused white spot in the position
of the lower region of the liver. Dr. Joseph Hearn confirmed the
diagnosis by operation. Dr. George Pfahler has recently reported
t<> the Philadelphia County Medical Society the taking of a successful
278
ELECTRO-T UK 1 1 A I ' K r T I ( 'S.
skiagram of a subphreuic abscess. In January. 1905. I diagnosed skia-
graphically, at the Philadelphia Hospital, a supposed hepatic abscess,
but at a subsequent operation Dr. Ernest Laplace proved the affection to
be cancerous.
Preutz, of Jena, in a study of 234 hepatic abscesses, speaks com-
mendably of the great value derived from radioscopy. Mynmata and
fibromata are most difficult to skiagraph, especially in the uterus, where
superiniposition of the shadows of the pelvic bones interferes with a
differentiation of the tumor from the surrounding tissues. Their shadows
will be easily recognizable when the neoplasm is large, but manual palpa-
tion will detect this quite as readily as the skiagrapher can assert the
presence of this condition. It is worthy of mention that skiagraphs can
frequently detect the presence of myositis ossificans.
EnckondromatO) being cartilaginous tumors, are difficult to skiagraph
because of their transparency to the rays. When the phalanges are thus
affected, the condition is clearly presented on the negative.
IJ]><»nata are differentiated from solid and cystic tumors by their
throwing a lighter shadow, because fat is less opaque to the rays than
the above named neoplasms.
X-ray diagnosis between a
chronic abscess and a lipoina is
quite as difficult as is the differ-
entiation by clinical means.
Sarcomata ami corrimmutta
cannot be differentiated by their
skiagraphic appearance. They
both cast equally dense shadows.
Tumors of the Brain. — The
difficulties encountered in diag-
nosing skiagraph ically cerebral
neoplasms are due to the super
imposition of the shadows of the
tumor and the bony vault, the
softened consistency of the pal h-
ological condition present, the
distance of the shadow from the
plate occasioned by the arching
contour of the skull, and the
production of secondary rays
due to the marked density of
tliis particular region. Formerly I employed the photographic plate;
more recently I used a board made in two sections that slide upon a base.
(Fig. 160. ) The boards are hollowed out to conform to the curvature of
the skull, and may be so adjusted as to widen the concave excavation, and
thus accommodate any size of skull. In this cavity is placed a double
FIG. 100.— At THOR'S HEAI> REST.— F F, flexi-
ble photographic film, conforming to the sl>!i]>e of
the skull and employed for locating foreign bodies,
•etc., in the brain. A k-ml win- is run from the glu-
jM'llii to the inion and also over the position of the
fissure of Rolando.
THE CLINICAL APPLICATIONS. 279
coated gelatine film, and the patient' s head is accurately accommodated
to the shape of the cavity. This also insures steadiness of the part, so
very important in this difficult procedure. Localization can be mapped
out by placing metallic- wires over anatomical landmarks.
The use of a compression diaphragm, for preventing the production
of secondary rays, is largely in vogue in Germany, and has lately become
popular in America, but this is undesirable, as the area skiagraphed is
too small to allow of definite and logical conclusions.
The diagnostic value of the X-rays in neoplasms, abscesses, clots,
etc., is less than in instances of the presence of foreign bodies. Extended
literature on the subject is yet to be written.
Dr. Pfahler1 gives an interesting account of a case of brain softening
occurring in the service of Dr. Charles W. Burr. " This case," he says,
'• was one of thrombosis of the niid-cerebral artery, with cystic degenera-
tion, and causing aphasia and heniiplegia. The examination was made
post mortem. The brain was replaced and the skull and scalp closed. I
then made a negative of the affected side and also of the opposite side,
because I believed that possibly the normal side could be compared with
the affected side. This case, however, demonstrated that this cannot be
relied upon, for the lesion was shown upon both negatives, but with much
more definite outline on the affected side. The skiagraph showed, above
the cerebellum and petrous portion of the temporal bone, a light area
which corresponded exactly with the outline of the area of degeneration.
This skiagraph showed, also remarkably well, the convolutions of the
cerebellum.
"The second case was also one of Dr. Burr's, in which an irreg-
ular area of degeneration was found in the distribution of the mid-
cerebral artery and which had caused hemiplegia. The skiagraph
showed transparent areas which corresponded exactly with the area of
degeneration."
Dr. Pfahler2 believes, that u we should be able to show in the skia-
graph most large lesions, such as new growths, softening, hemorrhage,
and abscess, but that we should never take the responsibility of an
operation purely upon skiagraphic evidence."
Dr. Church, of Chicago,3 records a case of cerebellar tumor in which
the Rontgen rays were used by Mr. "W. C. Fuchs. Skiagraphs of the
t unit ir were obtained. At the autopsy a highly vascular gliomatous tumor
was found, the tumor being the seat of several old and recent hemor-
rhages, and also of a recent clot of considerable size.
Obici and Ballici4 demonstrated the presence of a tumor in a boy
who died of brain tumor, the experiment being performed post mortem.
'The American Journal of the Medical Sciences, December, 1904.
*Ibid., December, 1904.
slbid., February, 1899.
4 Ri vista di Patholog., October, 1897, cited by Church.
280 KI.K( TIM )-TI I EBAPEUTIC8.
They also experimented with tumors of different kinds placed in the
1 trains of cadavers, and were in sumo instances able to obtain localizing
shadows.
Oppenheini,1 in reviewing the subject of brain tumors, remarks that
his attempts with the X-rays for diagnostic purposes were unsuccessful,
although he was enabled to determine that a tumor placed within the
cranium upon the brain was distinctly noticeable.
Pancoast and McCarty 2 conclude that the value of the Bontgen rays
in brain lesions is at present dubious.
Dr. M. Benedikt, of Vienna.3 described a number of most interesting
conditions that were both studied and skiagraphed by Dr. Kienbock.
From a series of cases related by Dr. Beuedikt we cull the following facts
in his own words: "Kolar, M., engine-driver. On June 6, 1897, while
leaning out of the engine, he struck his head against a lateral object.
He lost consciousness, vomited, and was confined to his bed for six days.
He tried to resume his work, but could not continue. On October 16, of
the same year, he came for the first time under my observation. He com-
plained of violent headaches, and his face had the rigid expression of a
mask. On January 20, 1904, I had two profile diagrams taken \vith the
Rontgen rays by Dr. Kienbock.
''When we ask what pathological process we must assume in this
case, the answer is a pachymeningitis, especially haemorrhagica, with all
its consequences, also of alteration in the osseous parts. The enlarged
shadow of the osseous circumference is not principally the result of thick-
ening of the bones, but is produced also by pachyineningeal deposits."
*4 Bornstein Marcus met with an accident Dec. 24, 1903, while enter-
ing a railway car not yet lighted. He fell over a trunk and received a
contusion on the tibia and on the index finger of the left hand. The
nature of this accident seemed to point to a light lesion. To my great
astonishment, at the examination (Jan. 4, 1904) serious symptoms were
found. Standing with open and closed eyes the patient oscillated for-
ward and to the left side. The supra- and infra-orbital nerves of the left
side were sensitive to pressure, and the parietal, frontal, and temporal
bones sensitive to percussion. In these localities the patient felt pains
when he walked. The turning of the head excited pains, more toward
the left than to the right side. The cervical and dorsal vertebra were
sensitive to pressure, the sensitiveness involving not only the processus
spinosi, but also the lateral walls of the vertebrae on the left side. The
pupil reflex was feeble.
*• The left arm and both legs (especially the left one) were adynamic.
The patellar reflex was feeble, and especially on the left side. The left
ear was more sensitive to the tuning-fork, from the air and from the
diseases of the Nervous System, 1900. Translated by K. Mayer.
•University nf Pennsylvania Medical Bulletin. March, 1903.
3 The Archives of Physiological Therapy, February, 1905.
THE CLINK A L APPLICATIONS. 281
lt<i nes of the head. I was more astonished when Professor Reuss found
beginning bilateral papillitis n. optici. The range of vision was much
diminished concentrically, and in the left eye there existed a complete
defect of vision in an inferior and superior sector.
"In this case the diagnosis was justifiable that there were serious
anatomical intracranial lesions, and, as the case was a recent one, also
blood effusions. Radiographs confirmed this diagnosis."
I have successfully skiagraphed a blood clot in the brain, and I can
do no better than quote the words of the late Dr. F. Savary Pearce,
whose intense devotion to neurology and whose searching inquiry into
the pathological manifestations of brain lesions made his word authori-
tative. In his article u Epiphenomena of Cerebral Hemorrhage/'1 he
says, ''We would like to mention the possibility of the X-ray being a
favorable adjunct toward determination of a blood clot within the brain'or
not, as a point in diagnosis between hemorrhage or thrombosis and this
confusing class of Bright's palsies. In a case coming to autopsy at the
Medico-Chirurgical Hospital ten days ago. Dr. M. K. Kassabian had
been fortunate enough to find what he thought was a ' shadow ' of the
thrombotic area in the left lenticulo-striate area region, and this proved
to be so at the post-mortem examination. In this case, however, there
was no complication of nephritis in making the clinical diagnosis."
During 1904 and 1905, I skiagraphed at the Philadelphia Hospital
a series of cerebral cases in the services of Drs. AN'. AV. Keen, F. X.
Dercum, and Charles AV. Burr. Realizing the imperfection resulting
from the lightness of the shadow found in skiagraphing brain tissue, I
took two skiagrams of suspected conditions and applied to the negatives
obtained the principles of stereo- skiagraphy. The superimposition of
the two views thus derived resulted in a clear-cut picture of the part
under investigation.
Recently I skiagraphed a cerebral case at the Philadelphia Hospital.
The patient's skull was bandaged, thus concealing the presence of any
abnormality. I was ignorant of his clinical history. AVhen the plate
was developed, I noticed in the motor region, a light area, the size of a
goose's egg. I then went to the ward to inquire as to the patient's symp-
toms. I found that this special area was the one complained of; the
ivsult of a trauinatism, which manifested itself in a slight paraplegia of
the opposite side. This was undoubtedly an ecchymosis of the cerebral
meninges. A false diagnosis was not probable, as there was no wet dress-
ing or iodoform employed, no exudation of serum or blood, and likewise
no pressure on the plate that might simulate such a diseased area. Sub-
sequent examinations failed to reveal the affected region, although the
skiagraph was taken under the same circumstances. Ultimately the
patient got well, showing the ecchymosis (exudate) was absorbed.
1 American Medicine, Aug. 9, 1902.
ELECTRO-THERAPEUTICS.
l>rpoxH# in Glumlx. — The shadow thrown by these deposits
is in some regions of the body dense enough to be mistaken tor calculi.
If there be an abscess cavity, sinus, or fistula, its depth and extent may
be sufficiently ascertained by introducing either a probe, a packing of
iodoform gauze, or a rubber drainage tube, and taking a skiagram while
the introduced substance is inxitu.
Empyema and pleural effusions will be treated of when discussing
diseases of the thoracic organs.
Enlarged mediastiual glands, calcified glands, and bronchial glands
are often visible.
VII. The Articular System.
. In the normal joint, the cartilage being transparent to the rays, the
negative will show the inter-articular space black, but it will appear
white on the skiagraph. The articular extremities of the bones will look
smooth. In adjusting the tube, part, and plate, care must be taken to
see that the rays fall directly upon the joint; for if this precaution
be not taken, there will result an overlapping of the shadows of the
articular extremities, the latter leading to a confusion, and causing a
possible error between a diagnosis of the true condition, ankylosis, and
subluxatiou.
As muscles, tendons, and ligaments are slightly less opaque to the
rays than are the bones, the tearing off of any of these, as in some sprains,
can sometimes be shown on the skiagram, provided that the shadow falls
particularly on the muscular field, and that the negative is full of details,
the result of good technic.
A. DISEASES OF THE JOINTS.
Acute Arthritis. — In this affection the skiagram reveals nothing in the
early stage, save a slight cloudiness or haziness at the inter-articular
space, due to congestion. Later this haziness increases, and if pus be
present, the shadow cast on the negative will be darker, as this is less
opaque to the passage of the rays than is serum. If the arthritis con-
tinue for a few months, the inflammation will extend to the articu-
lar ends of the bone, and they will be more opaque to the rays, and
consequently appear white on the negative.
Acute and Chronic Articular Rhi-nmaiixm. — The acute stage is identical
with the description given under acute arthritis. When this condition
assumes the chronic form, the skiagram will show destruction of the ar-
ticular ends of the bones, causing displacements of the opposed bony
surfaces and the attendant deformities.
Gout. — In this disease the tophi (which are composed of sodium
urate) are transparent to the rays. Yet peri-articular shadows of the
tophi are often visible in the digits.
THE CLINICAL APPLICATIONS. 283
Tuberculous Arthritis. (Fig. Kil.) — The early stages of tuberculous
arthritis are most difficult to distinguish from other arthritic conditions.
But as soon as the bone becomes involved the shadow on the negative will
be identical with the appearance of tuberculosis of bone previously de-
scribed ; but with abscess formation, the dark spots on the skiagram will
reveal the true nature of the malady. When destruction of the soft parts
of the joint occurs with subsequent absorption of the head of the bone,
sequestra are formed, resulting in great distortion.
Cojcalgia. — In the incipient stage any haziness in the interarticular
space, iu comparison with the unaffected side, is indicative of changes
in the syuovial membrane of the joint, — this is likewise true of the
epiphyseal line.
Lovett and Brown, iu a most elaborate research,1 arrived at these
conclusions: "The earliest changes observed radiograph ically in hip
disease are, first, diminution in the density of the shadow, and second, a
relative diminution in the size of the shadow cast by the affected bone ;
in other words, atrophy of the bony substance.
''The best radiographic evidence is considered to be bony thickening,
indicated by a shadow projecting inward from the pelvic side of the
acetabulum ; the head and neck of the femur also may show this
evidence.
"Decreased radiability, observed as au indefinite, cloudy appearance,
which involves not only the bony medulla, but the cortex and periosseous
structures as well, is frequently seen. This cloudiness was found to be
due to the presence of thick serum, pus, or finely divided detritus, and is
apt to be misleading if depended upon to the exclusion of other indica-
tions. It was sometimes observed where the inflammatory process was
extra- articular, as iu abscess of the groin.
"Erosion of the bone substance, when present, is usually clearly
evident on the plate, but is not of itself conclusive evidence that hip-
joint disease is present."
Loose bodies, such as displaced or detached cartilage, are difficult of
detection because of their transparency. If their shadows are superim-
posed with those of the bones, recognition is of course impossible, as on
the shadow of muscles, their detection, at times, is possible. Small sesa-
iiioid bones, which may simulate foreign bodies, can also be skiagraphed
in or around a joint.
Coxa Vara. — "The neck of the femur varies in length and obliquity
at various periods of life and under different circumstances. In infancy
the angle is widest and becomes lessened during growth, so that at pu-
berty it forms a gentle curve from the axis of the shaft. In the adult it
forms an angle of about 130° with the shaft, but varies in inverse propor-
tion to the development of the pelvis and stature. In consequence of the
1 New York Medical Journal, January 28, 1905.
284 ELECTRO-THERAPEUTICS.
prominence of the hips and widening of the pelvis in the female, the neck
of the thigh bone forms more nearly a right angle with the shaft than it
does in man." (Gray.)
Skiagraphy in cases of coxa vara reveals the true clinical condition.
(Fig. 162.) It is found that the axis of the neck to the shaft has materi-
ally changed its angle, that the affection is non-tuberculous, and that the
trochauter has changed from its normal position to a higher plane. In
skiagraphing this condition, inversion and eversion of the feet must be
vigorously guarded against. This is best accomplished by securely bind-
ing both feet in the position of a right angle to the leg. A plate large
enough to include both hips must be employed ; the patient must lie ab-
solutely flat on his back, with the tube placed over the pubic symphysis
in the median line. Some operators prefer the ventral to the dorsal de-
cnbitus position. Of course, the position assumed will slightly vary the
length of the neck of the bone. Consequently the necessity of compari-
son between the affected and the normal sides.
Genu valgum is the result of overgrowth of the inner condyle and an
incurvation of the femoral shaft. The X-rays will show the amount and
the angle of deformity, and also any alterations in the relaxation and
elongation of the ligaments of the knee-joint.
Genu varum is the opposite of geuu valgum, and in these cases the
X-rays will also furnish the operator with complete clinical data.
Deformities of the foot, including talipes in its various forms, dis-
placements of the toes, and deformities of the hands and digits can be most
advantageously studied by corroborating the facts of clinical experience
with the X-rays.
B. ARTHROPATHIES.
In the early stages, arthropathies, as manifested in tabes (Fig. 163),
present a haziness in the joint, identical with the appearance evidenced
in other forms of arthritis. Later the interarticular space becomes more
hazy, the periarticular structures are destroyed, the ends of the bones
irregular and nodular, with rarefaction of the osseous tissue and possibly
complete disappearance of the bone. In some instances, in place of rare-
faction, we find thickening or eburnation, with the projection of bony
excrescences.
Syringomyelia. — Several authorities1 state, that in syringomyelia there
is progressive destruction of the joints, greater in extent than is noticed
in tabes, but marked by an absence of bony excrescences. Mor van's
disease, often associated with syringomyelia and characterized by the
formation of painless felons, shows skiagraph ically an irregular appear-
ance and a thickening of the bone, frequently with the presence of
sfini(>stra. Pulmonary tuberculosis and general systemic diseases may
1 Bouchard, " Traite de Kadiologie Mcdicah-," 1!«>4.
FIG. 161.— TUBERCULOUS ARTHRITIS OF THE KNEE-JOINT.— The left-hand picture shows tubercu-
lous arthritis of the knee-joint ; 4—5 indicates the distended capsular ligament ; 3, a narrowing of
the inter-articular space ; 1 and 2 show the changed character of the epiphyses. The skiagraph was
taken after the limb had been braced for two months. Right-hand picture shows the normal limb.
(Case of Dr. J. K. Young.)
FIG. 162.— COXA VABA.— As a result of tuberculosis of the knee-joint. C, cast around the
right knee-joint. (Case of Dr. James K. Young.)
FIG. 163.— Arthropathies of the knee-joint, in a patient with tabes dorsalis.
(Case of Dr. Chas. K. Mills.)
FIG. 164.— Penny in the oesophagus.
THE CLINICAL APPLICATION'S. 285
also show arthropathies, but will not show the destruction of the articular
ends of the bones, but there will be revealed a periarticular. semi-opaque
condition.
VIII. Foreign Bodies and their Localization.
In nothing have the X-rays proved themselves of more incalculable
service than in the detection and localization of foreign bodies. Prior
to the discovery of this priceless diagnostic agent, the surgeon found
himself helpless in cutting down upon a supposed embedded substance,
but with determination born of forlorn hope, too often he pursued an
erroneous course, only to find that disappointment and at times serious
infections were the rewards of his endeavors.
By the rays the skiagrapher learns not only the position of a foreign
body, its variety, size, and shape, but also the extent of damage incurred.
A. MILITARY SURGERY.
The X-rays have been especially useful in military surgery. Dr.
Haughton has said, "that the X-raj'S have furnished the army surgeon
with a probe which is painless, which is exact, and, most important of
all, which is aseptic."
In 1897 the X-rays were for the first time successfully used in the
Grace-Turkish war. It was there demonstrated that they were an invalu-
able adjunct in military surgery, and since that time improvements have
been made in the apparatus for trials in future field encounters.
The X-rays were also employed with marked success by Surgeon-
Major Beevor on the Indian frontier, during the Chitral Campaign in 1898.
Of no less importance were the experiences of Major Battersby, who
had charge of the Eontgen apparatus, while campaigning in the Soudan
a number of years ago. Following the battle at Omduruian, 121 wounded
British soldiers were brought to Abadith, 21 of whom could not have had
their condition correctly diagnosed without X-ray examination.
In the words of Captain \V. C. Borden, assistant surgeon in the
United States Army:1 "The use of the Eontgen rays has marked a
distinct advance in military surgery. It has favored conservatism and
promoted the aseptic healing of bullet wounds made by lodged missiles,
in that it has done away with the necessity for the exploration of wounds
by probes or other means, and has thus obviated the dangers of infection
and additional traumatism in this class of injuries. In gunshot fractures
it has been of great service from a scientific point of view, by showing
the character of the bone lesions, the form of fracture, and the amount of
bone comminution produced by the small calibre and other bullets, —
1 The Use of the Runtgen Rays by the Medical Department of the United States
Army in the War with Spain.
ELK( TK< )-TH BEAPBUTIC8.
conditions which could not have been otherwise determined in the living
body."
Nicholas Senu writes that the expectations as to the diagnostic value
of the X-rays in military surgery were actually realized in the Spanish-
American War. He states that foreign bodies were located, fractures
ascertained, and other surgical conditions studied, without subjecting the
patient to pain or any danger from infection.
Mr. Clinton Dent,1 special war correspondent in South Africa, speaks
interestingly of injuries by Mauser bullets. If the dense part of the long
bone is hit by a bullet of the Mauser type, there is a drilling, compli-
cated by fracture. The extent of the injury depends upon the angle at
which the bullet strikes the bone, upon the velocity of the bullet, and to
some extent upon the age of the person. Mr. Dent also observes, "that
a line drawn between the apertures of entrance and exit does not afford a
reliable clue of the course that the bullet has followed/' He also states
that fractures with a drilling of the tibia and the upper and lower ends
of the humerus and radius are common.
Major Matignon, in reference to the Eusso-Japanese war, describes
at length2 the installation of an X-ray apparatus in the Fifth Division of
the Japanese army in Manchuria. This apparatus consisted of a Ruhui-
korff coil, 30 cm. long and 12 cm. in diameter, with a spark-producing
power of from 15 to 18 cm. The tube was bi-anodic and 20 cm. long.
The current was supplied by a dynamo, energized by hand-power. Two
persons were enabled to bring about sufficient velocity to produce the
desired current by means of gearing. A portable dark room was pro-
vided, and Major Matiguon remarks: "I was able to discern clearly
the fractures and the presence of foreign bodies in the hand and in the
arm." He further states that the use of accumulators and their bur-
densome construction can thus be readily dispensed with.
B. VARIETIES OF FOREIGN BODIES.
These may be transparent, translucent, or opaque to the rays.
The transparent include such substances as splinters of wood, pieces
of coal, diamonds, paper wads, leather, clothing, etc.
The translucent include a fragment of porcelain, paste diamonds,
small fish bones, other small bones, seeds of fruits, small pieces of
glass, etc.
The opaque include metallic substances, such as bullets, coins, nails,
buttons, pins, needles, jack-stones, marbles, and dice ; also surgical dress-
ings,— dusting powders (e. <?., bismuth, iodoform), lead-water and lauda-
num, corrosive sublimate, dermatol, permanganate of potassium, etc.,
hard-rubber tubes, and iodoform gauze.
1 British Medical Journal, April 21, 1900, p. 969.
Archives d'Electricite Mcdicale, June 2o, 1906.
THK CLINICAL APPLICATIONS.
287
The table In-low shows the relative transparency of equal thicknesses
of various substances .water 1 i as found by Bottelli and Garbasso.1
TAP.LK <>F PEUMEAP.ILITY OF RnNTUKA RAYS.
MATERIAL.
Sl'Kcmr
(iKAVITY.
TRAN-
1-AKEM V.
MATERIAL.
SPECIFIC
GRAVITY.
TRANS-
I'AKENt Y.
Pine wood
(i:>t;
2.21
Iron
7.87
0.101
Walnut
0.66
1 50
Chalk
2 7
0.330
Parattin .
0.874
1.12
Antimony
6 7
0 126
Rubber (pure gum)..
093
1 10
Nickel "
867
0095
Wax
097
1 10
Brass
8 70
0093
Stearine
097
094
Cadmium
8 69
0090
Paste board ....
080
Copper
8 96
0084
Ebonite
1.14
0.80
Bismuth
US"
0.075
Woollen tissue
0.76
Silver
105
0.070
( /eUoloid
0.76
Lead
11 38
0.055
Whalebone
074
Palladium . .
11.3
0.053
Silk
074
Mercury
13 50
0044
Cott.m
0.70
Gold
19.36
0.030
Charcoal (hardwood)
0.63
Platinum
22.07
0.020
Starch
0.63
Ether
0.713
1.37
Sugar
1.61
0.60
Petroleum
0.836
1.28
Bone
19
056
Alcohol
0793
1.22
Magnesium .
1 74
1 1 .->( )
Amyl alcohol ....
1.20
Coke . . .
048
Olive oil
0915
1.12
< ilue
0.48
Benzol
0.868
1.00
Sulphur
1.98
047
WTater
1.000
1.00
Lead plaster
0.40
Muriatic acid
1.260
0.86
Aluminium
2.67
038
Glycerin ... . ....
1.240
0.76
Talc ( soapstone )
Glas^ ...
2.6
26
0.35
034
Carbon disulphide. . .
Nitric acid
1 293
1.420
0.74
0.70
Tin
0118
Chloroform
1.525
0.60
Zinc
720
0.116
Sulphuric acid
1.841
0.50
C. F<>KKK;N BODIES ix THE DIGESTIVE, KESPIRATORY, AND GENITO-
VRINARY TRACTS.
(Esophagus. — Foreign bodies in this region can be detected by the
fluoroscope and skiagram, and should be examined in both positions. I
recently skiagraphed a child with a penny lodged in the oesophagus, as
shown in Fig. 164.
Segond2 reports a case where a tooth-plate had accidentally been
swallowed and lodged in the oesophagus. It was located by the X-rays at
the region of the supra-sternal concavity, and extracted by external
oesophagotoiny. A hook-like projection of the plate forced its way into
the mucous and submucous coats of the organ, requiring repeated
fluoroscopic examinations before extraction was achieved.
Mr. Ballance, of St. Thomas Hospital, London, says that by
means of a fluoroscopic examination, a hat-pin was demonstrated in the
1 Bolletino della Societa Photografica Italiana, 1897.
- Lyon Mi'dicale, Auguet 5, 1898.
l>ss ELECTRO-THERAPEUTICS.
oesophagus of an infant fifteen mouths old. It had travelled to the lower
third of the tract, where it had fastened itself. A gastrotomy was
performed and the pin removed.
Dr. Nathan Raw 1 reports the swallowing of a tooth-plate by a luuatic.
The foreign body had descended to a level just slightly below the
inter-clavicular notch. The fluoroscope revealed the exact position, and
also showed the plate with its longest diameter lying parallel with the
transverse axis of the oesophagus.
Stomach. — Almost every variety of foreign body is found in the stom-
ach, but the movement of that organ makes detection difficult. In skia-
graphing the stomach, the patient should be placed in the ventral
posture. Previously, he should have been cautioned against ingest inu
food and drink, as the former will increase the density of the shadows
and the latter, in addition, offers an opacity to the rays. The foreign
bodjr is invariably found at the pyloric orifice.
Several years ago, at the clinic of the Medico-Chirurgical Hospital I
demonstrated, by means of a skiagram, the presence of tacks, nails, and
blades of pen-knives in the stomach of the "ostrich man."
W. S. Halsted2 publishes a radiogram of a juggler's stomach, from
which he removed 208 foreign bodies, including 20 links of dog-chain,
8 pieces of china, 7 knife-blades, 54 nails, and 35 wire nails.
Diamonds and small stones, being transparent to the rays, defy detec-
tion. Sometimes diamond thieves have swallowed the stones, but the
latter could not be found either by fluoroscopy or skiagraphy. In many
of the mints, suspected employes are subjected to X-ray examinations
to detect the presence of stolen coins in the stomach.
Intestines. — In the intestines foreign bodies, such as coins, pins, nails,
Murphy buttons, etc., can be seen gradually to traverse the bowel. The
peristaltic action of the intestines often interferes with this detection.
The skiagrapher is further hindered in the cases of children, their crying
and moving presenting an additional obstacle. So long as the foreign
body is being moved by peristalsis, the surgeon should not attempt to
operate. It requires three or four days for a foreign body to be dis
charged. Skiagraphy is of special value in impaction of the rectum
by foreign bodies, so commonly found in the hysterical and insane ; it is
also of utility in detecting foreign bodies in the appendix.
Larnyx, Trachea, and Bronchi. — The foreign bodies lodged here :n<-
identical with those found in the stomach. The method of examination
is likewise similar.
Genito-Vrinary Trad. — Almost every conceivable variety of foreign
body is to be found in the urethra and bladder of the male, and in the
vagina, uterus, and bladder of the female. Recently I examined a pat icnt
'The Liverpool Medico-Chirurgical Journal, September, 1901, p. 345.
1 Johns Hopkins Hospital Reports, 1900, vol. ix. p. 1054.
THE CLINICAL APPLICATIONS. 289
for fractures of the femora, but instead I discovered a forgotten pessary.
Forgotten pessaries have often been detected by the X-rays, when the
cause of the suffering baffled the skill of the attending physician.
Foreign Bodies Entering front Without. — These include bullets, needles,
cinders in the eye, broken ends of instruments, etc. In surgery we have,
in addition to the retention of instruments in the cavity of the wound, a
slipping in of a forgotten section of drainage-tube, and the closure of a
wound without removal of iodoform gauze, etc.
D. THE X-RAYS ix OPHTHALMOLOGICAL SURGERY.
Foreign Bodies in the Eye. — The use of the X-rays in ophthalmology
is principally confined to the detection and localization of foreign bodies
in the eye. Dr. Van Duyse was perhaps the first to perform experiments
for locating foreign bodies in the eye, and in March, 1896, he communi-
cated his results to members of the Medical Society of Gand.
His first work consisted in the introduction of a small bullet into the
eye of a rabbit, carefully pushing it up posteriorly to the iris. He pro-
duced an exophthalmos, and by slipping under the exophthalmic globe a
small sensitive plate, he was able to define a shadow of the contained
foreign body. By another expriment he proved that metallic bodies in
the anterior chamber could be very easily demonstrated by placing a
sensitive film of proper shape and size between the eyelids at the inner
canthus and allowing the rays to penetrate the globe from the temporal
side.
Dr. Leukowitsch1 detailed his experiments and results on sheep's
eyes, with the use of two tubes. He contended, however, that better re-
sults had been obtained by the use of one tube only. In experimenting
on the human eye, he employed small sensitive plates, semicircular in
shape, thus permitting the largest possible area being introduced at the
inner angle of the eye opposite the lacrymal bone. A large part of the
eyeball can readily be brought within easy range of the rays by simply
rolling the eyeball. Rotation of the ball caused a point of fixation,
which was obtained by employing a glass indicator bent into two right
angles, a short and straight terminal so placed as to point exactly to the
antero-posterior axis of the cornea's centre.
Dr. Max J. Stern, at the Philadelphia Poly clinic,2 proved that a
foreign body in any part of the eyeball could be shadowed on the plate at
the side of the head, and radiographed four patients with steel in the eye-
ball. He determined the approximate positions of the metal in the eye
from a study of the shadow of the body in relation to the shadows on the
plate of the orbital bones ; but the variation in the position of the eye-
ball in the orbit rendered this method liable to considerable error.
'The Lancet, August 15, 1896.
2 Trans. Amer. Oph. Soc., 1896.
19
290 ELECTRO-THERAPEUTICS.
In February, 1897, Drs. Ring and Hansell each reported one case,
and Dr. de Schweinitz two cases of steel particles in the vitreous located
by the X-rays. In one of these cases two previous unsuccessful attempts
had been made to extract the steel, and it was only after the radiographs
indicated its approximate position that it was extracted by the magnet.
These cases were probably the first that demonstrated that the bony
walls of the orbit and the coats of the eye were permeable tq the rays.
By comparison of the shadow of the metal with that of the margin of the
malar process of the superior maxillary bone, and the knowledge of the
relation of the Crookes tube to the sensitive plate, the location of the
foreign body could be easily demonstrated.
Dahlefeld and Pohrt1 report that good records were obtained of
small fragments of wire and small shot that had previously been intro-
duced into the orbits. Their method of detection consists in placing a
focus tube on the opposite side of the head (10 to 15 mm. distant from
the temple) and a sensitive plate against the temple corresponding to the
affected side.
Fridenberg2 and Friedman* both made two exposures of the eye
and orbit at right angles to each other, while Stockl* used pieces of
lead, fastened at various points around the orbital margin, from which to
measure the situation of the foreign body. Leonard made a number of
exposures to give a series of triangles to locate the body.
For the want of space, I shall include only those methods which in
my experience have been found most useful.
Dr. "Wm. M. Sweet5 was the first to devise an accurate method of
localization, employing for this purpose a plate-holding apparatus, fixed
to the side of the head on the injured side, the fixed points of measure-
ment consisting of two ball-pointed rods, adjusted at a known distance
from the centre of the cornea.
In describing the method, Sweet6 says: "The determination of the
location of pieces of metal in the eye or in the immediately adjacent
tissues by means of the Rontgen rays demands that the shadow of the
foreign body as shown on the radiograph be studied in relation to the
shadows of at least two opaque objects of known position. The method of
judging the approximate position of the body in the eye from the rela-
tion of its shadow on the photographic plate to the shadows cast by the
bones of the orbit is less accurate than the method by triangulation, even
when carried out by making two exposures upon the same plate with the
tube in different positions, or by making several separate exposures."
1 Deutsche medicinische Wochenschrift, No. 18, 1897.
2 Medical Record, May 15, 1897.
3 Klin. Monateblatt, Oct. 1897.
4 Wiener kl;n. Wochen., No. 7, 1898.
5 Trans. Amer. Ophth. Society, May, 1897.
6 Diseases of the Eye, by Hansell and Sweet.
THE CLINICAL APPLICATIONS.
291
The localizing apparatus designed by Sweet consists of two metal
indicators, one pointing to the centre of the cornea and the other situated
to the outer canthus at a known distance from the first. Two exposures
are made in order to give different relations of the shadows of the indi-
cators and of the body in the eyeball, one with the X-ray tube horizontal
or nearly so with the plane of the indicators, and the other with the tube
below this plane.
" The principle of the method may be understood from the perspec-
tive drawing (Fig. 1G5). Rays coming from the light situated at A cast
FIG. 165.— Principles of the method of localization. (Courtesy of Dr. Wm. M. Sweet.)
shadows of two ball-pointed rods and an object in the eyeball, and give
the view shown on the surface C. In this instance the tube is in front of
the vertical plane of the two indicators, and consequently the shadow of
the centre ball will be throM'n back of that of the outer ball. When the
light is carried below the plane of the two indicators, the shadows of the
two rods are formed on the surface D, and the shadow of the foreign
body in the eye assumes a new position. If the distance of one of the
indicating rods from the centre of the cornea is known, and the distance
292
ELECTRO-THERAPEUTICS.
between the two indicators is measured, the position of the metal in the
eye may be determined, since the shadow of the foreign body preserves
at all times a fixed relation to the shadows of the indicating balls, in
whatever position the light is placed.
" Accurate localization requires that the axis of the eyeball shall be
parallel with the two indicators and with the photographic plate, thai
one of the indicating balls be opposite to the centre of the cornea and at
a known distance from it, and that both indicators are at a measured
distance from each other. The plate-holder and indicators have been
combined into a special apparatus which firmly holds the head of the
patient, as shown in Fig. 166. The arrangement of the parts of this
FIG. 166.— Indicating apparatus secured to the side of the head. (Courtesy of Dr. Wm. M. Sweet.)
apparatus is such that the indicators, while freely adjustable, are always
parallel to each other and to the plate, and the two balls are perpen-
dicular to the plate and 15 cm. distance between their centres when the
apparatus is in place. It is necessary that the patient rotate the eyeball
to bring the ocular axis parallel with the plane of the photographic
plate, and that the operator adjust the indicators so that the centre ball
is opposite the centre of the cornea.
"To determine the position of the foreign body in the eye, two
circles are drawn, representing the horizontal and vertical sections of the
normal adult eyeball, and upon these are marked the situations of the
indicating balls at the time the radiographs are made.
THE CLINICAL APPLICATIONS.
293
FIG. 167.— Outline drawing of a radiograph, made
with a tube slightly above the plane of indicators. A, ball
opposite the centre of the cornea ; B, ball to the temporal
side ; S, foreign body. (Two-thirds normal size.)
"Lines are drawn through the shadow of each of the indicating
balls on the two radiographs. On the negative made with the tube hori-
zontal and parallel with the plane of the indicators, a measurement is
made of the distance the shadow of the metallic body is above or below
the shadow of each of the in-
dicators. This distance is
entered above or below the
spots representing the two
indicators on the diagram of
the vertical section of the eye-
ball. Thus, in the radiograph
(Fig. 167) the distance of
the foreign body (8) below
each of the indicators (O S
and X S) is entered below
the spots A and B, front
view, Fig. 169. A line drawn
through the points C and D
gives the direction of the
X-rays at the time the
shadow of the foreign body was cast upon the plate. Similar measure-
ments of the distance that the shadow of the foreign body is below
the shadow of each of the indicators are made on the second negative
(Fig. 168), and these are likewise entered below the points A and B, rep-
resenting the two balls on the vertical section of the eyeball. These
measurements are A F and
BE. A line drawn through
the points E and F gives
the direction of the rays
when the second negative
was made. Since these two
lines indicate the plane of
the shadow of the foreign
body at each exposure, the
intersection of the lines
must be the location of the
metal in the eye, as meas-
ured above or below the
horizontal plane of the
globe and to the temporal
or nasal side. To deter-
mine the distance of the foreign body back of the centre of the cornea, the
negative made with the tube horizontal is taken, and the distance is
measured that the shadow of the ball opposite the centre of the cornea
lies posterior to that of the external ball. This distance is entered directly
FIG. 1GS.— Outline drawing of radiograph, tube below
the plane of indicators. A, ball below centre of the cornea ;
B, external ball ; .S', foreign body. (Two-thirds normal size.)
294
ELECTRO-THERAPEUTICS.
above the external ball ou the diagram representing the horizontal
section of the eyeball. A line drawn from K through the centre
ball gives the direction of the rays at the time the radiograph was
made. On the same negative is measured the distance that the shadow
of the foreign body is back of the shadow of each of the indicators, and
these distances, B J and A H, are entered on the diagram. A line is
drawn through the points J and H, and since this line represents the
plane of the shadow of the foreign body, the point at which a perpen-
dicular drawn from the situation of metal as shown on the vertical sec-
tion of the eyeball intersects this line indicates the situation of the body
Size of body by by mm.
Situation
miaback of center of cornea,
mmbelow horizontal plane .
mm.to side of
vertical plane.
Honzontat
section.
Side view
Front view
Front view.
- D
Side view
Fio. 169.— Dr. William M. Sweet's chart for plotting location of foreign bodies in the eye.
I Two-thirds normal size. )
back of the centre of the cornea. If the position of the tube from the eye
has been measured, its distance is indicated on the line drawn from K
through the centre ball A. A line through J to this point indicates the
divergence of the rays. This means of determining the position of the
plane of shadow of the foreign body is more accurate than when the
measurement is made of the shadow of the body above each of the balls,
and should be followed, especially if the body is some distance away from
the anterior segment of the globe or is in the orbit.
"If the foreign body has passed into the orbit, the rotation of the
eyeball to insure parallelism of the ocular axis wit h the plane of the
plate leads to a slight error in the determination of the position of the
THE CLINICAL APPLICATIONS. 295
metal. To eliminate this error necessitates a knowledge of the angle of
the orbit with the plate or, its equivalent, the amount of deviation of
the eyeball from the primary position, and the consideration of this
angle in plotting the diagrammatic circles representing the eyeball.
" The indicating apparatus is secured to the side of the head corre-
sponding to the injured eye, and the tube placed about 12 or 15 inches
(30 or 38 cm.) to the opposite side and slightly forward. The patient is
in the recumbent posture, to insure steadiness of the head. After the
FIG. 170.— Mackenzie Davidson's localizer.
indicating rods have been adjusted, the patient fixes an object about 5 to
10 feet distant, so placed that the visual axis of the injured eye shall be
parallel to the photographic plate. An exposure of from 10 to 20
seconds will clearly outline the bones of the orbit, and secure a shadow
of any body opaque to the rays in the eyeball or in its neighborhood."
Another method of equal accuracy was introduced by Mackenzie
Davidson, who published- a description of it in the British Medical
Journal, January 1, 1896.
Davidson's Method. (Fig. 170.)— The theory of this method briefly is
as follows : l " The Crookes tube is placed in a holder, which can slide
horizontally. A perpendicular is dropped from the point in the anode of
1 The Archives of the Runtgen Ray, May, 1898.
296 ELECTKO-THERAPEUTICS.
the tube where the X-rays originate on the point where two wires cross
each other at right angles, and one of the wires must be parallel to the
horizontal bar along which the tube-holder slides ; so that, when the tul>e
is displaced along the bar, a perpendicular dropped from the X-ray point
in the anode would always fall upon this wire. The wires in reality rep-
resent two planes at right angles to each other, and the photographic plate
representing the third plane. Eventually I obtain the three planes
which are at right angles to each other, and whose relation to the part
of the patient's body skiagraphed is known.
"For practical purposes it is convenient to have the wires stretched
across a flat board or sheet of vulcanite, and this can be placed on a table
in the correct position below the horizontal bar, and fixed to the table by
means of drawing pins. The wires being inked so as to mark the skin, a
photographic plate, enclosed in black paper in the usual way, is placed
beneath the cross wires. The perpendicular distance from the anode to
where the wires cross each other is carefully measured and noted.
" It is now necessary to decide at what distance apart the tube is to be
displaced in order to take the two skiagrams. It does not matter greatly,
2J, 5 or more inches (6 to 12 cm. etc.) of displacement may be given.
Having decided this point, movable clips are so placed as to limit the
sliding of the tube-holder to the required extent. The tube is then dis-
placed to one side, and the patient places the part to be photographed on
the cross wires, being careful not to move, once the skin has come in
contact with the wires; because it is of the utmost importance that the
shadow of the cross-wires on the negative should be in register with the
ink mark left on the patient's skin. Further it is convenient to put a
small coin on one corner of the plate, and also mark the patient's skin
nearest to it. This reveals to the operator the relation of the plate to
the skin.
"One exposure is made, and the tube is then displaced. A second
exposure is given, preferably on the same plate, provided a suitable
apparatus be used to enable the plates, if a different plate be used, to be
changed without disturbing the position of the parts at all.
"Having developed and fixed the negative, it will show a single
shadow of the cross- wires, but two shadows of the foreign body. In
order to interpret this correctly, I devised the following apparatus, which
may be called the ' cross-thread localizer ' :
"A sheet of plate glass is fixed horizontally, having two lines
marked upon its surface, crossing at right angles in the centre. A
mirror hinged below it allows the light to be' reflected from below, so as
to render details on the negative visible by ordinary light.
"A scale fastened to a horizontal bar slides up and down on two
rods which support its ends. The scale has small notches opposite its
marks. This is so placed that a perpendicular dropped from the O° or
middle point of the scale falls exactly where the lines cross on the glass
THE CLINICAL APPLICATIONS. 297
stage. Furthermore, the edge of the scale is parallel to the line running
right and left on the glass. The negative is now placed upon this glass
stage, the operator being careful to bring the shadow of the cross-wires
into register with the cross on the stage, placed with its marked quadrant
in correct position. The gelatine surface can be protected by a thin
transparent sheet of celluloid.
1 ' The scale is now raised or lowered so as to bring the O° precisely
the same distance above the negative as was the anode of the Crookes
tube when the negative was produced. All that is now necessary is
to place a fine silk thread through the notch on one side of the O° on
the scale, and another thread through a notch on the other side, at
exactly the same distance as that which measured the displacement of
the X-ray tube.
"Small weights are attached to the ends of the two threads to keep
them taut, while the other ends are threaded into fine needles fastened to
pieces of lead. Thus the needle with the thread can be placed upon any
point of the negative and remain in position. In short, the negative is
now relative to the cross-lines, the scale, and the notches from which the
two threads come, exactly the same as it was to the cross-wires and
Crookes tube when being produced.
k' A needle with the thread is placed upon any point on one of the
shadows of the foreign body, and the other needle is placed upon a
corresponding point in the other shadow, and it will be found that the
threads cross each other, just touching and no more. The point where
they cross represents the position of the foreign body. A perpendicular
can be dropped from this point to the negative below, and a mark made
at the point where it touches the negative. Then with a pair of
compasses, the distance of this point from the two cross-wires can be
measured.
"The height of the plate where the threads cross gives one co-
ordinate, that is the depth of the foreign body below the skin, which
rested on the photographic plate. The other two measurements give the
other two co-ordinates.
11 As the mark of the wires is left on the patient's skin, all that is
required is to measure the two co-ordinates on the skin that give the
point below which the foreign body will be found at the depth given by
the third co-ordinate.''
GroxsiiHtn'x Method of Localizing a Foreign Body in Eye. — Karl Gross-
man,1 in localizing a foreign body in the eye, utilized the eye itself for
the purpose of obtaining the necessary parallax of the shadow ; the
vacuum tube, the head of the patient, and the photographic plate retain
their relative positions to one another unchanged. He describes this
method as follows: u Either one or two pairs of skiagrams are taken.
1 Liverpool Medico-Chir. Journal, January, 1899, pp. 359-361.
298 ELECTRO-THERAPEUTICS.
The first pair is obtained by making the patient look (a) downward, (6)
upward, ill the same plane, the X-rays coming from the other side of the
face and somewhat in front of it. If the foreign body be in the eyeball,
the shadow has moved from (a) to (6) as follows : upward if in the
anterior half-hemisphere, downward if in the posterior half-hemisphere,
forward if in the inferior half- hemisphere, backward if in the superior
half-hemisphere ; the axis of these four half-hemispheres being at the
same time the axis of rotation for the upward movement.
"If the shadow has not moved, the foreign body might still be in the
eyeball, — viz., at any point on the axis of rotation. In this case the second
pair of skiagrams would become necessary, the patient this time having
to look at a point (c) teniporalward, (<Z) nasalward, in the horizontal
plane. A movement of the shadow from (c) to (J) would mean the
presence of a foreign body in the eye, — viz., in the temporal hemisphere
if forward ; in the nasal hemisphere if backward. The relative position
of the tube, head, and plate need only remain the same for the two r\-
posures of each pair, — viz., for (a) and (6) on the one hand, and for (c)
and (<Z) on the other, — but may be a different one for each."
Fox's1 Method of Localization. (Fig. 171.) — Briefly this method con-
sists first of cocainizing the eye and in the introduction, beneath the
lids, of an appliance called a "conformer." This device consists of
an elliptical wire of gold, divided by cross-wires of gold (concaved
on one side so as to slip over and fit the anterior surface of the eyeball)
running in opposite axes, dividing the eyeball into quadrants, anteriorly.
The next step in this method consists in skiagraphing the eye in two
directions, so as to get good imprints on the sensitive plate of both the
foreign body and the conformer. Thus, we produce a skiagram in the
anterior diameter, placing a small sensitive i>late in front and against the
eyeball, and the tube in back of the head, with the target pointing in the
direction of the eyeball. The tube should be distant from the sensitive
plate 22 to 30 inches (55 to 75 cm.). The time of exposure is from 1*
to 2J minutes, depending, of course, upon the thickness (or rather the
antero- posterior diameter) of the head examined. With a properly
exposed plate and a correctly developed negative, there will result a
picture showing the relation the foreign body bears to the dividers of the
conformer. A second skiagram is produced by placing the sensitive
plate against the temple corresponding to the side that is to be examined,
and the tube on the opposite side, with the target pointing in direct line
with the temples. The tube should be from 20 to 30 inches (50 to 75 cm.)
distant from the sensitive plate. The time of exposure should be from 1
to 1| minutes, depending upon the thickness of the head in this diameter.
This skiagram shows the depth of the foreign body, measured from the
peak or base of the conformer.
1 Philadelphia Medical Journal, February 1, 1902, pp. 213-220.
K.B.
FIG. 171.— Fox's LOCALTZER.— Bullet in the orbit: 5 >-, shot. The wire over the cornea illus-
trates Fox's method of localization. 1, frontal sinus ; 2, thickness of frontal bone ; 3, the zygoma ; JV.J?.,
nasal bone.
-
THE CLINICAL APPLICATIONS.
This method is entirely different from any of the others, and, unless
great care is exercised in securing the exposures at right angles to each
other, the chance for error in localization is great. Prior to this method
I placed the couformer over the closed eyelids.
E. VARIOUS METHODS OF LOCATING FOREIGK BODIES.
Screen Method. — This was the first method employed. In order to
attain the best results, the examiner should have had thorough experience
in this line of work. The fluoroscope should first be used, to demonstrate
the presence of the foreign body. The hood is next removed from the
screen, and the latter used sep-
arately, in the same position as
when first located. A mark,
made by an indelible pencil, is
placed on the part directly over
the spot where the shadow of
the foreign body presents itself,
this mark being directly behind
the screen.
A second mark is made on
the opposite side of the member
corresponding to the area of the
foreign body. These marks, ly-
ing in an even plane, should be
both marked "1" and " 1."
The depth of tissue in which the
bullet lies is next ascertained by moving the screen slightly up and
down ; if the shadow of the foreign body moves considerably, it indi-
cates that the foreign object is deeply imbedded. On the contrary,
if the shadow moves but slightly, it indicates that the object is superfi-
cially imbedded. The next step consists in viewing the foreign body at
exactly right angles to the first position ; to do this the part under exami-
nation, and not the tube, should be turned. The skin of the part should
be marked over the area of the shadow at both sides by the figures "2,"
ii2."> Next in order draw lines from 2-2 and 1-1, and the point of
intersection corresponds to the exact location of the foreign object. For
marking the skin, .some prefer diluted silver nitrate crayons, but, as
they are more or less irritating, I employ indelible pencils. Fig. 172
illustrates a simple method of localization.
Punctograpli. — This consists of a stout brass ring securely mounted to
a handle of ebonite. A pencil of aniline is attached to the base of the
handle. The pencil is controlled by a check spring, and when the latter
is pressed, the pencil is released, which now jumps through the centre of
the brass ring, marking the skin at the point where the shadow presented
FIG. 172. — THE RIGHT-ANGLE METHOD OF LO-
CALIZATION.— P, photographic plate; T1, position of
the tube; T2, position of the tube at right angles to
the above; F.A, foreign body.
300 ELECTRO-THERAPEUTICS.
itself, as seen through the screen. In localizing a foreign body by this
method, two of these instruments are simultaneously employed. The
screen should be clamped to a frame, thus allowing the hands perfect
freedom for manipulating the two instruments.
In examining the forearm for a foreign body, let us say a bullet, the
part is brought between the screen and the tube, and the shadow revealed.
The first punctograph is then placed so that the opening of the brass
ring encircles the shadow cast by the bullet. A second punctograph is
applied similarly and directly opposite the first. The springs of both
punctographs are now simultaneously released, and there result marks
on the skin at opposite ends of a line. The arm is next rotated through
the quadrant of a circle, the punctographs again being applied, and the
springs released as in the beginning. It must thus become self-evident
that four marks are now upon the arm, and by ordinary calculation and
measurement the position of the bullet may be easily determined.
Reiny*8 Method. — The Remy localizer, which is an extremely compli-
cated device, and is with greatest difficulty elucidated by the use of dia-
grams, is thus briefly reviewed by A. \V. Isenthal, F.R.P.S., and H. Snow-
den Ward, F.R.P.S., members of the Council of the Routgen Society.1
"The Reiny localizer is a complicated apparatus, founded on the
principle that it is necessary to 'materialize' those two X-rays which
connect the anode with the foreign body and its screen shadow for two
positions of the tube. By means of suitably placed sights and stops, one
is enabled to bring the pointed rods (representing the X-rays) always
back to their proper plane, so that the latter and the depth of the
foreign object may be marked on the patient." 2
Barrel's Method. — Frank R. Barrel, M.A., B.Sc.,of the University
College, Bristol, England, thus tersely describes his localizer.
" My method requires no plumb-line, no threads, and no levelling.
My 'apparatus' consists of two metal cylinders whose ends have been
carefully turned perpendicular to their axis. A convenient size is four
inches long and one inch in diameter. Place these cylinders upright on
the plate during an exposure, and close to the limb holding the foreign
body. The shadows thrown indicate the focus position of the tubes. To
secure good long shadows, place the cylinders near the end of the plate
furthest from the tube. After the first excitation shift the tube six or
ten inches, the cylinders are also shifted towards the opposite end of the
plate, and then the tube is again excited, giving rise to the second set of
shadows from the foreign bodies and the cylinders. Lines are ruled
along the edges of the two corresponding cylinder shadows for one tube
position, and, producing them till they meet, we obtain that point on the
'Practical Radiography, Dawbarn and Ward, Publishers, 1901.
2 For a comprehensive description of the apparatus and its mode of application,
the reader is referred to Archives of the Rontgen Ray, August, 1900.
8 Archives of the Rontgen Ray, May, 1900.
THE CLINICAL APPLICATIONS: 301
plate which was vertically beneath the tul>e focus during the correspond-
ing exposure. Connecting the two points thus found with the corre-
sponding shadows of the foreign body, we obtain two lines which intersect
in a point which is vertically below the actual foreign body."
S/x-ittott'x MrtlHxl.1 — For such cases as needles or bullets in the hand,
arm, or leg, — /. e., in parts easily manipulated, — no special apparatus is
required and no photographic process involved. Shenton describes his
method as follows : "Hold the part, for example, a hand containing a
needle, before the fluorescent screen. Start with the screen and the
anode of the tube as nearly parallel as possible. When needle and bones
are distinctly seen, sway the screen and hand from side to side, and note
the change in relation of bones and needles. It is evident that the image
of whichever is furthest from you and from the surface of the screen
will move the faster. If the needle moves across the bones, its position is
deeper than the bone ; if bones move across needle, the latter's position
must be between the surface of the screen and the bone. Should the
needle appear to remain stationary, place a pointer against this image on
the screen, and ascertain whether it moved a little or not at all. Verify
these results by reversing the hand and repeating the manoeuvres. A
little practice enables one to give as near an estimate of the needle's real
depth as any surgeon could require, and such suggestions as 'just beneath
the palm,' 'midway between bones and skin,' 'lower end between the
bones,' 'upper one-eighth of an inch between the skin of the back of
the hand,' are, in my experience, sufficient for any operator. I doubt
if a calculation in millimetres would be of more use. The body is an
awkward thing to apply the millimetre scale to, and a little pressure on
the skin, or a little swelling beneath it, will overthrow such minute
calculations. The needle's depth being ascertained, it only remains to
find its position in the horizontal planes, a task which presents few
difficulties.
•• When found, this position should be marked upon the skin. The
advantages of this method are its rapidity of performance, the process
taking but a few seconds, and the economy of material, both photo-
graphic and electrical. For localization in other parts of the body, and
for photographically recording results, I have constructed an instrument
which in principle is the same as the method just described, save that the
tube is swayed, while the part viewed is held in position by bauds and
tension springs. The tube is moved by the observer from his side of the
screen, the distance it travels being regulated by sliding steps. A fine
vertical wire is stretched in the centre of, and in contact with, the screen.
The image of the foreign body is to correspond with this line when the
tube is in the mid-position. Upon moving the tube from the extreme
right to the extreme left, the image of the foreign body on the screen is
1 Archives of the R.'mtpen Ray, August, 1899.
:;OL> ELECTRO-THERAPEUTICS.
seen to pass from left to right. Its relative rate of travelling, compared
with the same portion of bone, is noted as before. For accurate measure-
ments the true position assumed by the foreign body is marked by
pencil on a celluloid film in contact with the screen. This measurement
being secured, the distance the tube travels, and the distance from the
mid-point of the line adjoining the two extreme positions of the tube,
must be ascertained. A simple rule of three will now give the distance
of the object sought from the screen."
Harrison'* Mrthod.1 — "A seven-inch square is drawn on a board and
its centre is accurately marked ; at the ends of a line drawn through the
centre, perpendicular to two of the sides, two upright rods are fixed (for
convenience of carriage, these can be made to take in and out) ; at a
height of seven inches on each of these pillars, a hook or loop is placed.
Take the case of a needle in the hand. A double photograph of the
needle and hand is taken with the light alternately right and left. A
tracing of this photograph is then taken on the sensitive side, marking
distinctly on the ends of the needle. The tracing is then placed so that
its centre coincides with the centre of the square. Pins are then stuck,
slantingly through the tracing, into the board at the ends of the needle.
Cross threads are carried from the pins to the loops and kept stretched
by small weights. Where these threads intersect will show the position
of the needle relatively to the sensitive plate, which is represented by
the tracing."
Double Focus Tube Localization. — This method was devised by Leon-
ard 2 and is as follows : The technic required for triangulation methods
prevented their general employment, and to simplify the application of
the same principles, Leonard has had made a tube with two cathodes and
two anodes, and hence two sources of rectilinear rays. This avoids errors
when the position of the tube has to be changed or separate plates used,
and it has made rapid accurate localization with the fluoroscope easy.
The fluoroscopic method is as follows : Fix the screen in a perpendicular
position. Place the tube horizontally so that the mid-point of the line
connecting the two sources of rays is perpendicular to the plane of the
screen, and at a known distance from the centre of the screen marked by
an opaque cross. Place the limb before the screen so that the two shadows
of the foreign body will fall equally distant on each side of the opaque
spot and on the same line. Mark the spot in the patient's skin with
nitrate of silver. By placing an opaque rod on the other side of the limb,
where its shadows are equidistant from the opaque spot, the perpendicu-
lar is found and marked on that side. The foreign body, therefore, lies
on this line at a distance from the opaque spot, that is determined by
measuring the distance between the two shadows with calipers and
1 British Medical Journal, April 2, 1898.
'American X-ray Jour., November, 1899.
THE CLINICAL APPLICATIONS. 303
plotting the shadowy paths by the graphic process, as when plates are
employed, or by the cross-thread method.
Stereoscopic Method. — This method has already been discussed. I
employ it, as it has yielded satisfactory results.
THanffvfation Method of Localizing Foreign Bodies with Measurement
on a Graduated " T" Scale. (Figs. 173, 174.)— In order to find the depth
of the foreign body on the scale, bring the lower bar to the figure 10 on
the upright. Connect a line at 20 on the uppermost horizontal bar, inter-
secting at 1.6 [DE] on the middle horizontal bar, which registers 4.53cm.
011 the vertical bar, as shown in the following formula :
A = Position of the tube in the first exposure.
B = Position of the tube in the second exposure.
AB = Distance of the displacement.
C = Foreign body.
D — Shadow of the foreign body on the plate (first exposure).
E = Shadow of the foreign body on the plate (second exposure).
CA = 50 cm. — CD.
There are two triangles, = CAB and CDE.
DE = 1.6 cm., which is known.
AB = 20 cm.
CD _ CA 20 CD = 2(50 cm. — CD)
2 - 20 20 CD = (100 cm. — 2CD)
20 CD + 2 CD = 100 cm.
22 CD = 100 cm.
100
CD = - — = 4.53, distance of the foreign body.
SMB
Orlhodiagraphic Localizer of Grashey. — Frequently it is found that
foreign bodies imbedded in the tissues cannot be located with exactness,
even when felt beneath the skin, or when Rontgen photographs are taken
in different projections, because of the possibility of the foreign body
varying its position to the bony parts from minute to minute. If the
hand during the operation is not kept in exactly the same position as
during the taking of the photograph, then the projection will be wrong.
Recently Dr. R. Grashey, of Munich, devised an orthodiagraphic
localizer. (Fig. 175.)
The operator sits before the table and is looking with one eye into
the tube, and he sees an illuminated picture in the mirror of the crysto-
scope. With the other eye (the room not being darkened) he can look
directly at the wound. The current is interrupted and closed by the help
of a pedal. The tube is enclosed in a box, containing below a diaphragm,
capable of effecting so small an opening that only a limited field of opera-
tion is illuminated. In this way, and by a plate of lead glass inserted in
the front wall of the box, the operator is protected. The box is fixed on
a support connected with one leg of the table, and revolves horizontally.
Thus, it can be turned aside with a sterilized cloth, and when its use is
304
ELECTKO-THEBAPEUTIC8.
again required it can be turned back, and it will be at once over the
former position, above the fl Horoscope. The forearms of the operator rest
comfortably on movable supports. N
The illustration (Fig. 176) shows the path of the rays emanating
from the anode of the tube K. that is in the box BK. Through the open-
ing B, in the diaphragm, we see the body K, containing the foreign body
FIG. 173.— "T" scale used in triangulation method. FIG. 174.— Scheme of application of the "T" scale.
F. Upon the fluoroscope L, inserted on the table O, this picture is ob-
liquely reflected by the mirror S, in the dark chamber D, into the tele-
scopic tube T. In that case the anode focus and the centre of the fluo-
roscope M, marked by a little shot pasted on it, lie vertically one below
the other. Thus it becomes easy to adjust any other body orthodiagraph-
ically in line with the normal ray, as, for instance, the foreign body F
contained in the hand K. If you move the point of a knife into the
illuminated picture until its shadow covers that of the shot and also
the foreign body that has previously been adjusted, then the point of the
blade must be exactly above that of the foreign body.
THE CLINICAL APPLICATIONS.
For the determination of the location of a foreign body, whether
in the eyeball or orbital cavity, take two separate skiagraphs, with the
FIG. 175. — Orthodiagrapliic localizer of Grashey.
t IP
FIG. 176.— Diagrammatic view of the same.
tube-holder and plate in the same position in both instances ; or during
half the exposure the patient rolls the eyeball ; if the shadow of the
foreign body appears double, the offending substance is in the eyeball ; if
in the orbital cavity, the shadow will be single.
to
CHAPTER IV
APPLICATION OF THE X-EAYS IN DISEASES OF THE
THOEACIC OEGANS.
THIS is subdivided into the respiratory and circulatory systems.
The value of the X-ray as a diagnostic agent in thoracic examinations
has been and is being constantly demonstrated. The thorax and its
contained viscera are easy of examination both by the fluoroscope and
skiagram, largely due to the circumstance that the lungs are transparent
to the rays. By a fluoroscopic examination we observe the excursions of
the diaphragm, the expansion and retraction of the lungs and ribs, the
different phases of the cardiac cycle, and the pulsations of the aorta.
The fluoroscopic interpretation is not the work of the novice. The
beginner should first study the thoracic viscera fluoroscopically upon thin
subjects and children, so as to accustom himself to the appearances
presented normally.
The two methods of examination are with the fluoroscope and the
skiagram. The advantages of the fluoroscope are these ; it is inexpen-
sive, easy of application, the part may be viewed from any direction,
the intensity of the rays can be altered, the position of the patient, tube,
and fluoroscope can be changed, movements of the thorax and its con-
tained viscera can be studied and tracings made of their shape, size, and
position. The disadvantages are the liabilities to burns, the lack of
differentiation of the tissues of slightly varying densities, and the fact that
the image is only transient.
I. Fluoroscopic Examinations.
Anterior and Posterior Views. — The screen, in an anterior view of the
chest, shows a dark zone extending from the base of the neck to the
diaphragm, a little to each side of the median line of the body ; this is
the shadow cast by the dorsal vertebra, sternum, and heart. On both
sides of this dark zone are the much lighter shadows produced by
the lungs ; traversing the lung shadows, on both sides from the shadow
cast by the spine, are successive darker bands, the ribs. The heart's
pulsations, its position, shape, and size can all be viewed by careful screen
examinations. The ventricular chambers always present a dark shadow,
the right auricle giving usually a lighter shadow than the left. Above
the shadow of the ventricles and slightly to the left is the shadow of the
pulmonary artery. In the first left intercostal space may be seen a part
of the arch of the aorta. The shadow of the heart's apex will be observed
to blend with the shadow of the diaphragm. The border of the pulsating
306
APPLICATION OF THE X-RAYS. 307
heart presents a slightly lighter shadow than its interior. The cardiac
outline is best viewed through the anterior thoracic wall. A posterior
view of the heart is less distinct, because of the intervening spine and
lungs and of its anterior position in the chest cavity.
In a posterior view, a dark shadow corresponding to the left side of
the heart is seen to the left of the spine, and a smaller and slightly less
distinct but denser shadow of the right auricle is seen to the right of that
produced by the spine. The organs of the thorax, represented on the
screen, may be easily recorded in the following manner : The operator
should employ a screen of sufficiently large dimensions to cover the entire
chest, and upon whose dorsal aspect has been placed a sheet of white linen
writing paper. In order to maintain a constantly steady position of the
screen for a uniform and correct tracing, the patient should be seated
comfortably, so that he may not move. The screen should be supported
by a movable frame fastened to the arm, coining from, a metallic upright
free from all undue vibrations, as otherwise the examination will prove
unsatisfactory. The screen having been placed either in front or in back
of the patient's thorax (leaving 1 inch (2.5 cm.) space between the screen
and chest), we are ready to trace on the paper the image cast on the
screen by the use of an opaque pencil, preferably one that is indelible. I
believe, however, that the orthodiagraph is always more desirable.
Lateral and Oblique Views. — In the lateral view, especially when seen
from the patient's left side, the operator observes the heart in contact
with the anterior chest wall, also the profile view of the heart, the aorta
arching backward to approach the vertebral column, and an unobstructed
interval between the posterior part of the heart and the spine.
The oblique view, which can be antero- lateral or postero- lateral, right
or left, is taken with the fluoroscope at an angle of about 45° to the
vertical axis of the body. This view is of value in an obscure diagnosis,
in furnishing additional and often confirmatory data.
Examination of the Lungs. — The image of a normal lung, on a fluores-
cent screen or fluoroscope, is bright, the rays penetrating with less resist-
ance the spongy tissue than ordinary dense tissue. This brightness of
the screen differs in degree during the various stages of respiration.
When the lungs are inflated to their fullest extent, there is represented
on the screen a uniform bright light shadow. At the end of the fullest
expiration the above degree of brightness has considerably diminished,
as the lung tissue has become more compact. Between these two extremes
there is a medium degree of brightness, obtained when respiration has
temporarily been halted midway between inspiration and expiration.
As we would also naturally expect, in children and in thin adults the
lungs appear brighter on the screen than in muscular or corpulent indi-
viduals. In the latter class of cases, as more tissue must necessarily be
traversed by the rays, there is more chance for their absorption, hence
the giving of more "shadow."
:>(is ELECTRO-THERAPEUTICS.
In examiiiiug a lung from below upward, the brightness of the
shadow very slightly increases as we approach the apex. Usually the
right lung presents a slightly lessened degree of shadow brightness as
compared with the left. The shadow of the right apex in normal cases
is always darker than the left. No satisfactory explanation has ever
been given concerning this difference. Some authorities maintain that
it is due to a slight hypertrophy of the muscle tissue of the right side
of the chest. It is more marked in right-handed people, and we might
naturally infer that the opposite would be true in left-handed people,
although observations on such subjects have also proved the contrary to
be the case.
Normal Heart and Diaphragm. — Dr. F. H. Williams1 states that the
radioscopic appearances of the normal heart and diaphragm as seen by
a screen examination in the anterior view are the following :
" In health the diaphragm moves as follows : Quiet breathing, one-
half inch (1.3cm.) ; at full inspiration 2£ to 3 inches (6.5-7.5 cm.), and
slightly more on the right than on the left side. A part of the aorta in
some patients may be observed in the first intercostal space ; in the sec-
ond intercostal space a portion of the pulmonary artery ; the left border of
the ventricle is chiefly seen during a full inspiration, when the apex and
a portion of the lower border are also visible ; the maximum pulsation
is at a point corresponding to the cavity of the ventricle, about where its
outline crosses the fourth rib ; during full inspiration the heart moves
downward to the sternum. To the right of the sternum the outline of
the large vessels is seen and, less distinctly, the right auricle between the
second and fourth ribs. The right auriculo- ventricular line curves, with
a slight indentation, from the second to the sixth ribs inclusive. During
the momentary elevation of the diaphragm this line is pushed upward
and outward. During a forced depression of the diaphragm it elongates
and is carried downward and inward toward the sternum. Under ordi-
nary conditions we find the lowermost portion of the heart's shadow fus-
ing with that of the liver and the diaphragm."
Dr. Albert Abrams* says : "The average normal excursion of the
diaphragm in quiet breathing is five-eighths of an inch or 1J cm.; between
full inspiration and expiration, on the right side, 2 1 inches or (about) 6.7
cm. ; left side, 2f inches or 7 cm.
"In long-chested persons diaphragmatic excursions are greater than
in short persons with deep chests."
Measurement of the Diaphragmatic Incursion. — Dr. H. Guilleniinot 3
says: "On account of the slope of the diaphragm backward and down-
ward, the highest point of the diaphragmatic arch is nearer the anterior
than the posterior surface of the body. Moreover, the point of contact
1 The Rontgen Rays in Medicine and Surgery.
7 Journal of the American Medical Association, May 3, 1902.
3 Archives of the Rontgen Ray, January, 1906.
APPLICATION OF THE X-RAYS. 309
of the tangent ray is displaced with the movement of the diaphragm,
and this displacement varies with the subject and with the distance of
the anti-cathode. All these cases of error are avoided by the use of
orthodiascopy/' He, in collaboration with M. Yauuier, obtained a
tabulation of 23 cases, comprising normal lungs and tuberculous lungs in
every stage. From their observations they arrived at the following
conclusions :
1. il On the right side the mean position of the diaphragmatic curve
is 16.5 cm. below the suprasternal line, and on the left side it is 18.5
cm. below that line.
2. "The normal amplitude of the diaphragmatic incursion is from
16 to 18 mm. It is approximately equal on the two sides.
3. " Any variation in the amount of the incursion on the right and
left sides is a pathological symptom, and in most cases has a serious
clinical significance.
''The ratio between the amplitude of the diaphragmatic incursion
and the costal angle depends greatly on the type of respiration, whether
costal or abnormal.
'• The inequality of the incursion of the diaphragm on the right and
left sides is an important aid to diagnosis."
The Measurement of the Costal Angle. — Guilleminot has shown the
possibility of radiographing the thorax in inspiration or in expiration.
This may be accomplished by dissociating the phases of inspiration and
of expiration by means of an automatic interrupter.1 By this means,
one can obtain a cinemato-radiograph of the respiration. On these
radiographs one may measure the obliquity of the ribs between two-
points on the upper margin of the rib at a distance of If and 2i inches
i4 and 8 cm.), respectively, from the median line. If we now take any
horizontal line and measure the vertical distances of these two points,
the difference of the two ordinates will give us the obliquity of the
rib for a distance of 4 cm., and this divided by 4 will give us the
obliquity per centimetre. This is the cotangent of the angle with the
vertical, made by a line passing through the given points.
"By this means it is easy to determine the costal angles of inspira-
tion and of expiration. Their difference is the functional costal angle,
which may vary from 3° to 5°.
"The orthodiascopic procedure is much more simple.
• • With practice one is able to distinguish the projection of the up-
per border of a rib at its position of maximum elevation and depression
while the patient breathes rather deeply.
11 In each case it is important to note accurately the physiological
type of the respiration, which may vary in all possible degrees between
the abdominal and the superior costal type. For this purpose the
1 Comptes-rend. Acad. Science, June 12, 1899.
310 ELECTRO-THERAPEUTICS.
tracing of the costal range should be accompanied by a tracing of the
diaphragmatic incursion.
"If we take the means of these measurements, we obtain the
following results :
(Inspiration, 77J° )
Left 1 y Mean position, 74i|°
(Expiration, 72|°J
f Inspiration, 76} °1
Right < .Mean position, 74f °
(Expiration, 73 °j
"In these observations the mean angle is the angle which the
rib makes with the vertical when it is in a position midway bet worn
inspiration and expiration.
"The absolute coincidence of the mean angles on the right and left
sides is certainly accidental, there being considerable divergence in cer-
tain instances.
"The mean costal angle may therefore be said to be approximately
equal on the two sides, and to be about 74° to 75°.
( Left, 78.6° }
Inspiration \ }• Mean, 78.2° ^
( Right, 77.8° j
j- Difference = 5.4°
( Left, 72.7° )
Expiration \ V Mean, 72.8° j
( Right, 72.9° J
"The functional costal angle, therefore, in healthy subjects is equal
on the right and left sides, and usually varies between 5° and 6V
Causes of the Restriction of the Diaphragmatic Wave. — Albert Abrams1
says, in this connection: "The restricted diaphragmatic movements
must be regarded as very suspicious of phthisis. This sign, first referred
to by Williams, of Boston, has had no theory advanced to explain its
existence. I will briefly summarize my investigations which gave birth
to the theory that an emphysematous condition of the lungs exists in
phthisis. Rokitansky and Brehmer noted that lungs too voluminous
coupled with a small heart characterized the phthisical habitus. If the
physician were to depend on percussion dulness as an evidence of early
phthisis, the affection would never be recognized ; lung resonance, not
dulness, is the early physical sign of phthisis. The rays are invaluable
in the recognition of emphysema ; in this condition, the lungs seem too
large for the chest, the diaphragm is low and its excursions restricted."
Diseases of the Diaphragm. — "In spasm," says Abrams, "dia-
phragmatic movements are practically suspended on the affected side.
'Journal of the American Medical Association, May 3, 1902.
APPLICATION OF THE X-EAYS. 311
Suddenly the diaphragm contracts and descends several inches below its
normal descent. Singultus may accompany the descent, whilst cyanosis
and dyspnoea become intense. In paralysis, movements of diaphragm
on the affected side are suspended ; during inspiration, the midriff rises.
In diaphragmatic pleurisy, movements of the diaphragm are very much
restricted or even suspended. The upper part of the lung is brighter
than normal, owing to over-disteution.
li Average Normal Excursion of the Diaphragm. — In quiet breathing,
li centimeters ; between full inspiration and expiration, 6.7 cm. on the
right side and about 7 cm. on the left side. In long-chested persons
the diaphragmatic excursions are greater than in short persons with
deep chest.
" Width of the Normal Heart. — With the screen about 75 cm. from
the tube and with the target directed toward a point where the median
line is crossed by the fourth rib, the right heart measures 3 cm. from the
median line, and the left heart 8.5 cm. from the median line ; a total
of 11.5 cm."
II. Skiagraphic Examinations.
The lungs may be examined in two ways, fluoroscopically and skia-
graphically. What is stated below regarding the methods of examination
is equally true for both the normal and abnormal lung.
Position of the Patient. — Skiagrams of the lungs may be made with the
patient either in the sitting, semi-recumbent, or dorsal decubitus posture.
In my experience the latter has always proved to be the more satisfactory
of the two. The patient is requested to remove all clothing covering the
thorax, in some cases not even permitting the retention of a garment
next to the skin.
When the dorsal decubitus position cannot be taken, the patient
starting to cough, or if he is suffering from dyspnoea, he should be re-
quested to resume the semi-recumbent posture, having the head-end of
the table elevated to an angle of 45°, so as to insure greater comfort and
also in a measure to remove the pressure exerted upon the diaphragm
and the adjacent lungs. I always request the patient to elevate the arms
and clasp the hands over the head, in order to raise the scapulae and
thus remove their shadows from the shadow of the thorax.
Place two superimposed sensitive plates, well protected by a thin
layer of celluloid, under the patient's thorax. The size of the plates
employed will depend upon the size of the patient's chest ; the plate
should be slightly larger than the chest itself so as to extend on both
sides about two inches beyond its outer margins.
The tube should be placed with the target pointing directly toward
the centre of the whole thorax and from 20 to 25 inches (50 to 63 cm. )
distant from the plate, depending upon the thickness of the chest and the
312
ELECTKO-THERAPEUTICS.
penetrative power of the tube. The cathode stem of the tube should
extend toward the foot end of the table, to prevent alarming the patient
by the sparking that necessarily occurs in self-regulating tubes.
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q/7 Exposure. — Exposure should be as rapid as possible, other-
wise the incessant motions of the thoracic viscera will cause a blurred
shadow. Formerly this obstacle was partially overcome by telling the
patient to take a deep inspiration and to "hold " the breath. I then took
a short exposure (5 or 10 seconds), repeating the process five or six times
in one or two minutes. But this method has been greatly improved upon,
by the instantaneous process. Radiographs of the thorax have been
made by Von Ziemssen and Eieder in one second of time, by the appli-
cation of the Eosenthal method.1 Rosenthal employs a Volt-Ohm appa-
ratus, with a 60 centimetre coil, an electrolytic interrupter, and a Volt-
Ohm tube. The time of exposure is shortened by the use of two intensi-
fying screens, one being placed with its coated side against the coated
side of the film and the Schleussner film then laid between the intensi-
fying screens, the coated sides of which are toward the photographic
film. These are then enclosed in three light tight envelopes. The pa-
tient lies on his abdomen or back upon the photographic plate, or the
1 Miinchener medicinische Wochenschrift, 1899, No. 32.
APPLICATION OF THE X-EAYS. 313
plate is placed upon the particular part desired to be photographed, and
the current is opened for a moment and as quickly closed. The plates
are then removed and developed in the usual manner.1
III. Clinical Applications.
A. DISEASES OF THE BRONCHI AND LUNGS.
The X-rays have proved themselves invaluable in diagnosticating
pulmonary affections and conditions, affording in many cases confirm-
atory evidence and guiding the practitioner in numerous incipient condi-
tions into a correct understanding of the pathological changes present.
Early in the progress of pulmonary diseases, where marked changes are
not fully in evidence, the usual physical methods employed often fail to
elicit the proper pathognomonic signs, and it is here that the X-rays serve
as a most valuable adjunct.
Bronchitis. — Most cases of bronchitis fail to show the normal bright-
ness of the lung, when free secretion is once established. The character-
istic clouding is usually limited to the lower two-thirds of both lungs.
In this affection the excursions of the diaphragm are usually unrestricted,
except where the smaller bronchial tubes are obstructed by an exudate.
If the patient is instructed to cough, the secreted material may be expec-
torated or else temporarily removed from the lower portion of the lung ;
thus permitting the excursions of the diaphragm to be more perfectly
restored. In chronic bronchitis, with considerable coughing, there is
likely to be some dilatation of the right ventricle. If the bronchitis is of
tuberculous origin, small shadows of the involved areas are usually con-
fined to the apical regions. In bronchitis associated with influenza, a
few localized shadows may be discerned, which are really the complicat-
ing foci of a lobular pneumonia.
Bronc/iicctftxis. — This condition in itself does not produce any shadows
on the screen or skiagram, unless the adjacent lung tissue is consolidated
or infiltrated with calcareous substances. When studying this condition,
the patient should be examined in various positions and from all direc-
tions. The shadows of brouchiectatic areas are generally found in the
middle and lower thirds of the lung, and are usually posterior. In un-
complicated cases of bronchiectasis there are no causes for restriction in
1 In 1905, during the Rontgen Congress in Berlin, Drs. Rosenthal and Rieder, of
Munich, exhibiu-d skiagrams of thoraxes which were taken with an exposure of
one-tenth ( j<y) °f a second.
In 1901, Mr. Isenthal (Archives of the Rontgen Ray, vol. v., Xo. 5) exhibited in
London instantaneous skiagrams ; in 1904, Dr. Henry Hulst, of Grand Rapids, Mich.,
read a paper before the American Rontgen Ray Society in which he likewise showed
instantaneous skiagrams of the thorax ; in 1904 I experimented with different methods
on the same patient at the Philadelphia Hospital, and arrived at the above conclu-
sions. See tabulation, page 312. (Transactions of the American Rontgen Ray Soci-
ety, 1904.)
314 ELECTRO-THERAPEUTICS.
the movements of the diaphragm. If, however, an emphysema be pres-
ent, then the excursions will be restricted, and the midrift' will be
observed to occupy a lower position. As a result of a purely brouchiec-
tatic condition, the heart very rarely changes its shape, size, or position.
If such a cavity is healing, a considerable quantity of scar tissue is
gradually developed, which, by contraction, may displace the heart
from its normal position. In a complicating emphysema the heart is
displaced by the latter and not by the bronchiectatic disease. If the
chest is examined before the bronchiectatic cavity has been emptied
by coughing (the best time for examination of this condition being
after the patient has been resting in the recumbent position for several
hours), a distinct shadow corresponding to the cavity is very easily
seen, followed by a brighter appearance as soon as the contents have
been evacuated.
D. B. King1 furnishes notes on 20 cases studied by the Pontgen rays,
in addition to the other usual methods of examination. In each instance
the endeavor was made to detect the presence or absence of (1) dilated
bronchi. In advanced cases where the bronchi were much dilated, as
shown by the stethoscope or at autopsy, the Rontgen rays failed to reveal
their presence. (2) In cases of saccular cavities. Here the rays failed to
reveal such cavities, probably because of the associated fibrosis of the
lung. (3) The condition of the lung tissue. Fibrosis of the lung was
shown by increased intensity of the shadows. (4) The presence of foreign
bodies. . For the detection of foreign bodies in the bronchi, the rays are
of undoubted value. (5) Study of the action of the diaphragm. This \\ as
found to be impaired or obscured, depending upon the degree of change
in the lung. King states that the general value of Rontgen ray examina-
tion in cases of bronchiectasis is sufficient to warrant its employment on
more than one occasion, though this may give no further information as
to the real nature of the case than is furnished by ordinary clinical
methods.
Asthma. — In asthma the lungs cast a brighter shadow than the
normal, extending higher up and lower down in the thoracic cavity.
The position of the diaphragm is observed to be low, and its movements
much retarded. It is interesting to study a paroxysm of asthma
while the rays are penetrating the thorax. Such a paroxysm can be
provoked by injecting cold water into the nasal chambers or by packing
the nostrils with cotton. During a paroxysm, the lungs look very
similar to the condition seen in emphysema, differing however from the
latter in that there is a complete fixation of the diaphragm ; the disap-
pearance of the paroxysms being evidenced by the restoration of the
lungs to their natural shadow brightness. The heart occupies a 1<>\\< i
position and moves less frequently during inspiration than it does
'The Practitioner, February, 1904.
APPLICATION OF THE X-RAYS. 315
normally; the right ventricle is much increased in si/c. and the outlines
of the heart are unusually clear cut and sharp, owing to the brightness
of the lungs during a paroxysm.
Emphysema. — In this affection the pulmonary area is increased, and
when viewed with a screen it is much lighter than is the normal lung.
This area of brightness reaches high above the clavicles, and at the same
time it extends downward, depressing the diaphragm. It is said by some
that the diaphragm presents two more or less distinct curves (one on each
side), instead of one large curve as is seen normally.
During ordinary quiet breathing, the diaphragm appears to descend
very low in the thorax, though in a forced expiration it ascends to a
higher level. In pneumonia of one lung there is generally a compensatory
emphysema of the other, the emphysematous lung appears much brighter
on the screen than it does in health. The area of the heart when viewed
with the screen is very nicely defined in emphysema. The dark shadow
produced by the heart stands out boldly against the much lighter field
produced by the emphysematous lung. The heart occupies a lower
position in the chest and assumes a more vertical direction than when the
lung is normal. In the severer type of emphysema the screen shows
both the right auricle and the right ventricle to be much enlarged. If
tuberculosis is a complication, the pulmonary brightness appears spotted
by irregular darkened shadow areas, usually confined to one or the other
apex and occasionally involving both.
Broncho- Pneumonia. — In broncho-pneumonia circumscribed shadows
widely scattered throughout the lungs are observed on the screen, with
an occasional coalescence of the circumscribed foci. Under such circum-
stances the shadows are usually limited to the middle and lower lobes and
are seldom found in the apical regions. The diaphragm frequently
occupies a very high position, especially during inspiration, with great
restriction of diaphragmatic movements. If there are no complications,
the heart does not change its position. Shadows are occasionally pro-
duced in certain portions by the collapse of the lung tissue; coughing and
deep breathing cause their evanescence.
Pulmonary Tuberculosis. — The shadow on the screen of an early
pulmonary tuberculous lesion is difficult of interpretation.
Two very important signs that may be elicited by the rays, are a
slightly restricted diaphragmatic movement on the involved side (Wil-
liams' sign), and the hazy, darkened, and occasionally emphysematous
appearance of the lungs. As restricted movements of the diaphragm
frequently indicate an incipient tuberculosis, they should always be re-
garded with suspicion.
To determine the presence of Williams' sign, first view the excursions
of the diaphragm during ordinary breathing, and mark the highest ele-
vation on the lower chest by means of an indelible pencil. This tracing
should be made on both sides of the chest wall. This quiet breathing
316 ELECTRO-THERAPEUTICS.
should be followed by a full, deep inspiration, and the lowest point to
which the diaphragm descends should be noted in a similar manner, and
likewise on both sides.
Two or three deep inspirations successively following one another
may be necessary to bring out the lowest point to which the diaphragm
descends. The patient next expires as deeply as possible, and the
highest point attained by the diaphragm is traced in a similar manner.
When the excursion from a deep expiration to a deep inspiration is
diminished on one or the other side, there is also a diminished excursion
of the diaphragm during ordinary breathing on the affected side. The
fact that the diaphragm rises somewhat higher on the side of the lesion
during a forced expiration, should not be overlooked. In advanced
cases of tuberculosis the side of the diaphragm corresponding to the
affected side always rises much higher than does the normal side, though
at the same time the excursion up and down is continually diminished.
If one lung is partially or wholly diseased, the diaphragmatic excursion
on the sound side is slightly increased, as compared with the affected
side. The higher position of the diaphragm taken in advanced cases,
would seem to be due to a degeneration or shrinkage of the lung tissue
on the diseased side ; the excursions may also be diminished during
respiration by adhesion between the lung and diaphragm, or by an
increased quantity of air entering the organ, resulting from a paren-
chymatous destruction, etc. An exact study of the diaphragm's move-
ments is perhaps most satisfactorily conducted by a careful fluoroscopic
examination.
The hazy, darkened appearance of pulmonary lesions, especially
of the incipient tuberculous stage, should always be studied from
above downward, commencing at the apices. All hazy, darkened
areas on the screen should be outlined on the skin by an indelible pencil
or crayon.
These are usually brought out more distinctly after a full inspira-
tion. In attempting to detect such a hazy area at the apex or in a lobe,
the patient should be requested to droop the shoulder on the side under
examination, so that the shadow produced by the clavicle may l»e
lowered out of the field as much as possible. A better view of the
affected field may be obtained by having the patient stoop forward,
allowing the rays to enter the thorax at the mid-scapular region, placing
the screen directly over the supraclavicular space. The examiner should
(•(.in pare the light produced by the two apices both during full inspira-
tion and during deep expiration. The light coming from the tube should
be so regulated, by increasing or decreasing the distance between the tube
and patient, that the affected side is only faintly illuminated. When the
two sides are now compared, the sound side appears slightly brighter
than the other. The excitation of the tube may be controlled partly, by
a speed regulator or by a rheostat, but these are seldom required.
APPLICATION OF TIIK X-RAYS. 317
When both apices are involved in a tuberculous process, usually one
apex is more extensively affected than the other, t. r., there is distinctly
more haziness on the side most affected. A clouded appearance of both
apices is indicative of an already advanced form of tuberculosis. In the
early stages of this disease, an associated einphysematous condition
of the lungs, occurring in the middle and lower thirds, may be
demonstrated.
The value of the X-rays in incipient pulmonary tuberculosis may be
well illustrated by the reports of the following cases iu the service of
Prof. James M. Anders, which were under my care for a skiagraphic
examination.1
CASE I. — S. H., female, married, aged 28 years, cigar- maker, first
applied at the out-patient clinic of the Medico-Chirurgical Hospital,
Philadelphia, June 6, 1899, for treatment. A brother died of acute
phthisis. The patient had had some of the diseases of childhood ; but
the remainder of her history was negative. Her illness began with
paroxysmal pains in the praecordia, and this lasted for a considerable
period. The day previous to her visit she had expectorated blood, which
she stated was coughed up ; the quantity of blood was small, bright red,
and frothy. The abnormal physical signs were an impairment of the
percussion- note and harsh breathing, with prolonged high-pitched ex-
piration at the right apex, with absence of the vesicular quality, and
prolonged high-pitched expirations at left apex ; all signs, however, were
less marked than at right apex. Microscopic examination of the spu-
tum gave a negative result. Later an X-ray examination revealed an
abnormal shadow or marked haziness at the apices of both lungs, but
more marked at the right.
CASE II. — P. K., aged 29 years, cigar- maker, applied for treatment at
the out-patient clinic of the Medico-Chirurgical Hospital, November 10,
1899. The family history is entirely negative as to pulmonary diseases.
The patient suffered none of the diseases of childhood. He had had
typhoid fever one and a half years previously, which confined him to bed
for ten weeks. Since then he had been complaining of persistent gastric
disturbance, evidenced by eructations of gas and dull pains in the
epigastrium after meals ; there had been some dyspnoea on exertion, and
at intervals cardiac palpitation. A few days prior to his first visit, he
began to expectorate bright-red blood. Subsequently there was neither
cough nor expectoration. The amount of blood lost did not exceed half
an ounce. An examination of the throat and larynx was negative, and
the same was true of a physical examination of the thorax, although the
chest was of the paralytic or phthisical type. After excluding all causes
of haemoptysis, except pulmonary tuberculosis, an X-ray picture was
1 Journal of the American Medical Association, January 12, 1901, and reported by
me to the American Congress of Tuberculosis, May 14, 1902.
318 ELECTRO-THERAPEUTICS.
made. This showed commencing consolidation over circumscribed areas
011 both sides just below the apices.
CASE III. — J. O., aged 14 years, errand boy, was admitted to the
wards of the Medico-Chirurgical Hospital, November 13, 1899. Father
died, in his fifty-second year, of heart and lung disease, the precise nature
of which the patient does not know. One sister is in delicate health.
The lad had had the usual diseases of childhood and a severe illness of
unknown character a few years since ; had always been in delicate health.
The present illness began about four weeks before he came under my
observation. The first symptoms complained of were malaise, headache,
a slight cough in the evenings and mornings, more or less abdominal
pains, associated with slight diarrhoea. The evening temperature on
admission was on the average about 100° F., but abdominal pain, diarrhoea
and cough had largely subsided. Physical examination showed a para-
lytic or phthisical thorax, without any other abnormal physical sign.
After excluding typhoid fever, latent tuberculosis was suspected ; tuber-
culin was injected, followed by a positive reaction. An X-ray examina-
tion was also made by Dr. Kassabian, and showed a slight haziness below
the left clavicle. (See Figs. 177, 178.)
Cavitation. — As cavity formation begins in the centre of a consoli-
dated mass, after it has slightly advanced we may observe a lighter field
encircled by a darker shadow zone. If the outer margin of the cavitated
mass has been infiltrated with inorganic salts, we may demonstrate on
the screen a dark, narrow border-like shadow, encircling a larger light
field. If the cavity is filled with exudative material, there will be no
light reflex, presenting the appearance of a consolidated mass. This
would also be true if the entrance to the cavity were located at the upper
surface. In some instances this fluid can be readily removed by having
the patient lie down and cough, when the light reflex may be noted to
again return. A dilated bronchus, with exudative material and consoli-
dated structure surrounding it, cannot be differentiated from a small
cavity by means of the X-rays. Where the cavity is small and the wall
thickened, little or no light reflex may be visible on either the screen or
skiagram.
As the different pictures of pulmonary tuberculosis presented by the
screen and skiagram bear a striking similarity to other lung affections,
the employment of special methods for more accurately determining and
differentiating the true condition would seem of first importance. Thus,
Dally,1 who has made a great many pulmonary examinations by means
of the X-rays, states that the earliest indication of pulmonary tubercu-
losis is the unilateral limitation or loss of mobility of the diaphragm.
Prior to any shadow production (the result of tuberculous involvement)
the action of the diaphragm becomes gradually lessened on the affected
1 Lancet, June 27, 1900.
FIG. 177. — Tuberculosis of the right lung (posterior view) , and a photographic tracing of the same.
The skiagraph shows consolidation of the right apex and right base ; heart is displaced toward the
right. A, acromion process : Sp, spinous process of scapula ; Cl, clavicle; C, coracoid process ; 1, 2, 3t
4, 5, 6, 7, 8, 9, 10, ribs (posterior) ; I, II, III, IV, ribs (anterior).
FIG. 178.— Tuberculosis of the right apex (anterior view). Plate placed in front of chest. The
chest of the same patient as shown in Fig. 177. The lower cut is a photographic tracing of the above.
Ab, axillary border of scapula ; Vb, vertebral border ; S.A., superior angle ; RD, right side of the
diaphragm ; LD, left side ; T.S., triangular space, best seen with the screen against the chest, between
the heart and the diaphragm (for the diameters of the heart, see page 330) ; C, cavity, which was not
visible on the posterior view.
APPLICATION OF THE X-RAYS. 319
side. After the tuberculous process has advanced to the point of produc-
ing distinct cloudy shadows within normal lung shadows, the limitation
of diaphragmatic movements usually becomes more and more evident ;
it may, however, decrease.
Cases are reported where marked limitation in the mobility of the
diaphragm was present when only the apical region of the lung had been
involved. He further states that the typical shadow of an early pul-
monary tuberculous process is irregularly mottled, and that sucti an
appearance may be simulated by a new growth, but the latter can readily
be differentiated by the characteristic distribution of the shadow and by
the peculiar physical signs. A consolidated area produces a shadow of
moderate density, and this in itself is increased when the adjacent lung
tissue is hypenemic. He believes that a caseating process throws a still
deeper and darker shadow. The appearance of cavities will vary
according to the size, position, and whether filled or empty. Those empty
and located at the apical region of the lung are usually transradiant ;
when filled with pus they may remain unnoticed. In brief, Dally believes
that the unilateral limitation of diaphragmatic movement as seen by the
fluoroscope is very often the earliest sign of a beginning pulmonary
tuberculosis, and that only by the X-rays can pulmonary tuberculosis be
diagnosticated at an earlier stage than by the other means at the disposal
of the practitioner.
Dr. Dally l classifies the quality of the shadow, with the percussion
note manifested, as follows :
RONTGEN RAYS. .
Brightness Hyper-resonance
Transradiancy z= Normal resonance
Faint shadow = Impaired resonance
Dense shadow = Dulness
Opacity = Absolute dulness
. . PERCUSSION NOTE
Vieruzhsky, of the Nikolas Military Hospital, which is devoted
especially to the treatment of tuberculosis, reports elaborately on the re-
sults obtained by the various methods of diagnosticating tuberculosis.2
He is enthusiastic at the results obtained from the use of the Kontgen
rays in the diagnosis of the early stages of pulmonary tuberculosis. The
use of the spirometer as an agent assisting in the diagnosis of this disease
has not been satisfactory, the figures obtained in the measurement of the
respiratory capacity of the lungs being uncertain and variable. He is
well able to realize the deficiencies and limitations of the X-rays, but
he asserts that skiagraphy offers a means of controlling and confirming
the data of physical examinations.
Acute Mili<iry Tuberculosis. — This disease is difficult to diagnose clini-
cally ; and it is often overlooked by reason of the frequent absence of
physical signs. The only means then left to the practitioner is by an
1 Lancet, June 27, 1903. 2 Roussky Vratch, April 26, 1903.
320 ELECTRO-THERAPEUTICS.
X-ray examination. In this disease the screen or skiagram presents very
small darkened shadows, scattered throughout the lung.
Pneumonia. — The various stages of croupous pneumonia may be
studied both with the screen and the skiagram. A central pneumonia
which resists detection by the ordinary physical signs may be detected
by the aid of the X-rays.
In the stage of congestion there is a uniform dark shadow cast on the
fluorescent screen ; the result of an increased quantity of blood in the
affected part of the lung.
The stage of consolidation presents a still darker shadow, due to the
increased density.
A centralized consolidation, not demonstrable clinically, throws a
shadow on the screen, equally as well as a simple superficial lesion. In
croupous pneumonia I have observed the middle lobe of the right lung
to be the one most frequently involved. In this condition the excursions
of the diaphragm are almost entirely obliterated. In the majority of in-
stances the right side of the heart is enlarged and displaced to a greater
or less extent. In some cases involvement is so extensive as to shroud
the shadow ordinarily cast by the heart. That the cardiac displacement
is due to the pressure of the dense lung, is demonstrable by the rays.
The stage of resolution is characterized by the lung tissue returning
to its former normal structure, and when the shadow cast by the pre-
viously affected side is similar to that cast by the non-involved side, we
speak of the organ as having again returned to the normal. The
shadow of the previously affected area may persist until complete reso-
lution has occurred, while continued persistence of a shadow in this
region may indicate a thickened pleura.
A croupous pneumonia must be diagnosticated from pleurisy with
effusion, from an acute bronchitis, and from pulmonary tuberculosis.
The physical signs and clinical symptoms are frequently ill-defined in a
pleurisy with effusion, so that it may be confounded with a pneumonia.
In a non-encysted pleurisy with effusion, a dark shadow is thrown on
the screen, which changes its position with the change of position of the
patient. In a pneumonia there is no change in the shadow demonstrable
when moving the patient. In pleurisy with effusion there is a much
greater displacement of the heart than in an uncomplicated pneumonia.
Lately I examined a child for an unresolved pneumonia, affecting the
middle lobe of the right lung. The consolidated spots closely simulated
a dry pleurisy ; but the latter casts an irregular longitudinal shadow, the
former circular.
Atelectasis. — The shadows produced correspond to the areas involved
in the collapse of the lung. If collapse is extensive, the shadows cast on
the screen are corresponding in size. The excursions of the diaphragm
are not, as a rule, restricted, and its position is normal. The heart
does not change in its normal shape, size, and position in a beginning
APPLICATION OF THE X-EAYS. 321
atelectasis, though in advanced cases with fibrous tissue formation, fol-
lowed by contraction of large parts of lung tissue, the heart may finally
be more or less displaced. The shadows may disappear if the patient is
instructed to breathe as forcibly as he can.
Abscess and Gangrene. — The exact location of either an abscess or
gangrene is indicated by a dark shadow. These conditions are usually
found to involve the lower part of the middle lobe or upper part of the
lower lobe. As an abscess cavity usually opens internally, and the foul
material is expectorated, the shadows disappear immediately after the
cavity is emptied. The excursions of the diaphragm are usually more or
less restricted, depending upon the size and location of the abscess. The
position of the diaphragm is normal, and the heart does not change in
position. If the shadows are multiple, they indicate multiple abscesses.
B. DISEASES OF THE PLEURA.
Pleurisy with Effusion. — In pleurisy with effusion the diaphragm is
only slightly, if at all, observed on the screen, depending upon the
amount of the effusion present. Because of the pressure exerted by the
ilu id upon the adjacent lung tissue, the latter is more dense ; hence the
fluid throws a dark shadow upon the fluorescent screen, usually denser
than that cast in any other thoracic condition.
On changing the position of the patient, the change of level is easily
discerned by the aid of the fluorescent screen. The upper level of the
fluid is better seen in the sitting than in the recumbent posture. With
an abundant quantity of fluid within the pleura! sac, the heart as a
rule suffers considerable displacement, and far greater when the
pleural effusion is confined to the left side than when it exists on the
right side only.
The shadows of the ribs are usually very faintly shown on the affected
side above the pleural effusion. As a rule, the heart is displaced prior
to a downward displacement of the diaphragm. The excursions of the
diaphragm are usually much restricted, especially when the effusion is
abundant. Small effusions are often to be detected in the small angular
spaces on each side between the diaphragm and chest wall. Pleural
thickenings are not infrequently mistaken for small effusions. Pleural
adhesions are indicated by limited excursions of the diaphragm. After
aspiration a clearing up of the previous darkened shadow may be
noted, the ribs may again be detected, the heart will immediately re-
sume its normal position, and the excursions of the diaphragm are again
increased.
Even though there is only a small quantity of effusion in the pleural
sac, the lung tissue above the fluid level toward the apex presents a
darker appearance than the same field of the normal side, this being in
all probability due to a compression of the lung on the affected side. If
21
322 ELECTRO-THERAPEUTICS.
the right pleural sac is completely filled by fluid, this shadow fuses with
that of the heart (in the mediau line or slightly to the right), liver, and
diaphragm ; hence, all the brightness of the right side is totally lost.
Prof. Ch. Bouchard l was the first investigator to publish observations
made with the screen in pleural effusions. He demonstrated that the
X-rays do not pass through the effusion. He also showed that the shadow
indicated the upper level of the fluid, as confirmed by the ordinary
methods of physical diagnosis.
Dally,2 from his radioscopic study of pleurisy with effusion, concludes
that the level of the fluid changes with the position of the patient unless
the quantity of fluid is great and is encysted by adhesions. A puru-
lent effusion yields a shadow of greater density than a sero-fibrinous
effusion. The shadow is homogeneous, and in the case of the serous
effusion the shadow gradually increases in density from above downward.
However far the heart is displaced to the right, in most cases little
alteration takes place in the position of the apex relatively to the base.
Other conditions being equal, the heart is displaced more when the
effusion is left sided. A somewhat triangular shadow, not normally
visible, above and continuous with the shadow of the heart and pericar-
dium is cast by the mediastinum, which is displaced by the lateral
pressure towards the healthy side of the thorax.
Empyema. — In empyema the displacement of the heart and liver is
greater than with the same quantity of serous exudate. In pulsating
pleurisy, the heart movements transmitted to the fluid may be seen as
diffuse undulations, if the patient remains motionless for the time being.
According to my experience, the shadow of an empyema on a fluorescent
screen frequently seems to be a shade darker than that produced in an
ordinary pleurisy with effusion. This may be accounted for by the fact
that in an empyema there is usually associated a slight redema of the
chest wall over the seat of the exudate. When there is no such cedema-
tous condition coexisting with an empyema, the shadow cast by the
retained pus is of the same density as that of an ordinary pleural effu-
sion. An interlobar empyema (a condition very difficult to diagnosti-
cate by ordinary means) casts a shadow of the encysted pus on the screen;
the surrounding lung, above and below, presents the normal brightness,
provided there is little or no compression of the adjacent pulmonary
tissue by the enclosed fluid, the movements of the diaphragm are not
restricted, nor is the heart displaced from its normal position. Dia-
phragmatic pleurisy is indicative of an involvement of the pleura in
relation to the diaphragm. There is usually a small quantity of exu-
date present, which can only be revealed with difficulty, by a careful
screen examination. Of several cases of this condition that came to my
1 Archives d'£lect. M&iicale, July 13, 1896.
2 Lancet, February 27, 1904.
APPLICATION OF THE X-RAYS. 323
attention, four showed very distinct shadows on the screen. Hemor-
rhagic pleurisy cannot easily be differentiated from other types of
pleurisy by the X-rays.
A pleurisy of the sac with effusion may be complicated with an
empyema. An einpyeinatous condition of the left pleura would make its
appearance on the opposite side. In case a pleurisy has been disgnosti-
cated, complicated by unusual dyspnoea, the examiner should then look
for an associated empyema of the opposite lung.
Pneumothorajc. — The affected side presents a very bright area and
of rather large size. The lung tissue is retracted, and the diaphragm
occupies a lower position than normal ; its movements are greatly re-
stricted, and occasionally no movements are at all recognizable. The
cardiac outlines are clearly defined, with a displacement toward the
unaffected side.
Hydro-pneumothorajc and Pyo-pneumothorax. — In studying the affected
side of the chest, with the patient in the sitting posture, the fluorescent
screen shows a very dark area below and a lighter one above. It is best
demonstrated with the tube behind the patient, the target facing the
third intercostal space (fourth rib). With the change of position of
the patient, the fluid may be noticed to alter its level ; the fluid also
changes its level during respiration, rising during a deep inspiration and
falling during a deep expiration.
The excursions of the diaphragm are usually wholly obliterated,
while it also occupies a very low position, and the heart is displaced
toward the unaffected side. The pulsations disturb the upper level of
the fluid area, a condition which may be readily studied by the fluores-
cent screen. If the lung is examined in the median line and above the
fluid area, it usually appears slightly darker as a result of compression.
The degree of displacement of the heart and liver depends upon the
amount of air and fluid retained in the pleura! cavity. An apical tuber-
culosis of the affected side can very readily be diagnosed, as the
surrounding field usually appears intensely bright.
Subplurnic Abscess. — A subphrenic abscess gives a dark shadow in
the lower part of the thorax, and above it there is a lighter shadow due
to the presence of air. and, surmounting this, there will be a shaded field
caused by the compressed lung. The diaphragm occupies a slightly
higher position with a total abolition of its movements. The heart is
displaced toward the unaffected side, though this displacement is not so
extensive as in hydro-pneumothorax. The upper level of the dark area
changes with the change of position of the patient, and splashing of the
enclosed fluid may be recognized when the patient is grasped by the
shoulders and shaken.
Tumors of the Thorax. — Intrathoracic growths cast shadows upon the
fluorescent screen. These masses are generally circumscribed, and are, as
a rule, located in the upper part of the chest. Care must be exercised to
324 ELECTRO-THERAPEUTICS.
differentiate these growths from thoracic aneurism ; in the former the
tumor pulsates with an up and down movement, in the latter, the move-
ment is expansile.
If the tumor is not too large there is no restriction in the excursions
of the diaphragm. The heart is generally slightly displaced. Small
calcified lymphatic and bronchial glands are often noticeable.
Enlarged Glands. — Any enlargement of the thoracic, mediastiual, or
bronchial glands is easily shown on the fluorescent screen or skiagraph.
As the bronchial glands are usually first involved in tuberculous condi-
tions of the lungs, a few authorities have successfully demonstrated a
slight enlargement of the glands in the incipient stage. Any glandular
enlargement should be viewed suspiciously as the beginning of an adja-
cent tuberculous involvement, This condition is best viewed on the
screen by having the rays traverse the body diagonally.
IV. Application of the X-rays to the Circulatory System.
In fluoroscoping the normal heart in the anterior view, we observe
the shadow of the heart and aorta. These shadows are due to the opacity
of the contained blood and to the superimposed shadows of the verte-
brae and sternum. The posterior view shows the same structures in their
posterior aspects. The anterior view, however, is preferable, as the heart
being nearer the chest wall allows of a clearer shadow on the fluoroscope.
Fluoroscopy is preferable to skiagraphy in the study of the circulatory
system, as with it we can observe the cardiac cycle, the aorta and the
movements of the diaphragm, from various positions.
A. FLUOROSCOPIC EXAMINATION OF THE NORMAL HEART.
The heart may be examined with the patient in the sitting, standing,
or recumbent posture. The heart when viewed by the screen occupies a
characteristic position in the thorax, when the patient is seated on a stool.
During expiration it rests on the diaphragm, its long axis forming an
acute angle with the imaginary median line of the thoracic cavity. In
inspiration the heart moves downward and toward the median line ; the
right border of this organ is plainly seen to the right of the sternum, the
larger or left part of the heart is seen to the left of the sternum, — i.e.,
the long axis of the heart forms with the median line during expiration
a less acute angle than during an inspiratory effort. During inspiration
the transverse diameter of the heart is slightly decreased in length, at
the same time the number of pulsations are lessened. In expiration,
after the diaphragm has discontinued tugging on the heart, the transverse
diameter is again increased, as is also the amplitude of its pulsations.
The general contour of the organ can be more easily seen during inspira-
tory periods than in the expiratory, because the lungs, being filled to their
capacity, are more transparent to the rays, thus offering a more striking
APPLICATION OF THE X-RAYS. 325
contrast. The cardiac outline may be readily differentiated by means of
the ingenious artifice of Dr. Disan.1 By this method the outline of a
normal heart is traced on the chest by fixing with adhesive strips a copper
wire. A iluoroscopic examination is then made in the following way :
At first the greatest strength of current obtainable from the apparatus
is turned on. The observer looks through the fluoroscope and gets the
chief landmarks of the chest, such as the scapula, ribs, spine, diaphragm,
and upper convex border of the liver, the wire being at the same time in
full view. The current is now reduced until the heart becomes more dis-
tinctly visible. The fluoroscope is applied to a spot marked at the left
of the spine, corresponding to the fourth intercostal space in front of the
chest. Any alterations in the shape of the heart can thus be easily
demonstrated.
The shadows of the pulmonary vessel and in many instances the vena
cavii! can be recognized if the chest is made to assume a position diagonal
or oblique to the screen and tube.
The pulsations of the heart are less in number during a deep inspira-
tion than in expiration, or even in the ordinary quiet breathing. These
pulsations are lessened during a deep inspiration and by increase of the
air pressure upon the heart, — i. e., the pressure from the pericardium,
which is made more taut during the descent of the diaphragm.
The Orthodiayraph. — This instrument was devised by F. Moritz, of
Munich.2 (Figs. 179 and 180.) Its purpose is the bringing out of any
object in its exact size and without distortion. By it the size and shape
of all the recognizable internal organs, as well as other parts of the body,
can be determined. As the Rontgen rays are propagated from a point
on the anodal field in straight lines radiating in every direction, and as
the image of a body projected on a phosphorescent screen or skiagram is
a silhouette, the outline of the object presented coincides with the places
where the rays coming in contact with the edge of the body impinged
upon the screen. This outline, therefore, is the periphery of the base
of a cone, whose point coincides with the luminous spot of the anti-
cathode. As the object to be projected is located between the vacuum
tube and the screen, the image on the latter will be magnified, the degree
of magnification being dependent upon the ratio of the distance of the
object from the image plane and the distance of the object from the
vacuum tube. The image projected by a vacuum tube, so far from re-
cording the true dimensions and shape of the object, will show the latter
more or less magnified and distorted. In order to obtain the true shape
and size of the object, the rays touching the body and forming on the
plate an image of its outlines must be made parallel and strike the
plate at right angles, — i.e., the projection from a centre must be
1 Dominion Medical Monthly, February, 1897.
2 Berlin Allgenieine Electricitats Gesellschaft, and Munch, ined. Wochenschrift,
April 10, 1900.
326 ELECTRO-THERAPEUTICS.
replaced by a projection that is parallel. "SVith the orthodiagraph, pro-
jections true in shape and size are obtained in any desired position of
the drawing-plane.
The luminous screen which also carries the drawing stylus is con-
nected with the Eontgen tube by a U-shaped fi-ame. This frame, made
up of a number of jointed sections, permits of any desired adjustment of
the screen with the tube. A rod extending from the screen is longi-
tudinally adjustable in a split sleeve on the end of a tube lying parallel
with the axis of the drawing stylus. The tube is provided with a tele-
scoping member, on the projecting end of which a second split sleeve is
adapted to slide. This screen is formed on the end of an arm which is
thereby supported at right angles to the telescoping member. The clamp
holding the tube has a ball-and-socket connection with a member which
may be adjusted to any position along the arm. When properly adjusted
the propagating joint of the X-rays should lie on an extension of the axis
of the stylus. This may be done approximately by adjusting the tube
clamp and other members of the U-shaped frame. In order to obtain a
more perfect adjustment of the tube, — i. e., such adjustment as would per-
mit working with accurate perpendicular rays, — the screen may be ad-
justed in one plane, by moving its supporting rod longitudinally in the
split sleeve above referred to, and in a plane at right angles thereto, by
adjustment of the screen within its holder. By noting the shadow cast
on the screen by the end of the stylus projecting there through, the oper-
ator can readily ascertain when accurate adjustment has been obtained.
Parallel movement of the tube with the screen is obtained by means
of two levers, one pivoted to the other. A lever which supports at one
end the U-shaped frame is hinged to a second lever, which in turn is piv-
oted to a bracket on the end of the supporting column of the apparatus.
Each lever is provided with a counter- weight, movable along its outer
arm, and these weights serve to hold the parts in equilibrium.
The bracket just mentioned also carries a rod, to which the drawing
frame is attached by means of a universal joint. The drawing frame is
adapted to be covered with heavy bristol- board, held therein by holders
at the sides, and on this surface the drawing stylus is softly pressed by a
spiral spring.
Now the whole system so far described is movable around the axis
in the head of the main supporting column, and may be clamped in any
position by means of a milled nut; an additional fixing lever may l>e
grasped to prevent this system from suddenly dropping or loosening the
nut. At the same time, the accurately vertical and horizontal position
of the system is indicated by a spring catch. The length of the support-
ing column is such that on turning the system round its axis into a hori-
zontal position, the drawing plate will just be at a convenient distance
above a person lying on an ordinary table of about 30 inches in height.
The heavy base plate is provided with four rollers allowing of the
APPLICATION OF THE X-EAYS.
327
drawing apparatus being readily moved. By operating special screws,
these rollers may l>e removed, and the apparatus placed on the points
of the screws, which in addition will allow of the column of the
apparatus being given an accurately vertical position even on oblique or
uneven floors.
When a drawing is to be made directly on the body, the bristol-board
is removed from the drawing frame, and a dermatograph stylus should
be inserted into the drawing stylus, instead of a pencil. The drawing
FIG. 181.— Levy-Dorn's orthodiagraph for the standing position.
frame is provided with three pencil-holders, or ''plotters," as they are
called, which are movable in the plane of the screen or in that of the
drawing plate, and provided with scales in both co-ordinates ; the posi-
tion of a person with regard to the central ray may be thereby ascertained,
so that on the examination being repeated the same position of the per-
son may be accurately secured. A fourth auxiliary plotter has been pro-
vided with slides on a scale projecting from the extended axis of the
lower supporting lever.
328
ELECTRO-THERAPEUTICS.
In addition to reproducing the true shape and size of organs, the
apparatus may be advantageously used to ascertain the depth of foreign
objects. This can be done by measuring the apparent diameter of the
object when the Rontgen tube is stationary, and then ascertaining the
actual shape of the body by means of parallel movement of the drawing
Reimger,Gebberh BtSchall, Erlangen.
FIG. 182.— Levy-Doru's orthodiagraph for use in the recumbent posture.
stylus and the tube. Xow if a I is the apparent length of a foreign body.
r I its real length, D the distance of the anticathode of the tube from the
luminous screen, and d the distance of the object from the anticathode,
the formula - - will give the true distance of the foreign b<><ly
from the luminous screen.
The Levy-Dorn orthodiagraph is shown in Figs. 181 and 182. The
advantage of this instrument lies in the fact that during the examina-
tion of the heart the operator measures the vertical and horizontal axes
on the scales.
B. SKIAGRAPHIC EXAMINATION OF THE HEART.
The heart can be skiagraphed with the same technic as is applicable
to the lung, but the former requires more precision in the position of the
patient, tube, distance, etc. The patient may be seated on a chair and
the plate placed either over the chest (sternum), in the anterior or
c S
c "3
C 3
E «
c 5
PL. *
fc "3
APPLICATION OF Till-} X-KAYS. 329
ventral view, or to the back (posterior view). Ask the patient to raise
both arms, in order to remove the shadows of the scapula? from the
thorax. Centre the anode of the Crookes tube over the level of the third
rib in back and one inch below the upper end of the sternum in the
median line. The distance of the anode from the plate should be from
25 to 30 inches <;:>-::> c-m.X An anterior and posterior skiagraph should
be made at the same time, noting that no abnormality or deformity
exists. If the tube is placed in an oblique position the shadows will often
mislead and confuse. Anterior and posterior oblique (right and left)
skiagraphs should also be taken, in order to study mediastinal tumors,
and the arch of the aorta. The time of exposure should be as short
as possible, correspondingly to the cardiac cycle. Two methods of
skiagraphing the thorax are presented in Figs. 183 and 184.
M. (hiilleminot, of Paris, invented an instrument by which he can
make cinemato-radiographic pictures. The exposures can be made either
during inspiration, expiration, or during the ascent and descent of the
diaphragm ; and also during the systole and diastole of the auricles and
ventricles. I have made stereo-skiagrams of the thoracic organs of
young thin subjects, which have yielded for scientific study the true
perspective and relief effects of the heart, aorta, sternum, and vertebrae ;
such results are of clinical worth in studying aneurisms and cavitations.
Size and J/m.s-///v///o// of th<- Heart. — According to Abrams,1 with the
screen at about 29; inches (75 cm.) from the tube and with the target
directed toward a point where the median line is crossed by the fourth
ril>, the normal heart is seen to extend from the median line 1T\ inches
(3 cm.) on the right side and 3y^ inches (8.5 cm.) on the left side, the
total width of the heart being about 4 inches (or 10 cm.).
MobiJitii of the Jlcart. — Silbergleit* describes a case in which the
entire heart was capable of lateral displacement of several inches by a
change from the left lateral to the right lateral position. The patient
was a man of twenty-four years who came under observation for gastro-
enteritis and a moderate degree of chlorosis. He had no subjective
symptoms referable to the heart, and in the standing position or when
lying on the back physical examination of the organ was negative.
When lying on the left side, however, the apex beat was three centi-
metres outside of the mammary line, and the right border one centimetre
to the left of the left sternal margin. When on the right side, the apex
beat appeared close to the left sternal margin and the right border was
correspondingly displaced. This case is of scientific value, in that the
abnormal mobility is only an index of an existing cardiac lesion.
Sears3 states that Determann's experiments, made with the X-rays
and by percussion, demonstrated the mobility of the heart with change
'Journal of the American Medical Association, May 3, 1902.
M.-.li.-.il Kro.nl, June 20, 1903.
M. .ii.al Standard, January 1, 1901.
330
Ea^ECTBO-THBBAPBUTICS.
of position. lu the healthy individual turning on the left side produced
an average displacement of 2' centimetres to the left and 1 centimetre
upward ; turning on the right side occasioned a change of 1J centimetres
to the right and about £ centimetre upward. In some cases the displace-
ment was quite small, in others as much as 6^ centimetres to the left and
4 centimetres to the right, without distress to the subject. These greater
movements were found to occur, as a rule, in flabby and ill -nourished
individuals and in those whose abdominal organs were loosely anchored.
It was observed that women usually have more freely movable hearts
than men, especially after childbearing or from the use of tight slays.
Children have little signs of it, the newborn scarcely any, and in old
persons it is slight. Individuals of sedentary habit and feeble muscular
development are especially subject to the condition. The physiological
effect of the full stomach is noted, and also anything which tends to
elevate the diaphragm. During the latter part of pregnancy the heart is
much pushed up and is compressed, thus showing very little mobility.
Immediately after delivery, however, the highest grade is found, and the
apex may be displaced on the left side 9 centimetres from its original
position.
MORITZ TABLE.1
Healthy Adult Man (Age 17 to 56).
J3 °
Si 2
= 5
• I
1
2
2 13
£ a
9
HEIGHT OF THE
PERSON
DIMENSIONS
~ =
I 1
S
I ±
5 g
1
i .2 *-•
a
S a
i "5 "3>
S * "o
be
S ~
5S2
i ^ —
a
Q
gp
5
cm.
cm.
cm.
cm.
cm.
153-157 cm. or
average
4.4
7.9
13.0
10.2
98
6 ft. 9 inches
maximum
4.S
s.o
13.5
10.5
100
5 ft. 10i inches
minimum
4.0
7.8
11.6
10.0
SO
161-169 cm. or
average
4.4
8.8
13.4
10.5
102
6 ft. 0 inches
maximum
5.0
9.8
14.5
10.8
108
6 ft. 3^ inches
minimum
3.5
7.5
12.8
9.0
87
171-178 cm. or
average
4.6
8.8
14.0
10.3
100
6 ft. 4 inches
maximum
5.9
9.7
16.8
11.0
126
6 ft. 7J inches
minimum
3.0
7.8
1L>.5
9.0
92
Displacement. — In this condition the heart may retain its normal
shape, only changing its position. The most frequent cardiac displace-
ment is dextro-cardia, which is a congenital malposition. In the acquired
ML Gocht, "Ilandbuch
(von 17 bis 56 Jahren)."
der Rontgenlehre," " Erwaohsene gesunde Manner
APPLICATION OF TILE X-IiAYS. 331
forms of malposition the heart may be displaced low down in the chest,
the pulsations may be felt behind and below the lowermost extremity of
the sternum, or it may be placed to the right of the sternum or the left
outside the left nipple line, these facts being confirmed at the same mo-
ment with the fluoroscope. Fluid in the left pleural sac causes the heart
to be pushed toward the right side, while exactly the opposite condition
exists when the right pleural cavity is so affected ; but in dry pleurisy the
adhesions may draw the heart toward the affected side. Disteution of
the pleural cavity by gas, as seen in emphysema, also causes a displace-
ment either to the right or the left, depending upon the cavity that is
involved. An increased elevation of the diaphragm causes the heart to
assume a position on its long axis so that the right ventricle is pulled to
the anterior position, the chief feature of recognition being the increased
distinctness of the right side of the heart when the chest is examined from
behind.
Cardiac Atrophy, Hypertrophy, and Dilatation. — These conditions are
revealed by a screen examination. Atrophy presents a small size of the
organ. In hypertrophy or dilatation of the left ventricle, the apex has
changed from its normal position, the shadow area is increased, and the
clear space normally existing between the heart and liver (as seen on a
deep inspiration) is diminished in size or has totally disappeared. If the
right ventricle is increased in size the base usually appears more or less
drawn down and the long axis assumes a more nearly horizontal position.
Abdominal distentiou, with either fluid or gas, causes an elevation of the
diaphragm, hence another cause for change in the position of the heart.
I have often noticed that the heart atrophies in advanced cases of tuber-
culosis. In a pneumonia, displacement is usually toward the unaffected
side ; in an extensive emphysema the heart naturally occupies a posi-
tion lower than normal. Aneurisms, new growths, and adhesions are
aiming the other causes of cardiac displacement. Thome1 observed a
heart to shrink after its exposure to the Kontgen rays for thirty minutes.
In one case, the heart had shrunken in its long axis some 1J to 2 inches
( 4.."> to 5 cm.), while in its transverse diameter the contraction amounted
to li inches (4cm.). Experiments in this connection have been con-
ducted on dogs, the results in general showing a considerable shrinking.
Care should be taken when fluoroscoping the heart to differentiate
between true atrophy and displacement. In the Schott treatment of
lu'art disease, the attendant studies the patient's heart before and after
each treatment. I have never observed any change in the size of the
heart except an alteration in the pulse rate noted in certain neurotic cases.
Acute Dilatation of Heart. — F. Moritz2 stated that orthodiagraphy has
failed to confirm the occurrence of any appreciable acute dilatation after
'British Medical Journal, 1896, vol. ii. p. 1238.
2Miinchener medicinist-he Worhensrhrift. Hi.. N». !•">. April 11: " Acute dilatation
of the heart due to diphtheria."
332 ELECTRO-THERAPEUTICS,
physical exertion, after hot baths, the injection of alcohol, narcotic or
other medication ; chloral, chloroform, caffein, or kola. It has revealed,
however, that the outline of the heart is smaller in the upright position
than when the subject reclines. He believes that an interesting field
for research is opened by orthodiagraphy of the dilated heart, whereby
we can study the influence exerted upon it by rest in bed, digitalis.
carbonated baths, electric baths and gymnastics, etc. H. Dietlen1
states that he has examined 47 out of 65 patients suffering from
diphtheria with the aid of the Moritz orthodiagraph, the subjects reclin-
ing, and he found that 20 of these 47 presented evidences of myocard it ic
phenomena. In 15 of this group (75 per cent, of the cases of endocar-
ditis and 32 per cent, of the total number), dilatation of the heart
was unmistakably apparent when examined with the orthodiagraph.
Even extreme degrees of dilatation are liable to retrogress, so that the
prognosis is not necessarily bad.
Examination of the Heart. — Kraus2 has analyzed the findings of radio-
scopy of the heart in health and disease. He asserts that the shades of
difference between the heart shadows cast in cases of various valvular
affections are of greater diagnostic importance than dilatation of the
heart alone. These differences in shadows are due to changes in the
shape of the various sections of the heart, the immediate consequence of
the valvular defect. The consecutive hypertrophy of the musculature
and passive dilatation naturally reinforce and emphasize, as it were, the
differences in the outline. This is especially marked in the left convex
protrusion of the so-called left middle arc in case of mitral defect, also in
the varying behavior of the left lower arc with mitral insufficiency and
pure mitral stenosis, and, finally, in the outline of the shadow as it
spreads to the right, in case of aortic and mitral defects. Radioscopy
of the heart after artificial distention of the stomach is very instructive.
The presystolic pulsation of the right auricle can be distinctly distin-
guished from the contraction of the ventricle. Two and sometimes three
contractions of the auricle to one of the ventricle are sometimes noted.
Intermittence of the heart is seen to be by no means always identical
with iuterinittence of the pulse. In cases of tachycardia and bradycardia
radioscopy throws light on many hitherto unexplainable processes,
especially those of nervous origin.
Pericarditis (Pericardia! Effusion}. — If an enlarged shadow is cast by
the cardiac area, it indicates hypertrophy, or a pericarditis with effusion.
If there is presented a movement of the left border of the heart's shadow,
it indicates enlargement. In case no such pulsation is demonstra-
ble, pericarditis with an effusion should be surmised. The shadow of a
1 Miinchener medirinisrh.' \Vo<-h<.'ns<-hrift, lii., No. 15, April 11, 1905: "A<-uU>
dilatation of the heart dur to diphtheria."
• hcutsrhc incdidnische Wndu-nM-lirift, lU-rlin ami Ldpsic, xxxi., No. :i, .January
19 ; Journal of the American Medical Association, June 10, 1905.
APPLICATION OF THE X-RAYS. 333
pericardia! effusion is rounded or circular, while that of hypertrophy is
more or less pyriform. lu most cases the shadow cast by an effusion is
not so dense as that produced by the heart muscle itself, so that in view-
ing the shadow field we may find a variety of shades ranging from a
slightly lighter field to one that is dark. A change in the upper level of
the shadow may occasionally be noticed by changing the position of the
patient.
Aortic Aneurism. — Cases of aneurism, unsuspected and unrecognized
by the attending physicians, have been revealed by careful fluoroscopic
and skiagraph ic examinations. While aneurisms are sometimes un-
detected by X-ray examinations, a large number are supposedly diag-
nosed that in reality do not exist ; an early diagnosis, therefore, is most
important. The prognosis of aneurism was formerly regarded as most
unfavorable, but in the light of recent knowledge the so-called "com-
mencing aneurisms of the aorta" have been shown to remain often
stationary, and that they do not necessarily proceed to a fatal termina-
tion. They can always be studied during treatment as to their size,
position, pulsation, etc.
Fluoroscopic examinations are preferred by most operators because
they are enabled to see the tumor or pulsating condition and because the
condition can be examined from different angles and, positions. Both
methods should be employed, although I never use the fluoroscope.
The skiagraphic examination is identical with the technic described
on diseases of the lungs and heart.
The shadow of the normal aorta (when viewed anteriorly or posteri-
orly) is almost totally obscured by the superimposed shadows of the
sternum and the vertebral column, with the exception of a small shadow
to the left, cast by the left lateral a rtic bulge.
Aneurisms of the ascending portion of the arch of the aorta, being
nearer to the anterior wall of the chest than the posterior wall, cast
shadows extending to the right of the sternum and above the heart.
Aneurisms of the descending portion of the arch of the aorta
(Figs. 185 and 186) usually cast shadows to the left of the sternum, which
are nearer the posterior than the anterior wall of the chest. If the
aneurism is very large, the shadow will extend to both sides of the
sternum.
Aneurisms of the transverse portion of the arch of the aorta will cast
shadows slightly to the left, and if large the shadow observed will extend
up to the neck. This detection, however, is very difficult, and requires,
in addition to anterior and posterior examinations, left lateral and right
lateral oblique examinations.
Beginning or diffused aneurisms are difficult of diagnosis, especially
so in corpulent individuals. Gocht l declared that by means of the
1 Lehrbuch der Rontgenuntersuchung, Stuttgart, 1898, p. 199.
334 ELECTRO-THERAPEUTICS.
Rontgen rays it was possible to determine the presence of an aneurism
where doubtful symptoms were manifested.
Dumstrey and Metzner ' urged considerable caution in reaching con-
clusions regarding the existence of aneurisms by means of the Rontgen
rays, especially where physical signs or symptoms failed to be elicited ;
they furthermore believe that mediastinal tumors may give rise to the
same appearance.
Drs. Geo. Pfahler and Jos. Sailer2 assert that, after a careful com-
parative study with X-ray diagnoses and post-mortem examinations of
supposed aneurisms, they found that the tortuosity of the aorta was
in many instances confounded with the existence of aneurisms.
Dr. G. H. Orton3 says that, "In some cases, even with these four
examinations, the shadows of the aorta cannot be satisfactorily inspected,
owing to complications which may mask it."
Of late, I am making stereo-skiagrams of the chest, and find them
valuable in differential studies involving the aorta, heart, and lungs in
their respective relations to each other and to the bony thorax.
In many cases of small aneurism, the oblique method of examination
should be employed. This has been well described by Holzknecht
andBeclere:4 "It consists in rotating the patient so that the rays
penetrate the chest obliquely. If the screen is placed on the left of the
patient and the tube on the right side, the pericardial shadow is bounded
by two clear spaces ; the retrosternal in front, and the retrocardiac
behind. In this position the inferior parts of the ascending and descend-
ing aorta can be seen, but the arch is hidden by the shadows of the
shoulder muscles and vertebral column.
"Now if the patient is rotated so that the rays penetrate the chest
at an angle of 45° forward and from left to right, the best position
is obtained. In this position the cardiac shadow is angular, the lusc
continuous with the diaphragm, the superior angle prolonged into a
vertical offshoot, caused by the superimposed shadows of the ascend-
ing and descending parts of the arch. In this position many cases
of supposed aneurism which show the marked aortic bulge in the
antero-posterior examination are shown not to be true aneurisms. In
suspected cases the examination is not complete until this method has
been employed."
Another important sign in the diagnosis of aneurism, first pointed
out by Walsham, consists in a change in the position of the heart, which
comes to lie more transversely, the right side being apparently pushed
down by the aneurism, with a tilting upward of the apex. Orton, like-
wise, regards the position of the heart as a very valuable and constant
1 Fortschritte auf dem Gebiete der Rontgenstrahlen, vol. i.
2 The American Journal of the Medical Sciences, October 1, 1903.
'Archives of the Kontgen Kay, August, 1905.
* Archives of Physiological Therapy, October, 1905.
FIG. 185. — Aneurism of the descending aorta (posterior view). Plate applied against the back
of the chest.
FIG. 186.— Photographic tracing of the same. Heavy lines, outlines of normal heart ; dotted lines,
dilatation of the descending (D-< ) aorta. Observe the horizontal position of the heart, due to
aneurismal pressure. A >• , ascending aorta ; T •< , transverse aorta.
APPLICATION OF THE X-RAYS.
sign. There are shadows that may exist either to the right or left of the
sternum which may be confounded with the diagnosis of aneurism.
1. Dilatation of the aorta (not aneurismal).
2. Displaced aorta ( dislocated).
3. Enlarged glands.
4. Neoplasms.
5. Pulsating empyema.
1. Dilatation of the Aorta (Fig. 187). — This condition is often con-
founded with aneurism ; the shadow cast will be on either side of the
sternum, the diagnostic point being that this pulsating shadow will dis-
appear between the pulsations (the diastole); because with the contrac-
tion of the aorta the shadow thrown will be smaller, or it will be com-
pletely hidden by the shadows cast by the sternum and vertebral column.
In this differentiation the fluoroscopic examination will prove more
useful than will the skiagraph.
2. Displaced Aorta. — This condition usually appears to the left of
the spinal column, a pulsating shadow being evidenced as far as five or
six inches to the left of the border of the sternum. This is a much
greater area than will be projected by the aneurism of the arch.
Abnormalities of the thorax and spine should be excluded.
3. Enlarged Glands. — Enlarged lymphatic and bronchial glands
cast scattered shadows, with absence of the characteristic expansile
pulsations.
4. Neoplasms. — Mediastinal growths, i. e., carcinoma and sarcoma,
can be differentiated, in that the latter cast darker or denser shadows,
the edges are hazy, indistinct, and uniform, and by the absence of ex-
pansile pulsations. Care should be exercised not to overlook transmitted
pulsations.
.">. rnlxatiii(i Empyema. — Pulsating empyema and other intra-thoracic
abscesses will be differentiated by the history, their location, and form.
Aneurisms of the abdominal aorta cannot be well demonstrated in
corpulent persons, owing to lack of contrast with the surrounding tissues,
as the shadows of the aorta and vertebrae superimpose, when skiagraphed
in either the ventral or dorsal positions. Lateral and oblique positions
are always advisable in skiagraphing this condition.
Aihcroma. — Atheroma and calcification of the blood-vessels can be
well demonstrated. (Fig. 188.)
CHAPTER V
APPLICATION OF THE X-KAYS IX DISEASES OF THE
ABDOMINAL OEGANS.
I. Alimentary System.
THE employment of the X-rays in the diagnosis of diseases of the
alimentary system has not as yet yielded the same results or been as
easy of application as is evidenced in diseases of the thoracic organs,
for the obvious reason that there exist no tissue differences.
There are various means of producing the necessary contrast or
difference between these soft tissues : (1) by gaseous distention, which
renders the stomach more translucent ; (2) by the introduction of
opaque instruments or mechanical methods ; (3) the bismuth subnitrate
method, by which the organs become more opaque ; (4) the transilluini-
nation method, which consists in illuminating the stomach by the intro-
duction of fluorescent materials, radium, etc.
A. CESOPHAGUS.
In order to examine this tubular muscular organ, for its position,
direction, etc., we may introduce a rubber sound with a metal point, or a
rubber tube filled with mercury or fine shot.
The fluoroscopic examination should be made with the patient in the
semi-recumbent or standing position, so as to prevent the superimposition
of the shadows cast by the vertebrae, heart, aorta, etc. Allow the shadow
to fall on a clear area and apply the fluoroscope obliquely over the right
and left sides, and also in the right and left antero-lateral positions.
Skiagraphic examinations should be made in the same positions
as in the fluoroscopic method, but the posterior position is more com-
fortable for the patient.
Stricture of the (Esophagus. — Constrictions of the oesophagus can be
best ascertained by the introduction of a bougie with metallic ends, or
by the use of a metallic sound, and viewing its passage in the above
manner.
Stenoses of the (Esophagus. — Barba1 reports two cases of oesophageal
stenoses, in which he made radioscopic observations. The chief point
brought out in his study is, that the ordinary methods of examination for
stenosis of the oesophagus (the most important of which is the use of
sounds) do not enable us to differentiate an organic stenosis of the canal
from a narrowing occasioned by the pressure of tumors in the mediasti-
num or by other causes of compression. The presence of these causes of
1 Riforma Medica, December 23, 1905.
336
DISEASES OF THE ABDOMINAL ORGANS. 337
compression in the mediastinum is very difficult to determine by physical
examination, and only the Rontgen rays enable us to make an accurate
diagnosis. In the two cases reported, radioscopy showed that the ste-
nosis, in each, was caused by the compression of tumors in the posterior
mediastinum. In both cases, the radioscopic examination was aided by
the passage of a sound filled with a concentrated solution of bismuth
subnitrate, or else provided with a metallic stylet.
Divert ieul urn. — A diverticulum may often be diagnosed by the above
method. The bougie or sound may not enter into the pouch, however,
when it becomes necessary for the patient to drink bismuth suspended in
water ; one to two parts to 100 parts of water. When possible, skiagraphs
should be taken, as it requires but a few minutes and the operator does
not endanger his hands.
Tumors. — Dr. Hugh Walsham l reports two cases of carcinoma of the
oesophagus. He says that, " we must not expect so definite a shadow
as seen in cases of aortic aneurism." The diagnosis of an oesophageal
growth is more difficult than that of aneurism.
Before the screen examination he gives the patient two drams of
carbonate of bismuth, suspended in a little milk or mucilage. This
will map out the seat of the obstruction, whilst the topography of the
cesophagus can be traced by a metallic bougie.
B. STOMACH : SIZE. SHAPE, AND POSITION.
Examination by Aid of Gaseous Distent ion. — This method consists in
distending the stomach by the ingestion of certain chemical agents
which upon reaction result in the evolution of gases. The chemical
most frequently employed is Seidlitz powder. Upon the fluoroscope the
stomach appears as a dark area, upon the negative as a light area. This
method causes the distention of the stomach walls and the displacement
of the surrounding organs, so that little information can be gained by
this procedure.
Mfflmnirtil Method. — In this method, a rubber tube containing a
spirally coiled wire is introduced through the mouth into the stomach.
Turck's gyromele is a device employed to determine the outline of the
stomach by iluoroscopic means.
Neumann 2 uses a Politzer rubber bulb with a soft stomach tube for
aspiration of the stomach contents. After the stomach has been emptied
and a clean bulb attached to the tube, it is possible to determine the out-
line of the stomach with great precision, by listening to the sound when
air is forced from the rubber bulb into the stomach. A small amount of
air is sufficient for the test, thus avoiding distention of the organ.
In every instance radioscopy confirms the findings of auscultation as
1 Archives of the Rontgen Ray, April, 1903, p. 114.
1 Journal of the American Medical Association, July 23, 1904.
;;;;s ELECTRO-THERAPEUTICS.
the bulb is compressed and the air forced into the stomach. This test
is useful in dubious cases in the differentiation of gastric from intestinal
stenosis.
The Hisiniith Xnl> nit rate Method. — This method consists of the inges-
tion of subnitrate of bismuth, either mixed with food suspended in water,
or administered in capsule form. This method was introduced and first
employed by MM. J. Ch. Roux and Balthazard.1 In 1897, F. Williams,
of Boston, applied this method most extensively. The employment of
the bismuth test, at the present time, is universal.
Technic of the Bismuth Method. — Chemically pure bismuth subnitrate
should always be employed. Cases of poisoning, though not fatal, have
been reported where the impure salt was taken. The stomach should be
empty, no water should be partaken of, and the bowels should be
thoroughly purged twenty-four hours prior to the examination. Roux
and Balthazard use bismuth subnitrate in the proportion of 0.20 per cubic
centimetre. Williams has administered as much as one ounce of bismuth
emulsion. Hultz gives the patient the bismuth in a pint or more of
milk. Boas advises the partaking of bread and milk or of potato soup,
into which has been stirred one ounce, or more, of the bismuth salt.
Fluoroscopic Examination. — Williams recommends examination of the
patient with the fluoroscope, as " the stomach moves during respiration,
and therefore its outlines are blurred on the radiograph." 2
Holzkuecht and Brauner 3 assert that the passage of a bismuth tablet
into the stomach can be traced and its expulsion watched, and that "the
action of massage on the stomach, displacement of the organ during
respiration, etc., can be better studied by a fluoroscopic examination."
1 do not employ the fluoroscope, as it is dangerous alike for the
operator and patient, and because the taking of a skiagraph is only a
question of seconds. A severe X-ray dermatitis occurred in the hospital
while the attending physician and my assistant were examining such a
case with the fluoroscope.
Skiagmphic Examination. — The patient lies over a 14 x 17 inches
(35 x 43 cm.) plate, a penny being placed over the umbilicus and then
secured by adhesive plaster. The patient must remove his clothing.
The ventral or dorsal decubitus, sitting, standing, or semi -recumbent
position may be employed.
In the ventral position, the anterior wall of the stomach comes in
contact with the plate. In the dorsal position, the posterior wall will be
nearer to the plate. In the sitting or standing position, the weight of
the bismuth will depress the lower border of the stomach, so very impor-
tant in the study of cases of gastroptosis. The ventral position is to be
'C. R. tie 1'Academie des Sciences, 1896. Bouchard, Trait*- de Radiologie Mt'di-
cale, p. 995.
2 William*, The Rontgen Rays in Medicine and Surgery, p. 367.
•Wiener klin. Rundschau, 1905, vol. xliv. p. 1971.
DISEASES OF THE .ABDOMINAL OIHJAXS. 339
preferred, because the bismuth adheres upon the anterior gastric wall.
presenting clearly the fundus, the cardiac end, and the general contour
of the organ.
The Crookes tube should have a high vacuum. The anode is placed
perpendicularly over the third and fourth lumbar vertebrae, at a distance
of 20-25 inches (50-63 cm.) from the plate.
Time of Exposure. — The time of exposure should be as short as
possible, because of the danger of blurring, occasioned by peristalsis and
from the diaphragmatic movements. The exposure can be made suffi-
ciently short either after a full inspiration or after a forced expiration.
Narcotics to lessen peristalsis are seldom necessary. In corpulent
subjects, especially when the apparatus is inadequate, the intensifying
screen can be used ; but when a fine negative, full of detail, is to be
brought out, the granularity produced by the screen is a serious disad-
vantage. I employ a high-vacuum tube, with an electrolytic interrupter,
duration 3 to 15 seconds, thus allowing the patient to hold his breath
after a full inspiration.
Dr. Henry K. Pancoast 1 reported the cases of 40 patients, suffering
with gastric or gastro-intestinal symptoms. The technic he employs is as
follows: " Bismuth subnitrate held in suspension in mucilage of acacia
(proportion of two ounces of the powder to the pint) (or 64 grams to
one-half litre) was either poured into the stomach through the stomach
tube or was swallowed by the patient ; the latter method was principally
used. The bulk of the bismuth-acacia mixture varied from six to
thirty-two ounces (190 to 700 grams). Immediately after the bis-
muth had reached the stomach the pictures were taken, the patient
being in the standing position, and the plate in contact with the anterior
abdominal wall.
uThe rays were thrown posteriorly, the patient holding the breath
during full inspiration for an exposure of eight to fifteen seconds ; thus
eliminating blurring by respiratory and peristaltic movements. After
the picture has been taken, it is advisable to siphon the bismuth mixture
out of the stomach.
"In several cases as much as four ounces of bismuth was left in the
stomach with no unpleasant symptoms ; but on the other hand, six cases
showed toxic symptoms after this amount had not been removed. For
the purpose of obtaining the lower border and segment of the stom-
ach, six ounces of the emulsion containing one ounce (32 grams) of
bismuth is sufficient. This amount has been left in the stomach with
no bad effects."
Dr. Joseph Sailer, of Philadelphia, has reported untoward symp-
toms following the administration of bismuth. The symptoms varied,
but cyanosis, dyspnrea, nausea, etc., were noted in several patients. The
1 University of Pennsylvania Medical Bulletin, August, 1906.
340 E LK( T K( )-T II I • I! A 1 > K I ' T I ( 'S.
presence of antimony and arsenic was excluded, and it was thought that
the rays had a peculiar action on the trypsin, with disintegration of the
subuitrate. Undoubtedly the action only started after the bismuth had
been for some period in the intestine, and had been acted upon by the
ferments present.1
Dr. Henry Hultz2 asserts that: ;' Immediately after the bismuth
nieal two dorso-ventral exposures are to be made, one in the standing or
sitting position, and one in the recumbent position. Assuming that the
first Eontgenographs were taken at noon, the next one should be mad*-
about six hours later, the patient having partaken of neither fluids nor
solids since the noon hour."
He employs the following technic : A 16-inch coil, Wehnelt inter-
rupter, but one intensifying screen, a strong tube yielding Walter six
rays, placed 20 inches (50 cm.) from the plate. He succeeded easily
in skiagraphing the stomach of a medium-sized subject in one second,
and obtained a very good plate taken under the same conditions but
without the use of intensifying screens in three seconds. He prefers an
exposure of ten seconds without the screen.
Holzknecht and Brauner 3 recommend the following technic : The
views are taken standing and reclining and during inspiration and expi-
ration ; the most important information generally being obtained by radi-
oscopy. To examine the standing patient, the Eontgen tube and the fluo-
rescent screen are suspended by weights from a wooden standard, parallel
to each other. The patient swallows a tablet of bismuth and, after its
course has been traced, he drinks 50 grammes of water into which 10
grammes of bismuth have been stirred. After the findings of this test
ha\ i' been noted, the patient is directed to drink a mixture of 4 grammes
of tartaricacid and 5 grammes of sodium bicarbonate. On the following
day, the patient is given 400 grammes of milk gruel containing 35 grain nu-s
of bismuth while he reclines on the left side, with the Eontgen tube applied
to the dorsal aspect of the body ; subsequently he is examined when
lying on the right side and again when in the dorsal posture.
Heinmeter of Baltimore4 has recently used the following method :
"The dilated stomach is coated internally with bismuth subnitrate by
means of a powder blower, after which its outline can be distinctly
recognized through the fluoroscope."
Eieder5 says: "Let the patient swallow a mixture of 10 or 15 grammes
of bismuth subnitrate suspended in 50 c.c. of water, and observe deglu-
tition by the fluoroscope. The act of swallowing may be studied more
leisurely if a small quantity of the bismuth salt be given in a pill. For
'University of Pennsylvania Medical Bulletin, August, 1906.
1 Transactions of the American Rontgen Ray Society, 1906, p. 45.
Wiener klin. Rundschau, vol. xliv. p. 1971.
4 Diseases of the Stomach, p. 640.
• Miinchener merl. Woch., epitome in Medical Record, Feb. 10, 1906.
DISEASES OF THE ABDOMINAL ORGANS. 341
more exact observation, a bismuth meal is employed. Thirty grammes
of bismuth subnitrate are mixed with a little milk and this is then added
to 300 or 400 grammes of flour gruel, sweetened with milk-sugar to
obviate constipation."
Dalton and Reid ' obtain the position of the stomach by the employ-
ment of an O2sophageal tube containing bismuth.
The TransiUumination Method. — This method consists iu introducing
some radio-active substances, or an electric light or air into the stom-
ach, and then viewing the viscus with the fluoroscope or by taking a
skiagraph.
Max Einhorn 2 remarks that : " TransiUumination into the stomach
can be demonstrated with Kahlbaum's barium platino-cyanide, or by
means of a photographic plate. The latter method has the advantage
that no dark room is required and that the result obtained is visible to
every one, leaving nothing for imagination or speculation.
"In order to procure a radium photograph of the stomach I pro-
ceed as follows : The patient should be in the fasting condition (empty
stomach). The radio-diaphaue, containing 0.05 gm. (or more) of pure
radium bromide, is introduced into the stomach. The patient occupies
a recumbent position, and a photographic plate is put directly over the
gastric region and allowed to remain there for one or two hours, accord-
ing to the requirement of the case. The plate is then removed and the
radio-diaphaue withdrawn. The plate is then developed.
''Contrary to my expectations, radium enclosed in a quartz flask
failed utterly to transmit the photographic rays, while thin ordinary
glass answered the purpose very well.
"The shortest time for obtaining a photographic outline of the
stomach is one hour ; in less than an hour hardly anything is visible ; one
and a half to two hours bring out the outlines more distinctly. Insuffla-
tion of air into the stomach occasionally aids in obtaining a good picture.
u A few of the better radium photographs in my possession are
reproduced herewith and show that transillumiuation of the stomach by
means of radium is feasible. It is even possible to recognize an area of
light which had to pass through the posterior wall of the stomach and
the back of the thorax. One of my negatives shows a key which was
hanging below the left scapula and was thus photographed by the trans-
mitted light troui the stomach.
"Considerable sized tumors of the stomach or liver can, sometimes, be
recognized on the picture by the diminished trauslucencj'. Thus far, how-
ever, I have not succeeded in obtaining definite outlines of the growth."
Sinclair Tousey s finds the radio-active and fluorescent solutions, as
1 Lancet, April 1, 1905.
* Archives of Physiological Therapy, Sept. 1905, p. 115.
3 New York Medical Journal, May 21, 1904.
;>t_' ELECTRO-THERAPEUTICS.
prepared by him with quinine bisulphate and fluoresciu. are innocuous
when given by the mouth or subcutaneously, but do not produce singly,
or in combination, sufficient fluorescence to be of value in the examina-
tion of the stomach without the use of some additional light to excite
their fluorescence. In some cases, however, they will be of the greatest
assistance in the diagnosis of stomach lesions, and at times of advantage
in X-ray treatment.
In cases of gastroptosis, I have had experience with this method at
the Philadelphia Hospital, where it has not afforded me any satisfaction.
C. THE CLINICAL APPLICATION OF THE BAYS.
Stomach. — The behavior of the stomach during digestion has been
studied with the X-rays on cats and dogs by W. B. Cannon.1 The out-
line of the stomach was reproduced on the screen by giving the animal
small, but frequently repeated doses of bismuth subuitrate. After a
plentiful feeding the viscus was observed to be considerably larger,
gradually diminishing in size as the process of digestion proceeded ; at
the same time, the cardiac end acted as a reservoir for the ingested food
while the pyloric region presented marked peristaltic movements. It was
further noted that liquids soon pass from the stomach, while solids remain
there for an indefinitely longer period.
The activity of the digestive juices can be determined by giving the
patient a small quantity of bismuth iu a small capsule of gold-beater's
skin or gelatine. As the patient swallows, the shadow of the opaque
spot is demonstrable on the fluorescent screen so long as the capsule is
intact. When the gold-beater's skin has been disintegrated by the action
of the digestive juices, the particles of bismuth become diffused and
the black spot is no longer seen on the photographic plate or screen.
The time occupied by the digestion of the capsule is a measure of the
activity of the stomach and the quality of the peptic juices.
Repeated examinations will reveal the time that is required to empty
the contents of the stomach. The bismuth accumulates near the py-
loric end aud passes to the intestines. This consumes a period of about
6 or 7 hours.
Position of tfie Stomach. — Butler 2 asserts that : " The lower border of
a normal but much distended stomach may be found at the level of the
navel. If below the umbilicus the condition is abnormal." Quain believes
that : " It is generally a little (half an inch to an inch) above the highest
point of the iliac crest, and about opposite the disk between the third
and fourth lumbar vertebra."8 The shadows of the normal stomach
being approximately known, any increase or decrease in the interval from
1 American Journal of Physiology, vol. i., May 1, 1898.
" I >iagnostic8 of Internal Medicine," p. 543.
1 Quain's Anatomy, vol. i., p. 679.
DISEASES OF THE ABDOMIXAL ORGANS. 343
the umbilicus will inform the skiagraplier of any abnormal gastric posi-
tion. When the tube is at a distance of 20 inches (50 cm.) the distortion
will be very small.
Holzknecht,1 however, believes that: <;A stomach which is of nor-
mal size and situated in the normal position is rarely visible ; but when
gastroptosis occurs the stomach becomes visible. When the walls of the
stomach are infiltrated with carcinomatous deposits, abnormalities in the
contractions of the organ are readily observed, when food mixed with
bismuth is given to the patient."
Rieder had large quantities of bismuth mixed with the food and
given in eneinata. and then examined the patients with the screen. His
deductions are contrary to the teachings of text-books. When the stom-
ach is full, the pylorus, for instance, may be found to the left of the
median line. The full stomach lies vertical or diagonal, never horizontal.
There is always an accumulation of gas to be noted in the upper part of
the fuudus during stomachic digestion. He also observed interesting
facts concerning the motor functions of the stomach and of the various
parts of the intestines.
Gastroptosis. — This condition is best shown skiagraphically (Fig. 189)
while the patient is sitting or standing, or in both dorsal and ventral
positions ; otherwise the condition may not be detected. Often there
will be a difference in the position of the stomach depending upon
whether the skiagraph is made after full inspiration or after full
expiration.
The form, size, and shape of the stomach can be ascertained by a
careful study of the normal stomach and then by comparing it with
any supposed abnormality, being careful that the technic is identical in
each case.
G. Leven and G. Barret2 studied the outlines of the stomach by
following the path of a bismuth pill, and came to the conclusion that :
'• Our ideas of the shape of the stomach in life demand revision, also that
the lower curve of the organ does not sweep across the abdomen, but that
the cardiac end has a small amplitude from which the line runs inward,
then sharply down to, or below the umbilicus, and as sharply up again
towards the pylorus.
1 i The form of the stomach has therefore not the regular lines hitherto
drawn, and such as we see after death ; but the superior part is dimin-
ished in size by the dilatation of a tube-like process going downward
from the lower border towards the navel."
The authors aver that in the normal stomach this tubular part re-
ceives fluids till it is full. When more liquid is added, the tube begins
to expand, so that the level of the liquid remains constant for a time.
when the latter finally invades the rest of the cavity of the stomach. On
1 Berliner klin. Wochen., February 28, 1906.
2Presse Medicale, Paris, January 31, 1906.
344 ELECTRO-THEKAPEUTICS.
the other hand, in a dilated stomach the authors' characteristic method
of filling is not evident ; the fluid collects in the lower curve of the
viscus, and the level rises slowly and regularly.
Stenosis of thePyloric End. — \Vhen the average time which is neces-
sary for the passage of the food (bismuth) for a normal stomach is pro-
longed (over 0 hours), it is indicative of stenosis of the pyloric end, or
of gastric insufficiency, either caused by dilatation or atony. The ski-
agrapher should make several exposures to determine the time required
to empty the stomach.
D. INTESTINES.
If only the stomach is to be examined, the bismuth can be pumped
from the stomach after the skiagraphs are made ; if allowed to remain
for three, six, or eight hours, the bismuth passes into the intestinal canal
in 15 or 20 hours. It is possible to obtain skiagrams of the colon and
other portions of the intestinal tract.
Eieder ' declares that: "For the large intestines, rectal injections
may be used ; and that by the use of one litre of fluid containing bismuth
it is possible to insure penetration as far as the ileo-csecal valve."
Sounding ami Radiography of the Large Intestine. — Schiile2 has been
testing various sounds, including Kuhn's flexible spiral sounds and also
the Kassel soft tubes with flexible metal guide, terminating in a button
2Ho 3* inches (5.5 to 8 cm.) in circumference, thus obviating all danger
of perforating the intestinal wall. His conclusion is, that no convincing
proof has been obtained, to date, that a sound has been successfully
passed into the descending colon, to say nothing of the transverse portion.
The innumerable folds, windings, and swellings of the intestine render
it impossible to determine whether an obstacle to the progress of the
sound is of a natural or a pathological nature. On the other hand, the
direct visual inspection of the rectum and the sigmoid flexure by the
J. Schreiber and H. Strauss technic is perfectly reliable. Schiile found
that "high injections" were practicable, the best vehicle being oil. An
injection in the knee-elbow position of 300 to 400 c. c. of oil with 125
gm. of bismuth subnitrate, followed by radiography, showed that the oil
had penetrated to the ileo-caecal valve. In two of the patients there was
pronounced enteroptosis, the transverse colon in one hanging suspended
like a garland from the two points of attachment at each end, the centre
reaching far below the upper plane of the pelvis. On account of the
small amount of the oil injected, and the fact that the subject was in the
knee-elbow position at the time, the injection could not have been
responsible for the sinking of the intestine. The radiograms show per-
fectly the topography of the colon for its entire extent. They also prove
'Munch, med. Woch.. epitome in Medical Record, February 10, 1906.
'Archiv f. Verdauungs-Krankheiten, Berlin, last indexed page 863.
DISEASES OF THE ABDOMINAL ORGANS. 345
that the ileo-ca?cal valve is always continent. Tests on the cadaver
showed that extreme pressure, beyond what would be possible in the liv-
ing subject, is necessary to force it open.
Intestinal Obstruction. — Rudis-Jicinsky * reports two such cases : one,
a boy of 10, swallowed a tin whistle, and the usual symptoms of intestinal
obstruction followed. The site of the occlusion could not be determined
in the usual way. On X-ray examination, the whistle was found at the
junction of the small and large intestine. On the third day the whistle
was passed. A boy, of 12, had symptoms of obstruction and was in a
serious condition. The first diagnosis was one of invagination at the
lower portion of the ileuin. On X-ray examination an obstruction was
found in the small intestine under the umbilicus. Laparotomy was
performed, and the obstruction was discovered to be caused by a small
wooden whistle. The author has produced artificial obstruction in dogs,
and then traced a specially prepared pill to the point of obstruction by
means of the X-rays. The diagnosis in such cases was verified.
I believe that the exact location of the obstruction or of a particular
portion of the intestine cannot be determined because of the superimposi-
tion of the coils of the intestines ; but an approximate location in the
abdominal cavity can be ascertained by the direction of the passage
traversed by a specially prepared opaque pill.
An important case coming under my care was that of a man, 42 years
old, suffering with symptoms of intestinal obstruction. An X-ray exami-
nation was conducted, revealing a large-sized enterolith. The seat of
obstruction was at the ileo-caecal valve. An operation was performed and
the obstructing mass removed. Three years prior to this, the patient had
been a sufferer from biliary calculi, but refused to undergo an operation
at that time. It is very likely that this intestinal calculus was primarily
a biliary calculus which passed into the intestines and there remained
for a period of three years, gradually becoming larger and larger. The
exterior of this stone was uniformly softened, while the centre was ex-
tremely dense.
Following a biliary colic, it is always advisable to ascertain, by an
X-ray examination, if calculi have been passed into the intestinal tract.
Rrctal Imperf oration. — The following case is illustrative of this con-
dition. A child when born was observed to have an imperforate anus,
with an absence of rectal tract. A consulting surgeon suggested an
inguinal colostomy. The child lived with this annoying condition for
twelve years. It was then decided to try further surgical means. I
proceeded to examine the case, as follows : Into the rectum through the
artificial anus, I injected an emulsion of bismuth subnitrate, at the same
time passing a steel sound through the anus to the point of obstruction
at the lower end of the rectum. A skiagram proved the obstruction to
1 Medical News, Oct. 5, 1901.
: : ; I • • ELECTRO-TH I •: I ; A I ' KUTICS.
be two inches in length. The upper part of the rectum was anastomosed
to the iletiin, after first removing the coccyx. For ten subsequent days
the fiecal material passed through the newly constructed channel.1
Abdominal New Groicths. — The recognition of neoplasms located in
the abdominal cavity, by means of the X-rays, is a rather difficult task. If
the tumor is dense, it may cast a shadow upon the screen : if more or less
soft, no shadow will be cast. These pathological masses are frequently
recognized by their effects upon adjacent structures, as in a displacement
of the diaphragm, liver, etc. I have made numerous examinations of
suspected carcinomata of the stomach, some of the results being favor-
able, though the vast majority proved unsatisfactory. It must not be
forgotten that in carcinomata of the pylorus there is some interference
with the movement of the diaphragm on that side, the latter not de-
scending to so low a point as in the normal.
E. LIVER.
The correct general outline of the liver may be obtained by combin-
ing a fluoroscopical and physical examination. The upper or convex
border of this organ can very readily be ascertained by the fluorescent
screen, while the lower and concave border is best outlined by palpation
and percussion. Echiuococcus cysts, when located in the immediate
vicinity of the upper border, may be easily diagnosticated by this means.
When examining this organ, it is always advisable to have the adjacent
portion of the stomach and intestines filled with air or gas, so as to more
readily define the lower border of the liver. A skiagraphic examina-
tion, especially in adult cases, is very unsatisfactory. In young children
better results are obtained.
Biliary Calculi. — The results of a skiagraphic examination in this
condition depend to a very large extent upon the chemical composition
of the calculus. Upon the negative, only a very light shadow of the
stone is thrown and can, by a very careful examination, be seen only
with difficulty, even though it is of rather large size. Occasionally large
calculi can even be detected in the heptic duct. Calculi composed of
bilirubin and certain other substances are not very permeable to the rays.
Those calculi consisting of cholesterin, being largely composed of calcium
salts, show more distinctly on the negative than do the others. Early
experiments upon gall-stones have been reported by Neisser, Goodspeed,
and Cattell.1
A fluoroscopic examination for biliary calculi is thoroughly unsatis-
factory, and until a skiagram is taken no absolute diagnosis should be
rendered. The method I employ is as follows : The patient rests upon
the table (upon his back) with the head-end raised and the foot-end
1 For full report of this case see Hemmeter, " Diseases of the Intestines," vol. ii.
'Medical News, Feb. 15, 1896.
DISEASES OF THE ABDOMINAL ORGANS. 347
depressed, the whole top of the table slanting in a position of 45°. The
abdomen should be bared of clothing and lightly bandaged, in order to
lessen the peristaltic and respiratory movements. The patient is slightly
turned toward the right side. A sensitive plate of proper dimensions is
firmly fixed by a clarnp and bracket to a stand in front of the affected
region. A tube of the highest penetrative power is placed under the
table, with the target pointing in the direction of the gall-bladder, or the
patient may be placed in the ventral position, with the tube above. The
shoulders should be elevated, so as to bring the shadow of the gall-
bladder outside of the shadow of the lower lobe of the liver. The time
of exposure varies, depending upou the thickness of the part to be
traversed by the rays.
The presence of calculi is very difficult to detect, because their
chemical composition allows the passage of the rays, they being largely
composed of the hydrocarbon cholesterin. Moreover, the shadow of the
calculus is very liable to be obscured by the shadow of the contents of the
gall-bladder. When the stone finds its way into the intestine and there
becomes coated with calcium phosphate and carbonate, the shadow cast
will be more definite, as the latter salts offer a resistance to the passage of
the rays.
Dr. C. Thurston Holland * reports the following case : "A woman,
of 45, had two attacks of severe abdominal pain, one accompanied by
slight jaundice. A tumor was discovered in the right abdomen and
diagnosed as a distended gall-bladder.
" The radiograph was taken with a 12-inch coil and a mercury break.
Current employed was 24 volts and 10 amperes. A Cox regulator tube
was used with a spark-gap of 3 inches (7.5 cm.) and through a pressure-
tube apparatus designed by the author. An exposure of two minutes
was given. The stones, each three-quarters inch (2 cm.) long, were
lying end to end, from before backward, and cast annular shadows with
the patient lying with the abdomen downward on the plate. A second
radiograph, taken with the woman on her back, also showed the same an-
nular shadow, but, the stones being further from the plate, the shadow
was larger and not so well defined. A surgical operation disclosed two
stones of the usual type ; one weighed 100 grains (6.4 grains), the other
113 grains (7 grams), which were composed of concentric laminse of bile-
pigment and cholesteriu. Calcium was present, but greater in quantity
at the periphery, where the stones were much harder.
"The success attained in this case was due to the presence of lime-
salts, and to the employment of a pressure-tube apparatus which fixed the
part and cut off all except a small central stream of X-rays, and most of
the secondary rays, and thus prevented fogging of the plate and blurring
of the shadows."
1 Archives of the Rontgen Ray, Feb. 1906, p. 241.
348 ELECTROTHERAPEUTICS.
Dr. Carl Beck ' made 97 skiagraphs of 28 suspected cases of cholelithi-
asis ; in 19 of those cases the presence of biliary calculi was ascertained
by operation. In only two of these 19 cases was he able to obtain
shadows on the plates. Later, had good skiagraphs of gall-stones ex-
hibited at a meeting of the Academy of Xew York, held in January, 1901.
For cutting off the secondary rays I think the compression dia-
phragm is at times useful. I have had cases where the plates showed
shadows of the distended gall-bladder, but not of the calculi, because
fluid offers great resistance to the passage of the rays. In most instances
the shadow will be too low when the calculi have passed into the intestine.
Recently, at the Philadelphia Hospital, I was asked to take a skia-
graph of a very emaciated patient. I found the shadows of two renal
calculi in the left kidney, and a round, small stone under the twelfth rib,
on the right side, and a large one in the pelvis of the right kidney. The
latter was subsequently removed, but the former defied surgical detection ;
although I am sure the round shadow was that of a biliary calculus.
I do not think the fluoroscope is as reliable in these cases as is the
skiagraph, provided that in the latter the time of exposure is correct
and the subject is a suitable one. I never have had a case of this kind
where the diagnosis was solely made by the aid of X-rays and confirmed
by operation.
F. PANCREAS.
On account of its peculiar anatomical situation, this organ cannot be
easily recognized by an X-ray examination. In one instance I was able
to obtain a shadow of this organ on a skiagram. The patient was unusu-
ally emaciated, and from the clinical signs and symptoms, a diagnosis of
carcinoma of the pancreas had been made. The patient was prepared as
usual, and subjected first to a fluoroscopic and then to a skiagraphic
examination ; a very faint shadow was discoverable, superimposed upon
the one produced by the stomach. Since then, I have at frequent inter-
vals tried to make similar examinations on different subjects, but have
never succeeded in repeating or reproducing what then was considered a
rather satisfactory image of this organ. In this instance I distended the
stomach with air in order to allow as clear a field for this organ as possi-
ble. I am of the opinion that this fairly good result was due to a peculiar
abnormal principle which is opaque to the rays, and whose nature thus
far has not been determined.
G. SPLEEN.
This organ is easily shown in children by means of the fluorescent
screen. In adults the skiagraph only is satisfactory. The patient is best
examined in the recumbent position, being slightly turned toward the left
1 New York Medical Journal, January 20, 1900.
DISEASES OF THE ABDOMINAL ORGANS. 349
side. The sensitive plate is placed in front of the patient in the region of
this organ, with the tube below or behind. In those who are corpulent,
it is best to place the patient in the prone position with the plate beneath
and the tube above.
Just prior to the examination, the large intestine should be distended
with air. This procedure will serve to displace all of the adjacent organs,
and at the same time permit the production of contrast between the
lower edge of the spleen and the neighboring light area produced by
these distended organs. The upper border is in relation with the
diaphragm, and, in order to avoid the blurring of the image, the
rays should be permitted to emanate from the tube only during inter-
vals when the patient has ceased breathing. The screen examination
of the spleen in a child demonstrates the fact that the anterior border
moves slightly more than the posterior, as though this organ were turning
on its long axis.
II. Genito-Urinary System.
The great strides made in surgery and surgical bacteriology within
the past twenty years have effected a complete change in the conceptions,
the prognoses, and the treatment of many surgical affections. Neverthe-
less, prior to Rontgen's discovery positive diagnoses of many diseased
conditions were manifestly impossible. The truth of this statement gains
added support in the genito-uriuary field. Many of the pathological
states of the kidney could be ascertained only by cutting down upon
that organ, especially in suspected cases of calculi, displaced kidney,
hydrouephrosis, pyonephrosis, etc., frequently forcing upon the surgeon
the serious embarrassment of operating upon some distant organ, wherein
pain was experienced by the patient, the result of reflex irritation. In
the same manner invaluable assistance has been lent by this new aid in
the diagnoses, in many of the more obscure diseases and affections of
the ureters, the bladder, and the prostate gland.
The shadows of the kidneys are most difficult to show on the negative.
The upper portion of the right kidney presents an added obstacle in the
superimposed shadow cast by the liver. The affection of the kidney
most frequently brought to the attention of the skiagrapher is that of
suspected calculus.
A. ORDINARY METHODS.
It is common experience that a case of renal calculus will be evi-
denced by a few of the classical signs and symptoms which not infre-
quently confuse the mind of the diagnostician. Thus, Henry Morris,
the eminent English surgeon, found renal calculi in two-thirds of his
suspected cases. Brewer1 mentions two instances where distinguished
1 Annals of Surgery, May, 1901.
350 ELECTROTHERAPEUTICS.
surgeons diagnosed stone in the kidney as cases of appendicitis.
Bevan and Franks made the same error, the former suspected a case of
appendicitis, and the latter ovarian disease. Jacobson1 mentions at
length the differential diagnosis between incipient spinal caries and
renal calculi.
Prior to the discovery of the X-rays, the most advanced studies in
kidney affections were due to ureteral catheterization, introduced by
Howard A. Kelly, of Baltimore, and to Harris's invention of the segre-
gator, for drawing off separate urines from each kidney. The chief clini-
cal aids may be stated as follows :
General symptoms, chemical, macroscopic, and microscopic examina-
tions of the urine with the addition of the centrifuge, percussion over the
affected side, the ureteral catheter and sound, inspection of the bladder
and ureteral orifices, and the segregator. With the possible exception of
the actual finding of a stone in the urine, we are not absolutely convinced
whether we are to deal with a nephritic calculus, if there is one or many,
if it is in the ureter, or if one calculus is in the ureter and another in
the kidney. If upon exploration only one stone is found, it is not
conclusive evidence that others are not present, either in the ureter or
some other part of the kidney.
B. PENETRABILITY OF CALCULI.
The most useful and accurate method thus far advanced for the
detection of renal calculi is by means of the X-rays. Chapius and
Chauvel,* in Paris, were the first investigators to study renal calculi
by the aid of the X-rays. They mention that calculi, whose chemical
structure is uric acid, urates, or phosphates, cast shadows slightly less
opaque to the rays than do compact bones. As the kidney substance
is not so easily penetrated by the rays as muscular tissue, it would
be natural to infer that the negative would show a lighter shadow than
the adjacent tissue which is more penetrable by the rays. Dr. Mac-
intyre,3 of Glasgow, also made early and successful investigations on
renal calculi.
Dr. James Swain,4 of Bristol, was the first to detect the different
degrees of penetrability of different calculi. His method of investi-
gation was as follows : On a sensitive plate he placed different calculi
of the same dimensions, exposing them for periods of one, two, four,
eight, and sixteen minutes. He early observed that "the more dense
the object the deeper was the resulting shadow," and that the law first
laid down by Rontgen was not true of different calculi. If tabulated
1 British Medical Journal, January, 1900.
'Academic cle Mldecine, 21, iv., 1896.
"Lancet, July 11,1896.
4 Bristol Medico-Chirurgical Journal, March, 1897.
DISEASES OF THE ABDOMINAL ORGANS. 351
in the order of their highest specific gravity, their greatest permeability
to the rays, and their greatest density of shadow, the results attained are
as follows :
SPECIFIC GRAVITY. PERMEABILITY TO THE RAYS. DENSITY OF SHADOW.
1. Oxalate of calcium. 1. Biliary. 1. Oxalate of calcium.
2. Uric acid. 2. Uric acid. 2. Phosphatic.
3. Phosphatic. 3. Phosphatic. 3. Uric acid.
4. Biliary. 4. Calcium Oxalate. 4. Biliary.
Dr. Swain exposed one calculus of each type with a section of rib
and a piece of kidney. An increased time of exposure produced a
fainter shadow, so that at the end of the ''sixteenth minute," the calcium
oxalate and phosphatic calculi, with a faint trace of rib, showed on the
negative. The conclusions reached from these experiments are that the
shorter exposures are better than long exposures, also that calcium
oxalate and the phosphatic calculi show most plainly.
If the exposures are too prolonged, the less dense calculi will pro-
duce no shadow. Likewise a calculus of uric acid gives a fainter shadow
than the rib, and in an eight minute exposure much less of a shadow than
that of a rib covered partially with kidney. Thus we conclude that a
calculus of uric acid is difficult of detection.
The most accurate method is that advanced by Eontgen. The many
errors made in the diagnosis or elimination of renal calculi were all due
to a faulty teohuic, to an incorrect development of the plate, or to an
erroneous interpretation of the negative. It is imperative to produce a
skiagram that has detailed shadows of tissues less opaque than the least
opaque calculus.
By means of the X-rays we are enabled to diagnose hypertrophy,
atrophy, displacement, tumors, hydronephrosis, pyonephrosis, and peri-
nephritic abscess. Hypertrophy is a condition which is always unilateral,
and, by comparison with the kidney of the opposite side, is readily diag-
nosticated. The above mentioned conditions, however, can only be
demonstrated in those subjects not too corpulent, when the exposure has
been sufficiently long, and when the exposed negative has been properly
produced by the developing process. The margin of the hypertrophied
kidney is clear and sharp. If this sharp margin is irregular in any of
its part, the examiner has found a neoplasm springing from the cortical
area. Atrophy of the kidney is more difficult of diagnosis. The most
usual cause is the existence of a calculus.
Displacement of the kidney is a common affection, its occurrence
being indicated by a knowledge of its normal relations and by a com-
parison with the shadow produced by the abnormal position. Perine-
phritic abscess can also be diagnosticated by the rays. The conditions
favorable for best results are found in patients of slight build, and when
the intestinal canal has been thoroughly evacuated.
352 ELECTRO-THERAPEUTICS.
In hydronephrosis and pyonephrosis, a shadow showing involvement
of the pelvis of the kidney may be observed. This condition is more
readily diagnosticated from a good negative than is a periuephritic
abscess.
Cases of gonorrhoea, with pus in the region of the kidney, have been
diagnosed with the X-rays; the skiagram showing an irregular mass on
the convex border of the shadow produced by the kidney, the shadow
of which is denser than that obtained from the normal kidney* itself.
C. TECHNIC OF RENAL SKIAGRAPHY.
When renal calculi cannot be diagnosticated by skiagraphy, the
chief causes will be found to be under- or over-exposure and improper
development of the exposed plate, or because the tube lacks the necessary
high penetrative power.
Preparation of Patient. — In taking a skiagram see that the patient is
briskly purged, and that he abstains from all food for at least 24 hours
prior to the time of exposure ; in the interval, give him a high enema.
The bladder should be emptied just before the time of taking the
picture ; if this be impossible he should be catheterized. The patient is
placed in the recumbent posture, and the knees flexed, so that the normal
lumbar curve will come in closer contact with the plate. Two plates of
sufficient size to include both kidneys should be placed on top of one
another, and protected by a celluloid cover, in order to prevent injury
from excretions. The upper edge of the plate should correspond to the
position of the tenth rib, and the lower edge to the superior part of the
sacrum. This will include part of the ureters at the lower end of the
plate. The tube should be of the highest penetrative power, so as to
lessen the time of exposure. When both kidneys are to be skiagraphed
the tube should be placed in the median line above the patient, and at
a level corresponding to the position of the pelvis of the kidney.
If only one kidney is to be skiagraphed, use a smaller plate, placing
the tube in front of the patient, with the target pointing to the centre of
the kidney. As respiratory movements interfere with the production of
an accurate skiagram, the whole abdomen should be bandaged as tightly
as possible. Some examiners prefer the patient holding his breath
during exposure, but I have encountered some difficulties in attempting
to carry out this method. For skiagraphing the renal organs,! always
use the Wehnelt interrupter.
C. C. Slaberia and A. P. Slaberia,1 of Barcelona, recommend the use
of a moderately hard tube (except in cases of very stout patients, when
a hard tube should be employed) and a long exposure, varying from three
to six minutes in children, as much as thirty minutes in adults, and up
to sixty-five minutes in very stout persons. They do not employ an
1 Fortechritte a. d. Geb. der Rontgenstrahlen, Band v., Hefte 2, 3.
DISEASES OP THE ABDOMINAL ORGANS. 353
electron-tie break, nor have they seen any erythema or other injurious
effects, although in one instance the patient was skiagraphed seven times.
Except in the case of a displaced or very movable kidney, they advise
the dorsal position of the patient. Despite some advantages, they con-
sider the ventral position inadvisable because of the increased distance
of the kidney from the plate. Dr. Charles L. Leonard, of this city, was
the first to advocate a low- vacuum tube, with a spark-gap of li to 2 inches,
(4-5 cm.) which is self regulating, and which will give a large volume of
low- vacuum Rontgen discharge. He formulates this axiom, " that in a
negative possessing a differentiation in the shadow of tissues less dense
than the least dense calculus, no calculus can escape detection." Per-
sonally I agree with Shenton and those other skiagraphers who advocate
the high- vacuum tube with a short exposure. The latter is advantageous
in taking negatives of suspected calculi, for these can be applied while
the patient " holds his breath," thus avoiding diaphragmatic movements.
I always make several short exposures when skiagraphing this region. I
believe there is less likelihood of penetrating the calculus with the high
tube and short exposure, than with a softer tube and a longer exposure.
I cannot advise the use of the intensifying screen, because of the gran-
ularity presented on the negative ; neither do I recommend the compres-
sion diaphragm, as we do not know where to apply the latter, as it covers
only a small area at a time, and thus prevents comparison between the
abnormal and the corresponding normal part. Dr. Joseph F. Smith, in
his paper "The Rontgen Ray Diagnosis of Renal Calculus,"1 remarks :
"In 1899, Abbe collected from literature and tabulated twenty-five
cases in which a positive diagnosis had been made by the X-ray and later
confirmed by operation. To this list of twenty-five he added two cases
of his own, making twenty-seven cases reported up to that time. These
twenty-seven cases are arranged by years as follows : 1896. Macintyre,
of Glasgow, reported the first skiagraph of a stone taken in the body.
Swain, of Bristol, reported a case. 1897. Gurl, Nuremberg ; Fenwick,
England ; Thyne, Australia. 1898. Bevan, Chicago ; McArthur, Chicago ;
Lauenstein, Germany ; Alsburg, Germany ; Martin, England ; Taylor,
England ; Fenwick, England ; Leonard, Philadelphia, eight cases ;
McBurney, New York; Abbe, Xew York, two cases. 1899. Wagner,
Germany, two cases."
Speaking upon the probable errors likely to arise in cases of ne-
phritic calculi, Dr. Chas. L. Leonard, one of the greatest authorities on this
subject in America, says:2 " The absolute negative and positive diagnosis
of calculous nephritis and ureteritis can be made with an error of less
than 3 per cent. A statistical study of the 320 cases examined shows
that calculi have been found in 93 cases, or a little less than a third
of the cases examined. In many of the cases, in which a negative or
'Annals of Surgery, May, 1904. 2 American Medicine, June 4, 1904.
354 ELECTRO-THEEAPEUTICS.
exclusion diagnosis was rendered, the patients had such slight symptoms
as to render the presence of calculi possible, but not probable. In 47
cases the symptoms demanded operative intervention, and in all but one
the accuracy of a negative diagnosis was proved by the operation, and no
calculi were found. In many of the cases of negative diagnosis in which
there was no operation, the subsequent development of other conditions
showed that the diagnosis had been correct. In three cases of negative
diagnosis, small calculi, that had escaped detection, were subsequently
passed. Thus, there has been a total error of but four cases in the
negative diagnoses, one due to defective technic, and the others to
inaccurate reading of the plates."
Bevan l published a paper in the Annals of Surgery, reporting 13 or
14 cases, and claimed that the X-ray as a means of diagnosis was to be
relied on to a greater extent in cases of kidney stone than any other means
at our disposal. He thinks the best exposition of this entire work is to
be found in "Beitrage fiir Chirurgie," from the pens of Kummel and
Eumpel. Kummel takes the position of Leonard and Bevan, and pre-
sents practically these conclusions, that the X-ray, properly used, will
detect a stone in any individual, no matter how thick, or of what chemical
composition ; that the detection of the stone does not depend so much on
its chemical composition or the thickness of the individual, as it does on
the proper use of the X-rays.
Kummel and Rumpel 2 report a series of eighteen cases diagnosed
positively by the X-rays, all of which were subsequently operated
upon, and stone extracted. The conclusions drawn from their work are
as follows :
"The exact diagnosis of kidney stone is to be made only by means
of the Rontgen procedure.
"The presence of a kidney stone, whether located in the kidney
substance, the calices, or in the ureter, will be demonstrated upon the
plate in every case, by proper application of the Rontgen method.
"The negative result of the Rontgen method after repeated attempts
allows of the exclusion of a calculus.
"The demonstration of a stone shadow upon the Rontgen plate is
not dependent upon the size and chemical composition of the calculus,
but singly and alone upon the technic of the Rontgen operator.
"A high degree of corpulence in the patient may render the demon-
stration of a calculus by the Rontgen method very difficult, but in general
does not render it impossible.
"In every case of nephrolithiasis it is advisable to employ the
functional methods of investigation, since they show us by combined
application (a) whether a disturbance of the whole kidney function exists
'Journal of the American Medical Association, March, 1905, p. 1062.
2 Beitrage fiir klin. Chirurg., 1903, Band xxxvii., Heft 2.
DISEASES OF THE ABDOMINAL ORGANS. 355
or not, (6) whether we have to deal with a double-sided stone formation
or other coexisting kidney disorder, or whether in the already existing
disorder only one kidney is involved.
"The result of the negative Eontgeii investigation should be consid-
ered in connection with the condition of the clearness, concentration, and
freezing-point of the urine obtained by means of the ureteral catheter."
In the eighteen cases tabulated by Ruinpel. two of the stones removed
contained only triple phosphates. All the others consisted of mixtures
in different proportions of calcium carbonate, calcium phosphate, calcium
oxalate, and uric acid or urates. Five of the stones consisted largely of
calcium oxalate, fourteen of calcium phosphate, and two of uric acid.
Of the two stones consisting largely of uric acid, the composition of the
first was a mixture of uric acid with calcium phosphate, and the second,
a mixture of uric acid with calcium oxalate and phosphate.
Errors in skiagraphiug calculi may be due to several causes, — great
density of the parts, as in very stout persons, transparency of certain
calculi, as of the uric acid type, diminutive size of the stone, faulty
exposure, faulty development of plate, or any defect in the apparatus.
I am in accord with the view expressed by Dr. Charles L. Leonard,
that a positive or negative diagnosis of a urinary calculus should be
based upon the findings on the negative, as the calculus should always be
detected, if the negative shows a shadow of the least dense tissues. On
a good negative, the shadows of the following structures should be
visible : Shadows of the lumbar muscles, the transverse processes of
the vertebrae, and the twelve ribs.
D. URETERAL CALCULI.
These are difficult to skiagraph, as the shadows of the pelvic bones
superimpose upon the shadow of the calculi in the lower portion of the
ureter.
Of the 93 cases in which calculi were found, Leonard states that
there were four in which calculi were present in the kidney and ureter
of the same patient. Including these cases, 33 renal calculi were found
and 64 ureteral.
Tenny l has been able to add 33 cases of ureteral calculus since the
publication of the 101 cases collected by Schenck.2 The location of these
stones has been in a general way in one of three places, depending on the
physiological narrowing of the ureter. The first point of narrowing is
about 7 centimetres down, and has a diameter of 3.2 millimetres. The
second is just above or below the brim of the pelvis, and has a diameter
of 4 millimetres, and the third is at a point just above the bladder, and
has a diameter of 2.5 millimetres. The number of stones in the series of
1 Boston Medical and Surgical Journal, Feb. 4, 1904.
1 Johns Hopkins Hospital Reports, vol. 10.
KLMTKO-THKKAI'EUTICS.
:'>! cases caught in the above locations corresponds very nicely in its
diameters, 35 being caught in the first isthmus. 18 in the second, and 73
in the third. In the remaining cases, the locations were not given.
On the left side of the ureter, but sometimes on the right, is occa-
sionally noted a sharp, round, white shadow corresponding to the lower
FIG. 190.— Reid's apparatus for renal skiagraphy.
end of the ureter. This is caused by the presence of a phlebolith, which
must not be mistaken for a calculus. Dr. Russell H. Boggs, of Pitts-
burg, maintains that this shadow is due to a sesamoid bone.
E. W. H. Shenton,1 of London, believes that the flnoroscope is not
sufficiently used in examinations for renal calculi. He advises placing
the patient in a horizontal position, face downward, with the arms above
the head. Efforts should be made to make the lumbar spine straight,
even to the extent of placing a pillow beneath the abdomen. The tube
should be placed beneath the patient 6 inches (15 cm.) from the abdomen,
the actual distance varying according to the conditions of the tube and
the size of the patient. The screen is placed upon the patient's back.
A new apparatus for skiagraphing the renal region, devised by Mr.
'Archives of the Rontgen Ray, March, 1902.
DISEASES OF THE ABDOMINAL ORGANS.
367
A. I). Reid, of London (Figs. 190 and 191), and manufactured by Harry
"W. Cox, Ltd., of London, dispenses with the use of compressors and is
described as follows : The patient is laid upon the couch and an air cushion
is placed under the part to be radiographed. The plate is then placed on
the patient's back and the lead base with the upright arm is attached to it
When the patient breathes the
lead base is raised, the arm
moves the lever up and causes it
to make contact.
This contact is merely a
switch introduced into the pri-
mary circuit of the coil, and
consequently when it is closed
the current is enabled to pass,
and the tube flnoresces, simul-
taneously the clock shown in
the illustrations records the
length of the exposure.
It is, therefore, obvious that
the kidney — or any other part
of the body — must always be in
the same position whenever the
tube fluoresces.
Dr. Albers-Schonberg be-
lieves that the technic in renal
skiagraphy has not been suffi-
ciently studied. Hard tubes, he
argues, should not be used. The
shadows thrown by the last ribs
and the transverse process of the
first lumbar vertebrae are to be
taken as guides. If nothing is
seen at the first attempt, it should not be concluded that the result is
negative. The plate should be intensified, and allowed to dry. This
brings out many shadow details, previously invisible. To obtain the best
effects the plate should be examined at a distance of 5 or 6 ft. If any
specks are seen, which may possibly be due to calculi, another exposure
should be made within three or four days. In any case of doubt a sepa-
ratr exposure should be made. A lead pipe with an opening of 13 cm. in
diameter is placed close to the tube, and 50 cm. from the plate, so as
to cut off the secondary rays and obtain a well-defined shadow. (Figs.
I'.'i' and 193.) My time of exposure in renal skiagraphy depends upon
the corpulence of the patient, and the degree of high penetrative power
of the tube. The distance of the target from the plate is from 22 to 30
inches (55 to 75 cm. ).
FIG. 191. — Clock arrangement and break of the same.
358
KI.i:< TRO-THERAPEUTK S.
The method of examination of the kidney by the X-rays, when the
organ is outside of the body during operation, has been fully described
by the discoverer, Mr. Fenwick.1 It consists in examining the kidney
with the fluorescent screen after the organ has been removed as far as
possible from the abdominal cavity. In some cases, he says, the kidney
cannot be displaced out far enough to permit of a screen examination,
due to insufficient length of the renal vessels. An objection to this
method of examination is that the surgeon must necessarily remain
in darkness for at least ten or fifteen minutes before he will be able to
successfully perform a screen examination.
F. Voelcker and A. Lichtenberg 2 describe a process of pyelography.
The ureter is catheterized, and the instrument is advanced to the renal
pelvis. A 5 per cent, solution of a silver salt is then slowly injected
through the catheter.
There are individual variations in the amount of fluid which the
pelvis will tolerate : in one instance 5 c. c. gave rise to colicky pains, in
Fio. 192.— Compression diaphragm of Albers-Schonberg. (Kny-Scheerer Co.)
others 50 to 60 c. c. could be introduced. The shadow cast by the rays
will reveal any abnormality, such as a kinking, bending, constriction, or
dilatation of the ureter.
The authors employed the procedure in eleven cases, ten being
women and one a man. In four of their cases, their efforts were unsuc-
cessful. The operation is not very painful, but is more easily done after
an injection of morphia.
I present the following as a few of my cases, showing the value
of skiagraphy in determining the presence of nephritic calculi :
In the Medico-Chirurgical Hospital in 1901, I examined a case for
Drs. Rodman and West, but found only an enlarged kidney. The
1 The British Medical Journal, Oct. 16, 1897.
* Munch, metl. Woch., January and October, 1906.
DISEASES OF THE ABDOMINAL ORGANS
359
operation confirmed the diagnosis. In 1900, at the same hospital, I skia-
graphed a case for Dr. Elwood E. Kirby, and, instead of a calculus, I
found a collection of pus ; this was subsequently confirmed at operation.
FIG. 193.— The same, postero-anterior view.
For several years I made an annual examination of a patient, under
the care of Dr. Ernest Laplace. The negative showed a calculus in the
pelvis of the kidney, which was subsequently removed. (Fig. 194.)
In a case under the care of Dr. Alfred Stengel, I found a calculus in
the pelvis of the kidney, that for three years occasioned an unceasing
dull pain. Dr. Charles H. Frazier removed the stone at the University
Hospital.
At the Philadelphia Hospital in 1903, I skiagraphed a renal calculus
for Dr. J. B. Garnet, which was successfully removed.
In 1904, at the same hospital, Dr. Ernest Laplace operated for a sup-
posed case of appendicitis. After the operation the pain continued, and
three weeks later a skiagram revealed a calculus in the kidney. This was
removed, and the patient at once recovered.
E. THE BLADDER.
Examination for Calculi. — The preparation required is the same as
for a renal examination, and in addition the bladder and rectum should
be emptied just prior to the exposure. The patient should be placed
upon the table in the ventral position. The plate, or preferably two,
360 ELECTRO-THERAPEUTICS.
well protected, should be laid under the pelvis. The table is tilted so
that the head will be much lower than the feet, an expedient for bringing
the calculus as much above the pubis as possible, thus avoiding super-
imposition of the shadows of the calculus and the bone. The tube is
placed so that the rays will be parallel with the sacrum and pass through
the true pelvis without causing any superimposition of the shadows on
the negative. Skiagrams produced with the patient lying on the back
have been very satisfactory in my experience, especially so in corpulent
subjects, by placing the tube above the umbilicus.
In Fig. 195 is shown the skiagram of a large vesical calculus. At a
prominent Philadelphia hospital, the case was incorrectly diagnosed as
an enlargement of the prostate. The patient became progressively worse.
and as a victim of neurasthenia, he applied to the Nervous Department
of the Medico-Chirurgical Hospital, 1901. Dr. Ellwood R. Kirby sug-
gested the wisdom of an X-ray examination, when the large calculus, here
shown, was found. The patient was operated upon and made a perfect
recovery.
Englisch ' describes a total of 405 cases of calculi in the urethra or
diverticulum. He classifies them in various groups, and discusses each
in turn. The stones were in the membranous portion in 149 instances,
and in the bulbous urethra in 68 cases.
Closure of the Bladder, as shown Skiagraphically. — Leedhain-Greeu 2
found that, whether the bladder was fully distended or not, the outline
of the organ was oval, not pyriform, and the urethra was sharply cut
off from the bladder without a suggestion of a bladder neck. There are
reasons, therefore, for believing that the sphincter of the bladder plays a
more important part than Finger and Guyon credit it with, and that
under ordinary circumstances it is by this muscle that the bladder is
closed, whether distended or not.
F. PROSTATIC CALCULI.
F. Frank Lydston 3 reports that a farmer aged 34 was fallen upon by
a horse, and the perineum sustained a severe blow. Haematuria followed,
without obstruction of the urethra, and he was apparently well in 10
days. Six months later there was difficulty in micturition ; he passed
several small calculi, and has done so at intervals since. Examination
revealed an apparent calculus at the bulbo- membranous junction, M ith
enlargement of the prostate. Operation was advised, and through a peri-
neal incision a calculus weighing 720 grains was removed from the pros-
tate. Lydston believes that, as a consequence of the traumatic stricture, a
certain quantity of residual urine continually remained in the canal,
1 Arch. f. klin. Chir., Berlin, 1906, p. 743.
* Archives of the Rontgen Ray, May, 1906.
5 Annals of Surgery, March, 1904.
FIG. 194.— Calculus in the pelvis of the right kidney. (Case of Dr. Laplace.)
DISEASES OF THE ABDOMINAL ORGANS. 361
decomposition followed, with the formation of secondary calculi. The
obstruction caused dilatation of the prostatic ducts, small secondary
calculi were forced into the latter, and one of these became enlarged,
forming a nucleus about which was deposited the material which
resulted in the formation of the large stone. Stricture of the urethra
may at times be detected by injecting bismuth solution and then taking
a skiagraph. (For biliary calculi, see chapter on The Alimentary
System. )
CHAPTER VI
APPLICATION IN THE SPECIALTIES.
I. Obstetrics and Gynaecology.
OBSTETRICS.
IN radiographing the uterus and its contents much difficulty is
encountered, as in this part of the body the rays will have to penetrate
many thicknesses of tissues ; but, if the abdominal wall is not too fat. fair
results may be expected. Another obstacle is, the refusal of the patient
to remain in a constrained position for a sufficiently long time to obtain
the desired results.
The distance of the sensitive plate from the uterus, the movements
of the foetus, and of the uterus itself, and the respiratory movements of
the mother, are obstacles to satisfactory results.
Pelvimetry. — A new process of pelvimetry devised by Dr. Henri
Varnier1 demands brief attention. When a radiograph is to be ob-
tained, the operator arranges the X-ray tube at a short distance from
the part to be radiographed, usually varying from 16 to 24 inches (40 to
60 cm.). The result is that, since the radiographic negative registers
only the projected shadows of the object, the image obtained is some-
what larger than the original, at least for all the parts of the latter not
in direct contact with the sensitive plate.
In order to surmount this difficulty, Dr. Varnier removed his source
of Eontgen rays to a distance sufficient to permit them to behave practi-
cally the same as if they were parallel. He has shown that the rays may
come from a considerable distance and the ordinary double anode tubes
can be employed.
With a coil of 10 inches (25 cm.) spark and provided with a Ducretet
vibrator, he has been able, in an exposure of ten minutes and with a current
of 10 amperes at 26 volts, to obtain the outlines of a dry pelvis upon a
photographic plate placed at a distance of 25 metres from the Crookes
tube, and in an exposure of 20 minutes the same outlines were obtained
upon a plate 30 metres distant. It is usually better not to resort to such
distances, thus obviating long exposures.
At a distance of five metres the usual instruments of measurement
do not show any difference between the dimensions exhibited by the
object and the radiograph. For ordinary exigencies a distance of 2.5
metres is sufficient, as shown in the following measurements by Dr.
Varnier of a dry pelvis. The error found is of the same nature and
'Scientific American, May 1, 1901.
362
APPLICATION IX THE SPECIALTIES.
363
never exceeds 5 millimetres, — /. e., it is practically nil. The modus
operand! is extremely simple. The Crookes tube is placed at a distance
of 2.5 metres (98 inches) from the plate, with its cathode perpendicular
to the long axis of the upper brim of a normal pelvis, taken as a point
of observation.
The following table was compiled by Dr. Varnier from experiments
and measurements with a dry pelvis, and in it will be found the differ-
ence between the dimensions of the pelvis itself and the radiograph :
MEASUREMENTS MADE
DRY PELVIS
RADIOTYPE
DIFFERENCE
Maximum transverse diameter
mm
122
114
118
103
32
235
250
inches
= 4.803
= 4.488
= 4.1545
= 4.055
= 1.259
= 9.281
= 9.842
mm
126
117
121
108
33
235
250
inches
= 4.921
= 4.606
= 4.763
= 4.251
= 1.299
= 9.251
= 9.842
mm.
+3 =
+3 =
-1-3 =
+5 =
+ 1 =
+0 =
+0 =
inch
+0.118
+ 0.118
-fO.118
+0.196
4 0.040
+ .0
+ .0
Antero-posterior diameter (the only
measure up to the present ) . . . .
Left oblique diameter
Transverse bi-ischiatic ( the part
farthest from the plate )
Width of the first piece of the
coccyx
Distance of the anterii >r and posterior
iliac bones
Transverse diameter of the greater
pelvis
Along the line A B (Pig. 196) taken as a base, he arranges in his
frame a 40 x 50 centimetre (15. 74 x 19. 6S inch) sensitized plate. The dry
pelvis is then placed in pronation (?. <°., with the front downward) with
the line of crests resting upon C D and its antero-posterior diameter in
line with E F.
In order to operate upon a living person, it suffices to replace the
dry pelvis by the subject to be examined, who must lie so that the pelvis
will assume the same position. By using the data given, the measure-
ments may be accurately obtained.
The patient can be made more comfortable by employing the
author's tube-holder and table, placing the tube under the table and
having the patient assume the dorsal decubitus position ; often the
Trendelenburg position is useful, because of the gravitation of the
abdominal contents toward the diaphragm, thereby lessening the
obstruction to the rays.
Contreinoulins,1 of Paris, takes two skiagrams, with the tube in two
1 Bouchard, "Traite Radiologie Medicale," p. 1010, a contributed article by
M. Kabre.
ELECTKO-T 1 1EKAPEUTICS .
different positions, without disturbing the patient or altering the plane
of projection. The first negative is taken and then removed, and a
FIG. 196.— Varnler's arrangement for radiography.
second plate is placed in the same position. In each instance the normal
point of incidence is indicated on the skiagram. A tracing of the salient
points is made, to be ultimately transferred to a zinc plate. Threads are
stretched from points in the latter by which the two cones of projection
APPLICATION IX THE SPECIALTIES. 365
may be redrawn, their apices corresponding to the two positions of the
Crookes tube. The intersection of these cones is an index of the position
and size of the pelvic inlet.
Stereo-skiagraphy of the pelvis is the best method to employ in
pelvimetry and for the study of pelvic deformities.
The data given in the above table are those used in the special radio-
graphic department of the Baudelocque clinic, founded by Prof. Pi nan I
and Dr. Varnier.
Williams1 says : ''In order to determine the transverse diameter of
the superior briui of the pelvis, the following method has been devised
by me, by which the two halves of the pelvis are taken separately, but
on the same photographic plate. The patient lies on her back on a
stretcher, with the plate over the abdomen and the inlet of the pelvis
about parallel with the plate. When the right side of the pelvis is being
taken, the left half of the plate is shielded by a sheet of lead placed
under the plate. The tube is placed by means of a plumb line as nearly
as possible directly under the right border of the superior brim of the
pelvis, in the line of the pelvic axis — 3 centimetres to the right of the
median line. If the tube is at least 60 cm. from the plate, the distortion
in the photograph will not be great. After the first exposure has been
made, and the left side of the pelvis is to be photographed, the sheet of
lead is moved so as to cover the right half of the -plate and the tube is
placed immediately over the left edge of the superior outlet of the pelvis,
3 cm. to the left of the median line. Its proper position being obtained
by means of the plumb line, the photographic plate is not disturbed.
An exposure is then made of this part, and, thus, a photograph of the two
sides of the brim of the pelvis is obtained. By this method the error
due to the slanting direction of the rays falling on the pelvic brim and
the plate when only one exposure is made for both sides is avoided,
and no calculation is necessary to estimate the amount of exaggeration,
as in the latter case." This method is applicable to non-pregnant
cases. With the gravid uterus the plate cannot be brought in contact
with the part.
A skiagraph of the foetus may be produced quite readily after it has
been taken from the uterus. In 1896 Dr. Oliver diagnosed one ectopic
gestation, six weeks beyond term, in a woman aged 39 years. An attempt
was made to radiograph the mass within the abdominal cavity, but the
result was altogether unsuccessful. Operation proved the presence of
an ovarian sac, which contained a nine-months' foetus. After its removal
by operation a successful skiagram of the foetus was produced. Human
foetuses in various stages of development are to-day quite readily and
successfully skiagraphed. The older the fcetus the better will be the
resulting skiagraph.
1 " The Rontgen Rays in Medicine and Surgery," p. 379.
366
ELECTRO-THEK A I ' K I'TICS.
Gravid Uterus. — I have been able to produce, in a few cases, skia-
grams of gravid uteri. Dr. E. P. Davis1 states, that his experiments
showed that it is possible to obtain an outline of the living fostus in the
body of the mother, notwithstanding the thickness of the tissues, and the
distance at which the Crookes tube is necessarily placed from the foetus.
I made several stereo-skiagrams of pregnant women at the Philadel-
phia Hospital for Dr. Davis, and the result was eminently successful.
Anatomical specimens of uteri, and their contents, removed from the
body should occasion no difficulty. By varying the current and the time
of exposure, it is undoubtedly possible to obtain a useful picture of the
contents of the living womb.
Drs. Henri Yaruier and Ed. Piuard have diligently studied the
gravid uterus, both in the living and the dead, by means of the Eontgeu
rays. In the case of a woman dying from uraemia, they were enabled to
FIG. 197.— Author's head rest for stereoscopic work.
show the head of a seven-months' foetus at the superior strait. In the
second case, after death from some form of lung disease, they were enabled
to show the contour of the uterus, together with a part of the vertebral
column of the contained foetus.
Queirel and Acquavita2 assert that the evolution of the osseous sys-
tem is demonstrable, at premature birth, by the skiagraph, and hence
the determination of the age of the developing foetus assumes an impor-
tance in matters of medico-legal interest.
1 American Journal of the Medical Sciences, March, 1896, p. 268.
1 Bouchard, "Traite Radiologie M&licale," p. 1009.
APPLICATION IN THE SPECIALTIES. 367
GYNAECOLOGY.
So far the X-rays Lave been of little practical value in gynaecol-
ogy. Before long, however, correct diagnoses of various tumors, cysts,
abnormal positions of the uterus, diseases of tubes and ovaries, etc., will
undoubtedly be made by means of the Eontgen rays. At present the
shadows produced upon sensitive plates of the various conditions of the
pelvic and abdominal organs (except the bladder and prostate) are
insufficient in detail. Dr. Eden V. Delphey l says, that the main use of
the X-rays in gynaecology lies in the treatment of malignant disease, and
when a diagnosis is made sufficiently early, the neoplasm and often all
the pelvic reproductive organs should be removed by surgical means, so
as to get entirely beyond the malignant growth and prevent recurrence.
When this can be done, the protuberant portion should be removed and
the remainder subjected to the influence of the Eontgen rays.
II. Rhinology, Laryngology, and Otology.
The X-rays are at present coming into use in affections of the nose,
throat, and ear.
EHINOLOGY.
A screen examination of the nasal bones, when displaced, depressed,
or fractured, is well illustrated by this means. If supports, as silver or
aluminium splints, are placed under the depressed bones, their correct
position may easily be ascertained by a screen examination ; the same
holds good for exostoses and foreign bodies. Abscesses of the antrum
and frontal sinuses may be readily skiagraphed, and I find for these cases
head rests (Figs. 197 and 198) most valuable.
Diseases of the frontal sinuses may be skiagraphed in the occipito-
frontal and lateral positions. The former is difficult, because of the
thickness of the skull. By this view we note on the plate the presence
or absence of these sinuses, also their size, shape, symmetry or asymmetry,
the number of septa, the presence of contained morbid products, and the
extent of the orbital and ethmoidal recesses. The skiagraph in the lateral
position is easier of accomplishment, but it fails to show the details above
mentioned, because only one side is taken and therefore forbids compari-
son ; but it shows clearly the ethmoidal and orbital recesses and the
sphenoidal sinuses. Both views should always be skiagraphed. The den-
tiaskiascope, or endodioscope, first described by Dr. Macintyre and used
for examining the hard and soft tissues about the bones of the face, nose,
and larynx, deserves mention. Dr. Macintyre writes as follows :2 "The
fluorescent screen is placed inside of the mouth and the Crookes tube out-
side, or vice rci-wi. Small disks of glass are coated with the fluorescent
1 Annals of Gynaecology and Pediatrics, Feb., 1903.
2 Glasgow Hospital Reports, 1898, p. 306.
368
ELECTRO-THERAPEUTICS.
salt and covered with aluminium, or tongue depressors consisting of flat
strips of glass covered and coated in the same way may be employed. By
placing the tube outside, I am able to get an image of the septum and
other parts of the cavity of the nose, on the fluorescent screen in the
mouth. In the same way the roots of the teeth may be seen. If the
surgeon desires to examine the tissues externally, — i. ?., to pass the
FIG. 198.— AUTHOR'S HEAD REST FOB SKIAGRAPHING DISEASES OF THE FRONTAL SINUSES.— With
this device, the patient is seated and his head or face is applied to the board. There are two movable
padded head rests, one on the vertex and the other under the occiput; the chin is supported on a rest.
P. H. is a plate-holder lined with a transi>arent material, into which the sensitive plate can be slid or
inserted. It is also very convenient for stereoscopic work. This plate-holder can be adjusted according
to the angle of the face and forehead, as shown in the scale, and fastened at any angle. I find that a
30-degree angle is the best position for the patient. This angle is formed by the glabella G, the exter-
nal auditory meatus, and the anode of the Crookes tube. As the facial angle varies in different individ-
uals, it is necessary to adjust the tube accordingly. The more obtuse the facial angle, the more acute
should be the angle between the bundles of rays and the base of the skull, or a line connecting the
external auditory meatus and the glabella. The more acute the facial angle, the more obtuse shotCd
be the angle formed by the tube. The X-rays should form as near a right angle to the plate as possible,
always avoiding the shadow of the occipital bone. If the rays are directed through the cervical region,
the shadows of the vertebrae will throw irregular shadows over the sinuses. I find that this is un-
satisfactory.
rays through the neck, — we can place a small fluorescent screen on
one side and remove the Crookes tube to a suitable distance. By this
means I have been able to demonstrate the presence of foreign bodies,
and need hardly add that they are more easily photographed."
Monnier1 is able to diagnose the etiological factors of a chronic
1 Archives Internal, de Laryngologie, November 3, 1898.
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APPLICATION IX THE SPECIALTIES. 369
post-nasal suppuration associated with epiphora. He gives a^ the cause a
piece of a lacrymal sound which had remained in the nasal duct for some
twenty years.
LARYNGOLOGY.
While the X-rays have accomplished but little in the department of
laryngology, they have proved of great service in the detection and
accurate localization of foreign bodies in the upper portion of the diges-
tive and respiratory tracts, thus aiding the laryngologist to decide as to
the advisability and character of operations for their removal ; also in
the determination of the ossification of structures in the laryngeal and
tracheal cartilages. At present we can ascertain with scientific accuracy
the time and the points at which all the cartilages ossify. The X-rays
aid in the diagnosis of intra-thoracic growths involving the respiratory
tract, either by compression of the trachea, or by some form of vocal-cord
paralysis. They are also likely to prove useful in the earliest detection
of any tuberculous processes in the lungs. The observer must be trained
to this line of observation in order that perfection may be obtained. The
delicate variations in the shadows that form on the fluorescent screen can
be properly interpreted only by practice. Fig. 199 shows the presence of
a tumor in the trachea.
OTOLOGY.
The rays have been of slight value in otology. In two cases where
foreign bodies had been introduced into the ear, I was able to detect and
localize them by means of the X-rays. In each instance the external
auditory canal was greatly inflamed and swollen, so as to prevent an
ordinary examination of the part with a satisfactory result.
The diagnosis of mastoid abscess by the X-rays is feasible. Three
cases examined by me showed the presence of abscesses, and subse-
quent operations confirmed the diagnoses. In all these cases the nega-
tives showed a dense shadow instead of the porous appearance found
normally.
CHAPTER VII
APPLICATION IN DENTISTRY.
THE employment of the X-rays iii dentistry has opened up a prom-
ising field.1 Thus far skiagraphy has rendered invaluable aid, assisting
the dental surgeon in diagnosticating perplexing conditions and in con-
firming conclusions previously obtained. Thus, the position'of the roots,
the occurrence of fracture of a root, the presence of alveolar absorption,
the existence of fluid in the antruin, and many other pathological states
and conditions are readily revealed to us through this method of
investigation. The structure and evolution of the teeth can be studied
in the living subject.
I. Apparatus Used in Dental Skiagraphy.
The paraphernalia and technic employed in dental skiagraphy do
not differ from those used for other regions of the body. A small coil of
6- or 7-inch spark length is sufficient. For the denser structures, as, for
instance, the entire thickness of the maxillary bones, a tube of high
vacuum is essential ; the same kind of tube should be employed where
the skiagram must be taken rapidly, and where the exposure is con-
sequently short, as in cases of children.
II. Technic.
Fluoroscopic examinations in dentistry do not yield satisfactory
results. The two methods at present employed in dental skiagraphy are
the intra-oral and the extra-oral or buccal.
The intra-oral method consists in inserting a small piece of film (light
and moisture proof) over the alveolar tissue where trouble is suspected,
and in adjusting the tube so that perpendicular rays will fall upon the
teeth and film. A small sensitive plate, being inflexible, cannot be made
to adapt itself to the curvature of the part. Rollins, of Boston, encases
the film in an aluminium cover, while Price, of Cleveland, Ohio, uses
un vulcanized black dental rubber, protecting the emulsion with a sheet
of sensitive bromide paper. Kodak films cannot be used for this
1 The first skiagraph of the teeth was exhibited by Prof. Koenig, to the Society
of Physics of Frankfort-on-the-Main, in February, 1896.
In April, 1896, at the Congress of Erlangen, Walkoff demonstrate 1 many skia-
graphs of the teeth in living subjects. (Bouchard, "TraiU- Radiologu- .M< cli. ale.")
Dr. William J. Morton on "The X-rays in Dentistry." which appeared in
Dental Cosmo*, June, 1896, reproduced from his book : " The X-rays, or Photography
of the Invisible."
370
APPLICATION IN DENTISTKY. 371
purpose. Formerly I preferred a specially prepared, thick, double-
coated film, which I cut to the required size and enclosed in a layer of
black paper, after which the paper was so folded as to enclose snugly
the film, and the wrhole placed in a yellow envelope just large enough to
accommodate the size of the paper and film ; the smooth side correspond-
ing to the sensitive side of the film. Lately I have much preferred
Eastman's negative transparent films, which are neatly encased and
always ready for use.
Place the patient in the dental chair and adjust the tube. See that
the rays fall perpendicularly to the vertical axis of the teeth. If the
adjustment of the tube is faulty, the shadows of the teeth will be
distorted. In order to include, in the skiagraph, the roots of the teeth
place the film against the hard palate. Before its introduction into the
mouth, the enveloped film should be reinforced by a couple of rubber
bands. Skiagraphic work on the superior maxillary bone is less satis-
factory than upon the inferior maxillary, as the film cannot be brought
in a line parallel with the teeth. Two films can be exposed at one
time. As only one or two teeth can be included, the film should be
pressed against the affected part, the exposure varying from two to ten
seconds. By this method sharper definition on the negative is obtained,
and only a small area is skiagraphed.
The extra-oral or buccal method (Fig. 200) requires a plate 8 x 10 to be
brought in contact with the jaw at the suspected region. A block of wood
is wedged between the widely extended jaws, and the patient is directed
to lie upon the affected side, and to incline the head and neck to an angle
of about 45 degrees. The tube is now placed on the opposite shoulder, the
latter is protected by a sheet of lead (the tube being placed very close to
the shoulder), and the rays are sent obliquely at a distance of 20 to 25
inches (50-63 cm.) from the face, to avoid overlapping of the shadows
of the jaw. This method produces a picture of great area, and is
intended for bicuspids and molars of both jaws. Exposure varies from
half a minute to two minutes.
Dr. Sinclair Tousey,1 of New York City, thus describes, "A new
film-carrier and indicator for dental radiography with projection upon a
horizontal plane."
"It consists of a stiff card two and one-half inches (6 cm.) wide and
five inches (13 cm.) long, covered at one end by a sheet of rubber dam,
which forms a pocket into which the film, wrapped in black paper, may
be slipped. This end is placed horizontally in the patient's mouth, and
held there, by tightly closing the lips and teeth. The part of the card
which projects from the patient's mouth has a clamp of aluminium,
which may be turned to either side or straight, and carries a thin
aluminium rod which is always held at the proper angle to the plane of
1 Archives of Physiological Therapy, September, 1905.
372 ELECTRO-THERAPEUTICS.
the film. Diagrams of the teeth are printed upon both the upper and
lower surface of the card, and serve to indicate the position to which the
aluminium pointer must be turned laterally.
" For radiographing the upper jaw the patient sits erect with a film-
carrier in his mouth. The pointer is turned to the position on the dia-
gram where the teeth of chief interest are located, and the X-ray tube in
a Friedlander shield is brought into a position to correspond with the
position of the pointer. In other words, we have an aluminium rod
which points to the spot where the auticathode of the tube should be
placed. For the lower jaw, a film-carrier is turned down, and it will
often be found desirable to tilt the patient's head somewhat, in order to
cause the indicator to point to a spot at which it is practicable to place
the X-ray tube. It is hardly necessary to add that, since the incisor
teeth are an inch behind the pivot of the indicator, the auticathode must
be placed in corresponding relation to the pointer.
"The value of the film-carrier and indicator lies in the fact that it
readily and securely holds the film in position, without placing the
finger inside the patient's mouth. The proper relation of tube and film
are very readily acquired. The picture obtained gives an exact measure
of the length of the teeth, and, most important of all, the teeth of the
whole side or front of the jaw may be shown on one film. By using an
unusually wide film, it is practicable to secure a picture of very good
definition, of the teeth of both sides of the lower jaw, and also of the
incisor teeth, but the latter, of course, would be a confused overlap
ping mass. The radiograph of the upper jaw may show all the front
teeth, or, if taken at the side, all the side teeth and the antrum of
Highmore. To get the wisdom-teeth, either upper or lower, the baek of
the film must be held far back in the mouth, but this is less unpleasant to
the patient than the more usual way of pressing a small film against the
inside of the jaw far enough back for that purpose. The greater ease
with which it is practicable to show the entire vertical width of the lower
jaw is an additional advantage."
III. Clinical Applications.
Unerupted Teeth. — An important condition coming under the dentist's
care is the retention or non-eruption of a permanent tooth, owing to the
temporary tooth remaining in the alveolar socket, beyond the age con
sidered normal. If the skiagram reveals the unerupted tooth to be of
normal shape and so located as to permit of its eruption, the indication
is to remove the temporary tooth. Many cases of odoutalgia are un-
doubtedly due to an unerupted tooth ; in such cases the etiological factor
may be revealed by the X-rays. (Figs. 201, 202, 203, 204, 2or>, 206.)
Necrosis of the Maxilla. — Necrosis of the superior or inferior maxillary
bone can readily be shown by careful X-ray examinations. (Fig. 207.)
FIG. 200. — EXTRA-ORAL METHOD IN DENTAL SKIAGRAPHY. — LS, lead screen for the protection of
the operator. The arrows indicate the variable positions to which the author's tube-holder may be
shifted. The illustration depicts the sensitive plate placed upon a book and the lad's left (suspected
side) cheek resting on the plate, the dotted line shows the path of the rays.
Fio. 201.— UNERUPTED TEETH.— Malposition of the wisdom tooth in the lower ri*ht jaw and delayed
eruption of the wisdom tooth in the rijfht upper jaw, the latter indicated by dotted lines.
PIG. 20- — r.NKRriTEn T'PI-ER CrsiMD TOOTH.— The patient presented a swelling nt the ala of the nose
with reflex nasal and crbital symptoms. (Case of M. H. Cryer.)
FIG. 203. — DELAYED ERUPTION OF THE UPPER CC?PID TOOTH — The bridge is separating the first from
the lateral teeth on each side.
Fie. 204.— DELAYED ERUPTION OR THE UPPER CTSPID TOOTH.— The temporary teeth are in situ.
of the latter was removed, when the permanent cuspid tooth was detected.
One
FIGS. 205, 206.— Delayed second bicuspid on both sides of the lower jaw, in a girl of 12. The upper
picture is the right side of lower jaw, and the lower the left side oi lower jaw. (Case of Drs. Cryer and
Smith.)
FIG. 207.— PHOSPHOROUS NECROSIS OF THE INFERIOR MAXILLA.— Dotted area shows the portion of bone
removed. (Case of Dr. Cryer. )
FIG. 208.— CHRONIC ALVEOLAR ABSCESS or THE RIGHT CENTRAL INCISOR TOOTH.— Patient, age 18,
treated for the above condition for a period of four years, having six sinuses on the labial surface of
the gum. X-rays reveuled remnants of foreign body at the apex of the root. Dr. C. F. Horgan removed
the tooth (right central incisor), and, after cleaning and filling, the tooth was reimplanted. Two years
later the patient remained absolutely well, and the tooth is giving good service.
APPLICATION IX DENTISTRY. 373
A necrotic condition of the jaw, especially when advanced, as in phos-
phorus poisoning, gives the skiagram a lighter area than is produced by
the adjacent unaffected bone. In a few cases that have coiue to iny notice,
I have observed a peculiar condition, — namely, an irregular arrangement
of the teeth, failing to remain in the sockets, as seen normally. The light
area produced by necrosis is undoubtedly due to a decrease of organic
material, replaced partially by an increased amount of inorganic salts.
In a case, referred to me by Dr. Cryer, the patient presented a swell-
ing at the angle of the lower jaw. A skiagraph showed the absence
of true osseous tissue. The part was curetted, and, three months later, at
a clinic at the Philadelphia Hospital, the skiagram revealed a regenera-
tion of the osseous tissue.
Ankylosis of the Inferior Maxillary Articulation. — This may be true or
false, partial or complete, depending upon the cause. Fluoroscopic
examinations in this condition are unsatisfactory, except for observing
the movements of the temporo- maxillary articulation. The skiagram is
taken by the extra-oral method. A negative showing the affected joint
in the early stages usually presents an irregularity of the articulating
cartilaginous surfaces. In true ankylosis, as when following a fracture
involving a joint, the latter may be seen to be wholly obliterated. In
false aukylosis, the joint is seen to be much eroded, the fibrous adhesions
not being evident unless they have become partially infiltrated with
inorganic salts.
Fracture of the Inferior Maxillary Bone. — For this injury employ the
methods before described. In fracture of the symphysis, the plate should
be placed under the chin, the inferior maxilla being fully extended, in
order that the rays may penetrate the injured part from above. Some
prefer to place within the oral cavity a film, and have the rays pass
from the outside, as employed for unerupted teeth. The progress of repair
in this fracture, as well as in others involving this bone, may be easily
determined by frequent fluoroscopic examinations.
Broken Instruments. — Xot infrequently a dentist, in his endeavor to
fill the root canal, breaks an instrument, the fragment remaining inside
the cavity. In his endeavor to remove the particle, he may cause it to
become lodged more tightly and further up in the cavity. An X-ray
examination will enable him to decide upon a course most suitable for its
early removal.
Root-Canal Fillings. — An X-ray examination will demonstrate whether
a canal has been properly filled or not. Such an examination after the
filling of a root-canal would accomplish much toward the prevention of
an alveolar abscess.
Abscess of the Antrum. — Pus or other fluid in the antruin of Highmore
may readily be seen by careful fluoroscopic examinations. The X-rays
are eminently practicable in diagnosticating various diseases of the
antrum. Foreign bodies, as roots of teeth, are located with exactness,
374 ELECTRO-THERAPEUTICS.
and the relations of the teeth to the ant rum or abscesses about them may
clearly be demonstrated, also the position and shape of the floor of the
antruni, the presence of fluid or pus, etc., which may be contained
therein.
Alveolar Abscess. — Dead pulp in a tooth indicates a break in the con-
tinuity of the pericemental membrane at the apex of the root, and more
or less absorption of the adjacent osseous tissue, and occasionally of the
roots in long-standing cases. In the majority of instances such an al»« >-
is due to imperfect treatment, but in many cases the canal of the root is
so narrow and irregular as to make it almost impossible to fill the canal
or cavity to the apex. When a case presents symptoms of a pericemental
inflammation and the history is uncertain, the most rational procedure
is first to skiagraph the field, thus ascertaining the exact location and
extent of the lesion and often its cause. (Fig. 208. )
Tumors, such, as sarcomata or carciuomata, that frequently develop
in the antrum, can in some cases be demonstrated by careful X-ray exam
inations. A cavity that is free from pus, blood, other fluid, or tumors
shows a clearer and more sharply defined shadow than where one of the
conditions just named is present.
Orthodontia. — In deformities of the jaws due to or associated with
unerupted teeth, the dental skiagrapher can ascertain with great exact-
ness the size, shape, and position of the teeth within the bones.
Occasionally the dentist is called upon to regulate teeth, and before
so doing it is advisable for him to know the exact position of the roots,
and also to what extent the tooth canals are closed. If the apex of the
root is not fully developed, the teeth can be regulated more rapidly
and without danger of destroying the pulp.
CHAPTER VIII
THE ROXTGEX KAYS IX FOREXSIC MEDICINE.
I. The Legal Status of the X-Ray.
A. ADMISSIBILITY IN VARIOUS STATES.
EVER since Prof. Rontgeu's immortal discovery has been applied as
a diagnostic agent in medicine and surgery, the legal status of the X-ray
has been argued, denounced, and defended by attorneys the world over.
It seems most fitting to quote a few lines from the comprehensive contri-
bution of the Hon. W. W. Goodrich, Presiding Justice, Appellate Divi-
sion of the Supreme Court of the State of New York,1 second judicial
department.
" The general rule with regard to ordinary photographs has long been
that, wherever the person or thing would under general rules be relevant
if produced in court, or the jury would be permitted to see it if conven-
ient, a photograph of such person or thing, if properly authenticated, is
admissible when the original cannot be seen. Whenever the jury are
likely to be materially aided by the opinions, on matters of fact, of per-
sons specially qualified, they should have them, and, for the purpose of
illustrating and making clear the testimony of medical and surgical
experts, photographs taken by the Rontgen or X-ray process have been
admitted as evidence in the courts of several of the states. A reference
to these cases will show the present status of the law upon the subject.
The first case in which the question arose in this country is unreported,
but there is a summary of it in the Chicago Legal News. It was decided
in Colorado, in 1896, and, in admitting the X-ray photograph, the learned
Judge Lefevre said : ' During the last decade at least, no science has
made such mighty strides forward as surgery. It is eminently a scien-
tific profession, alike interesting to the learned and unlearned. It makes
use of all science and learning. It has been of inestimable value to man-
kind. It must not be said of the law that it is wedded to precedent ;
that it will not lend a helping hand. Rather, let the courts throw open
the door to all well-considered scientific discoveries. Modern science has
made it possible to look beneath the tissues of the human body, and has
aided surgery in telling of the hidden mysteries. We believe it to be our
duty in this case to be the first, if you please to so consider it, in admit-
ting in evidence a process known and acknowledged as a determinate
science.' '
Probably the leading case in this country on the subject under dis-
cussion is that of Bruce vs. Beall (99 Tenn. 303), decided September 30r
1 Brooklyn Medical Journal, December, 1903.
375
876 ELBCTBQ-THEBAPEUTIOS.
IMC. Judge Beard, writing for the Court, said: "In the progress of
the trial, one Dr. Gait man was introduced as a witness, and he was per-
mitted to submit to the jury an X-ray photograph, taken by him, show-
ing the overlapping bones of one of the plaintiffs legs, at a point where
it was broken by this fall. This was objected to by the defendant's
counsel. This picture was taken by the witness, who was a physician and
surgeon, not only familiar with fractures, but with the new and interesting
process by which this particular impression was secured. He testified,
that this photograph accurately represented the condition of the leg at
the point of the fracture in question, and, as a fact, that by the aid of
X rays he was enabled to see the broken and overlapping bones with his
own eyes, exactly as if, stripped of the skin and tissues, they were
uncovered to the sight. We might, if we so desired, rest our conclusion
on the general character of the exception taken to this testimony, but we
prefer to place it on the ground that, verified as was this picture, it
\\as altogether competent for the purpose for which it was offered. New
as this process is, experiments made by scientific men, as shown by this
record, have demonstrated its power to reveal to the natural eye the
entire structure of the human body, and that its various parts can be
photographed, as its exterior surface has been, and now is."
It is the opinion of some of the judges of Massachusetts, that X-ray
photographs are not admissible as evidence, contending that as cold
scientific truths they cannot be regarded as accurate. No one can posi-
tively attest to the absolute correctness of the reproduction. The truth-
fulness of the photograph is a matter of reasoning. In the Philadelphia
courts, the skiagram is admitted as corroborative evidence, provided that
it has been executed by an expert in the work ; the same ruling is in force
in the English courts. In Nebraska, the courts of final jurisdiction main-
tain that skiagrams must be taken by competent persons, who must be
able authoritatively and indisputably to assert, that the appearances
shown are accurate representations of the part.
In a malpractice suit, Carlson vs. Benton, in a Nebraska court, it was
decided by the judge that a skiagram could be introduced as evidence,
despite the fact that the skiagrapher was not experienced in this special
field of work.
In this case, an X-ray photograph of an injured leg, taken after the
injury had been treated by the defendant, was offered in evidence. The
uncontradicted testimony of three surgeons left no room, for a difference
of opinion as to the accuracy of the photograph, the court maintaining
that to exclude, under such circumstances, the skiagram as evidence, on
the ground that a sufficient foundation had not been laid, was an abuse
of discretion.
In medico-legal cases the X-rays are of inestimable value to the phv-
sieian or surgeon in sustaining a diagnosis, to the patient who is insti-
tuting the suit, and. laMlv, and probably most important, to the judge
THE KOXTGEX KAYS IX FOKEXSIC MEDK'IXE. 377
and jury, to whom medical terms and expressions are often so wholly
unintelligible. A skiagram of good ''definition" can be fairly well
interpreted by the average layman, and it will often assist an attorney in
determining whether a case should be compromised or carried to court.
The courts are always disposed to permit an exposition of scientific
methods that will elucidate the intricate questions submitted for judg-
ment. In certain tribunals, where the skiagram is rigorously excluded,
fluoroscopic examinations in the presence of the judge and jury are
permitted, and the knowledge gained therefrom is counted as evidence.
The physician or surgeon (and this applies especially to the
beginner) should always be guarded in expressing a positive opinion, as
to the results that may be expected, after a difficult fracture, such as one
involving the elbow, or the likelihood of the absence of deformity in a
fractured clavicle, or the prevention of limping after fracture of the
femur, etc. In any case where serious deformity and inconvenience may
or may not result, that physician is wisest who ventures only the truth,
explaining the probable results and informing the sufferer and his
friends that he will do the very best he can under the circumstances.
In those cases where one is quite sure of a correct diagnosis, and the plan
of treatment is the one customarily followed, a prognosis may be given
with a reasonable degree of certainty. All prognoses may be rendered
slightly more favorable when the general condition of the patient is
good and there is an absence of any complicating conditions.
In certain cases, the lines of treatment pursued may be perfectly
proper, but if the patient is subject to the misfortune of having other
maladies, as epileptic seizures, he may, by falling, cause a displacement
of a properly reduced fracture, in which case the attending physician or
surgeon is, of course, not held responsible.
B. TECHNIC OF MEDICO-LEGAL SKIAGRAPHY.
The techuic in these cases demands special care, so that the negative
shall be sharp and clear. It is not only advisable, but admissible in
many of the courts, to have a detailed history of the case jotted down,
the health of the patient prior to the injury, the time and the manner
in which the accident occurred, and the method of treatment pursued ;
;iv well as the character and location of any marks on the patient's
body, the length of time that they remained, etc.
The condition of the heart, lungs, and other organs after the
accident must not be overlooked. First, the patient should be most care-
fully examined in a darkened room by means of a screen or fluoroscope,
in such a manner that he and his attendants may not observe the result
obtained by the examination. The examiner should never be alone when
examining the patient, but should preferably have a physician or surgeon,
or another X-ray expert, to verify the facts observed. The information
378 ESLBCTBO-THERAPBUTICS.
\\i\\> ^ained should remain secret. Following the rluoroscopic exami-
nation. a skiagram should be taken and developed later, so that a record
of the injury may be preserved. Two plates should be placed one on top
of another, so that two negatives may be had for future reference.
Occasionally a plate is spoiled during developing, and the patient refuses
to undergo a second examination ; still the examiner has in his possession
a good record of the case. The plate should always be placed in position
in the presence of a witness, and it should have a mark upon it. such as
a key, ring, or letters, so that the operator may be able to identify the
part or side from which the negative was taken. The record should be
kept in a book, together with the history of the case and a detailed
account of the time of exposure, the distance of the tube, the number of
amperes and voltage of current used, the kind of apparatus employed.
etc. Negatives of the part should always be produced from directly
opposite points of view, and, where possible, the injured and corre-
sponding normal parts should be carefully skiagraphed for purposes of
comparison. After developing the plate, no information regarding it
should be imparted except to counsel or the attending physician.
The negatives should be prepared prior to going to court. To
render them more intelligible to the judge and jury, the names of the
bones seen, ete., should be written on them, whether right or left, lateral,
aitero-posterior, etc. An arrow, or other mark, should be on the
negative, to elucidate the seat of fracture, dislocation, or other injury,
and also the date of its taking. Under no circumstances should any other
mark be placed on the negative.
The injured and corresponding uninjured parts should be printed
and mounted side by side. The printing should be of equal and uniform
density, and upon it may be written any points that may be of value to
the judge, jury, etc., as, for instance, the diagnosis of the case in
question. Occasionally a tracing upon the print is permitted by the
lawyer for the defendant.
C. How THE SKIAGRAPHER SHOULD PREPARE FOR COURT.
the X-ray witness is called to court, it is important that he
prepare himself thoroughly with the anatomy, physiology, and pathology
of t he part involved. He should hold a consultation with the medical
or >iirgical expert who has employed his services. In this way a correct
opinion of the case can be imparted. The skiagrapher should have with
him the negatives and prints, the result of his X-ray examination, to-
gether with a set of bones of the part under consideration. When on
the witness stand, he should be careful and accurate in his statements.
In order that the jury may fully comprehend the statements uttered,
his answers should be as free from medical terms and technicalities as
possible. Answers should always be brief and to the point. The witness
under cross-exam ination should not lose his temper; instead, he should
TPIE ROXTGKX KAYS IX FORENSIC MEDICINE. 379
make every effort to remain calm and self-composed. Construct your
answers according to the findings on the X-ray negative. If asked to
answer questions irrelevant to the subject under discussion, or that do not
relate to the findings on the negative, the skiagrapher should simply
answer, ; ' I don* t know. ' '
In our present knowledge there are many things that defy a correct
interpretation on the negative, and we must frankly admit that fact.
When selected as an expert witness, the skiagrapher should direct the
attorney employing his services, to inquire as to the technic, data, etc.,
employed in the production of the X-ray negative, and the physician who
made the latter should be cross examined, and not the attending surgeon.
The subject of a differential diagnosis should always be brought forward.
The following are some of the claims made by plaintiffs :
That the physician or surgeon failed to properly diagnose the case.
That the attendant delayed too long in the reduction of an unrecognized
dislocation or fracture, thus seriously inconveniencing the patient and
preventing his earning a livelihood. That by tardiness in, or total neg-
lect of, reduction, temporary or permanent disability has resulted in a
joint. That aukylosis, neuritis, or palsies have been caused by splint
pressure, or that irreparable damage has been the outcome of callus for-
mation in the distribution of an important nerve trunk. The foregoing
claims may be prevented if the physician makes it a practice to have
early and skilful skiagrams of his cases, if he gives guarded prognoses
in all cases, and is careful and scientific in his methods of treatment. " If
a physician or surgeon departs from the generally approved methods of
practice, and the patient suffers an injury thereby, the medical prac-
titioner will be held liable, no matter how honest his intentions or
expectations were to benefit the patient" (Taylor).
The use of the X-rays is so universally commended in the modern
works on surgery and medicine, that the surgeon who fails to apply them
in doubtful cases, may justly be accused of negligent practice. In
medico-legal cases, the X-ray diagnostician is likely to be asked the
following questions :
1. Does the skiagram show fractures in all cases in which they exist!
This question may be answered thus, not only will a fracture be shown in
almost all cases, but the texture of the bone and the relative densities
of the surrounding parts will also be shown, and any disturbance in the
texture will be noticed. Rupture of ligaments, periosteum, and tendons,
diseased conditions of the bones, etc., may also be observed, but cannot
be excluded.
2. Does the skiagram show callus formation ! Yes, it may be seen
from the sixteenth day after the fracture, and up until the time of ossi-
fication, which may be as late as three months from the time of the
accident. The duration of this callus formation varies, according to
the age and health of the patient, whether the fracture is simple or
380 ELECTRO-THERAPEUTICS.
compound, its location, etc. When the bones are in perfect apposition,
callus formation will be hastened. Massage will also facilitate its produc-
tion. It will be seen from the foregoing that it is not always easy to
predict how long it will be before callus will be strong enough to sup-
port the parts, but by skilful X-ray examinations the amount and density
of the callus may be determined.
3. Another question often asked is, " Is the fracture united or not ? "
The answer to this question will depend upon the age, general health,
local complications, and mode of treatment employed. By pressing upon
the bones and at the same time viewing through the fluoroscope, we
can tell definiteljr whether union is firm, and by means of the skiagraph
we can tell the amount of callus.
4. In cases of deformity, we may be confronted by the question,
" Was this deformity avoidable or not 1 " The avoidable cases are those
resulting from an incorrect diagnosis on the part of the surgeon, or an
improper line of treatment. The unavoidable cases are those of oblique
fracture where the over-riding of the bones cannot be prevented ; extra-
or intra-capsular fracture of the head of the femur in the aged, where
shortening is inevitable ; in compound comminuted fractures, where it
is necessary to wire the ends of the bones, resulting in shortening ; and
in intra-articular fractures often terminating in ankylosis of the joint.
Functional disability and the degree of visible deformity do not
bear any definite relation to each other, as the deformity may be great,
but the patient nevertheless have good use of the part, and vice versd.
It is sometimes necessary for purposes of identification to reveal the
age of the patient or of the dead body, or to tell the age of a female
child, as in cases of rape, etc.
Advantage is taken of the fact that the epiphyses of the various bones
are known to ossify at different ages, and by making X-ray examinations
of the bones, and knowing at what period ossification takes place, an
approximate estimate of the age of the individual may be determined.
The age of a foetus can also be discovered by this means. The hydro-
static test for the determination of still-born infants may be corroborated
by the X-rays, as the lungs will appear opaque if they have never been
inflated, whereas if the infant has been viable for some time, they will
present more transparency. As an evidence of the existence of death,
tin- X-rays play an important part. After death, the pulsation of the
heart is invisible and the organ presents a sharp outline. This will
comfort those who are in constant terror of premature burial.
in February, 1899, Dr. J. William White, Chairman of the Medico-
legal Committee of the American Surgical Association, sent a circular
letter to each of the members asking replies to the following questions
concerning the value and medico-legal relationship of the X-rays :
1. Have you found skiagraphy reliable in the diagnosis of (a)
fractures attended with so much swelling of surrounding tissues that
THE KOXTGEX KAYS IX FOREXSIC MEDICIXE. 381
satisfactory palpation of the fragments is impossible? (6) Fractures
about joints? (c) Epiphyseal separations? (d) Fractures of the neck
of the femur? (e~) Uuuuited fractures? If, in any of the cases belong-
ing to one or the other of these classes, the skiagraph was misleading, we
would like particularly to have a print of it and the clinical history of
the case.
2. Have you any reliable cases of recognition of (a) fracture of
the base of the skull? (b) Fracture or dislocation of the vertebrae?
(c) Fracture of the sternum, scapula, clavicle, or pelvis !
3. Do you know any of the cases in which the testimony of the
skiagraph in cases of supposed foreign bodies in tissues, or of tumors,
gall stones or kidney stones, has led to ineffective or mistaken
operations ?
The conclusions arrived at are succinctly stated as follows : "The
routine employment of the X-rays in cases of fracture is not at present
of sufficient definite advantage to justify the teaching that it should be
used in every case. If the surgeon is in doubt as to his diagnosis, he
should make use of this, as of every other available means, to add to his
knowledge of the case, but even then he should not forget the grave
possibilities of misinterpretation.
" There is evidence that in competent hands plates may be made that
will foil to reveal the presence of existing fractures or will appear to show
a fracture that does not exist.
" In the regions of the base of the skull, the spine, the pelvis, and
the hips, the X-ray results have not as yet been thoroughly satisfactory,
although good skiagraphs have been made of lesions in the last three
localities. On account of the rarity of such skiagraphs of these parts,
special caution should be observed, when they are affected, in basing
upon X-ray testimony any important diagnosis or line of treatment.
"As to questions of deformity, skiagraphs alone, without expert
surgical interpretation, are generally useless and frequently misleading.
The appearance of deformity may be produced in any normal bone, and
existing deformity may be grossly exaggerated.
"It is not possible to distinguish after recent fractures between cases
in which perfectly satisfactory callus has formed and cases which will go
on to non-union. Neither can fibrous union be distinguished from union
by callus in which lime-salts have not yet been deposited. There is
abundant evidence to show that the use of the X-rays in these cases
should be regarded as merely the adjunct to other surgical methods, and
that its testimony is especially fallible.
"The evidence as to X-ray burns seems to show that, in the majority
of cases, they are easily and certainly preventable. The essential cause is
still a matter of dispute. It seems not unlikely, when the strange suscepti-
bilities due to idiosyncrasy are remembered, that in a small number of cases
it may make a given individual especially liable to this form of injury.
182 EL I :< T 1 1( >-T 1 1 K H A PEUTICS.
" In the recognition of foreign bodies the skiagraph is of the very
greatest value ; in their local i/.at ion it has occasionally failed. The mis-
takes recorded in the former case should easily have been avoided ; in
the latter they are becoming less and less frequent, and by the employ-
ment of accurate mathematical methods can probably in time be elimi-
nated. In the meanwhile, however, the surgeon who bases an important
operation on the localization of a foreign body buried in the tissues
should remember the possibility of error that still exists.
'' It has not seemed worth while to attempt a review of the situat ion
from a strictly legal stand-point, as different states and different jndp-s
vary in their interpretation of the law. The evidence shows, however,
that under many differing circumstances the skiagraph will undoubtedly
be a factor in medico-legal cases.
"The technicalities of its production, the manipulation of the appa-
ratus, etc., are already in the hands of specialists, and with that subject
also it has not seemed worth while to deal. It is earnestly recommended
that the surgeon should so familiarize himself with the appearance of
skiagraphs, with their distortions, with the relative values of their
shadows and outlines, as to be himself the judge of their teachings, and
not depend upon the interpretation of others, who may lack the wide
experience with surgical injury and disease necessary for the correct
reading of these pictures." 1
With the exception of the statements that skiagrams of fracture of
the base of the skull are unsatisfactory, and that the detection of callus
formation and fibrous union in recent fractures is not always possible,
there are few, if any, surgeons who to-day would endorse any such
conclusions. More exact methods of study and interpretation of nega-
tives, and greater refinements in the necessary technic have made X-ray
examinations and applications invaluable aids in medicine and surgery.
The very men who in 1899 ascribed doubtful value to the X-rays are
to-day its stanchest supporters ; indeed the judge and jury will frown
upon a practitioner for negligence who has failed to avail himself of this
most precise and scientific method in any case of doubtful diagnosis,
where, through its agency, practical results might have been procured.
II. The Physician's Responsibility in Cases of X-Ray Burns.
X-ray burns are divided into two great classes : Those produced
during an examination for diagnostic purposes and those brought about
by irradiation for therapeusis. Shortly after the discovery of the X-rays,
the use of this agent in diagnosis was not infrequently followed by a der-
mal it is. the result of inadequate apparatus, fewer refinements in technic,
and a limited experience in the application of the new agent. But in
spite of these various factors, the most successful, the most skilled, and
1 The American Journal of the Medical Sciences, July, 1900.
THE ROXTGEX BAYS IX FOKKXSir MKDICINE. 383
the most earnest student of the X-rays, with the best and most modern
apparatus, is liable at times to produce a dermatitis, for who can s:iy
which of us are victims of idiosyncrasy, or who knows the exact nature,
chemical and otherwise, of the X-rays?
When a patient applies for X-ray treatment, the skiagrapher should
mention the possibility of a burn, and he should either administer the
treatment himself or have it given under his direct supervision.
With idiosyncrasy and no exact measurement of dosage, the X-ray
specialist who follows the established rules laid down by his confreres,
and by experience, is taking the safest and the oul}r rational course.
This subject is best treated of by a recital of the more important
cases wherein damages have been asked by the complainant, urging care-
lessness, negligence, or incornpeteucy upon the part of the radiologist.
In a suit against Dr. Samuel Lloyd, of the Post-Graduate Hospital,
thr patient iraa warned of the danger of a burn. Two radiographs were
taken, when a diagnosis of appendicitis was made. Later the patient
complained of an X-ray burn prior to the operation. The operation dis-
closed an appendicitis of an advanced type. The suit was to recover
$50,000 damages for the ''burn/' The contention of the defence was that
the dermatitis from which the plaintiff suffered came from the antiseptic
preparation for the operation for appendicitis, and not from the rays.
The case, however, never came to trial.
In October, 1897, Dr. Frank Boyd1 was made the defendant in a
damage suit for producing a severe dermatitis with the rays, the plain-
tiff averring that carelessness was largely the cause of the dermatitis, as
well as an insufficient understanding of the rays at that early period
of their employment. The verdict rendered was in favor of the
defendant, the court holding that in this, as in other cases, the physician
was bound to use ordinary skill and judgment, placing the case upon
the same footing as chloroform anaesthesia.
In the case of Henslin vs. Wheaton, the Supreme Court of Minnesota
maintains that in an action for negligence and unskilfulness, the rule of
liability is the same as that applied to other actions for malpractice, and
one of ordinary care and prudence. ' Being the first case of its kind in
Minnesota, the judge remarked that no rule of care in such cases had
been laid down. But there can be no doubt that the rule applicable to
the care and skill required of physicians toward their patients in other
cases applies. That rule was stated in Martin vs. Courtney, 87 Minn. 197,
in the following language : "The legal obligation of the physician to his
patient, where his conduct is questioned in an action of this character,
demands of him no more than the exercise of such reasonable care and
skill as is usually given by physicians and surgeons in good standing."
The plaintiff testified that the exposure of his person to the rays was
'Journal of the American Medical Association, February 12, 1898.
884 ELECTRO-THERAPEUTICS.
for too long a period of time (30 to 40 minutes), and that the tube was
placed too close to his body (two inches, except at one visit, when it was
placed more distant).
The foundation was fully laid for the opinion of an expert touching
the questions involved in the case. But the expert was not a physician
and surgeon, and the defendant raised the objection that only one was
qualified to testify against him, under the rule pronounced in the case of
Martin r.s. Courtney, 75 Minn. 255, where it was held that in an action
against a physician or surgeon for malpractice, unskilful ness in treat-
ment being charged, the physician was entitled to have the propriety of
his treatment tested by physicians of the same school. The trial court
applied that rule to this case, but the Supreme Court was of the opinion
that it erred, contending that the application of the rays to the complain-
ant was not for the purpose of treating any disease or ailment from which
he suffered, but for the location of a foreign substance, thought to be in
his lungs (the gold crown of a tooth).
In the Courtney case, mentioned above, it was contended that the
apparatus for the generation of the rays, likewise the fluoroscope, has
been used very generally by electricians, physicists, skiagraphers, physi-
cians, and others for experimental and demonstrative purposes. It is a
scientific and mechanical appliance, the operation of which is the same
in the hands of all. It may be applied by any person possessing the req-
uisite knowledge, and there would seem to be no reason why its appli-
cation to the human body may not be explained by any person who
understands it. The rule in the Courtney case could therefore have no
application to the case being tried. For in the latter, the rays were not
applied as a remedial agent, but for the scientific purpose of discovering
the presence of a foreign substance in the lungs. A physician, therefore,
who applies the X-rays, not for medical purposes, but to locate a for-
eign substance, is not entitled to have the question of his care and skill
determined only by the opinions of physicians of his own school.
A suit of unusual interest has lately been heard in the high courts.
A child supposed to have run a needle into his knee received repeated
X lay examinations. Xo needle was discovered. A severe X-ray burn,
resulting in an ulcer, appeared on the inner side of the knee, which took
several months to heal. The examinations were made by a mechanic,
under the supervision of a medical man who had not a practical knowl-
edge of radiography. It appears also that he did not recognize the ulcer
a> an X-ray burn, but after its formation continued his examinations.
Discovering the cause of the injury, the child's parents asked damages
for alleged neglect on the part of the defendant. The trial lasted seven
days. Assuming the truth of the statement of the child's relatives, that
the tube had been held close to the knee for periods of a half hour, the
experts on one side gave their opinion that such application showed
ni'glijjence. On the other hand it was maintained that the tube never
THE ROXTGEX RAYS IX FOIJKXSK' MEDICINE. 385
came nearer the knee than eight or ten inches, and from the radio-
graphs produced, it was held by experts that the distance of exposure
must have been eight inches. The jury returned a verdict for the
defendants on every count, finding that there was no negligence.
In the United States a suit was brought for $25,000 damages against
Dr. Otto Smith and Professor AV. C. Fuchs, of Chicago.1 The plaintiff,
aged 37, broke his right ankle as the result of an accident on September
2, 1895. He was able to attend his business on May 1, 1896, and was
then practically as well as ever. He only suffered from slight stiffness
and occasional swelling in the ankle. On September 19, 1896, X-ray
photographs were made, each sitting occupying from thirty-five to forty
minutes, the tube being placed five or six inches'from the ankle. While
under the exposure the patient complained of sharp, tingling pains.
Three days after, a slight redness appeared between the big toe and the
adjoining one, which in three weeks had spread over almost the entire
dorsum of the foot, later forming a blister. An intensely painful ulcer
formed, for which condition amputation of the foot was performed. The
jury awarded the plaintiff a verdict for $10,000.
A rather remarkable case was that of a man named Shelly, who
brought suit against Dr. G. AV. Spohn, of Indiana, claiming $10,000
damages for X-ray burns upon his face and left hand. The patient
was treated for a cancerous growth on the under part of his tongue.
He was warned of the possibility of a burn before the treatment was
instituted. After two weeks a slight dermatitis developed on the
patient's face, and the treatments were then discontinued. The patient
claimed that the doctor directed him to hold down the lower jaw with
his left hand during his treatment. It was proved on trial that the
only real injury was to the hand, and this was shown to be caused by
infection of a wound on the hand. The hand became infected because
the patient persisted in wiping the saliva from his mouth, against the
advice of his physician. The court decided in favor of the physician.*
It will be interesting to note briefly the views entertained and the
verdicts rendered by European jurists. A few are subjoined.
Suit was instituted against "Dr. Sch." by a lady whom he treated
for a beard-like growth on the chin.3 A burn developed, involving not
only the chin, but also the neck and part of the chest. A verdict for
$75 was found against the doctor. He appealed, to have a truly compe-
tent expert summoned to decide, naming Schiff or Freund, of Vienna.
He also asserted that he was not responsible for the devastation caused
by the burn, as it was treated by other physicians who applied ichthyol,
1 A summary of the case appears in the American X-ray Journal, St. Louis, Mo.,
May. 1SW, X,). 5, p. 5GO.
-Mi'.lk-o- Legal Bulletin, January, 1903.
3 Allg. meil. Ct.-Ztg.
ELECTRO-THERAPEUTICS.
carbolic acid, etc., while experience has shown that strong measures are
injurious in such cases, and that X-ray burns should be treated with
exceptional mildness.
In France, a trial heard before the Civil Tribunal of the Seine, on
March 8, 1901, resulted in heavy damages for injury following the appli-
cation of the X-rays.1 In delivering judgment the court found that
Madame Macquaire suffered from osteitis of the femur, and was referred
to Dr. Renault for an X-ray examination. Three exposures were made ;
the first lasted forty minutes, the second, which occurred eight days later,
consumed forty-five minutes, and the third, which was given fifteen days
subsequently, occupied a duration of one hour and a quarter. A slight
erythema was noticed before the third sitting. The three exposures,
which gave a negative diagnosis, were followed by a deep burn of the
abdomen that necessitated treatment for two years. A scientific report
of the case was presented to the court by Professor Brouardel, ulio
stated that the operator's apparatus, which at one time was efficient,
had outlived its usefulness, and that he had given too long an exposure.
The court, commenting upon the defective methods employed,
observed that the defendant was called in not as a medical man, but
as an electrical specialist, but that, nevertheless, his medical title had
gained the confidence of his patients. A too long exposure was certainly
one cause of the accident. The third exposure of an hour and a quarter
was inexcusable, in view of the fact that the tissues had already been
injured by a previous exposure a little over half that time. The con-
clusion of the court was that Dr. Renault had committed a grave
professional error, and he was ordered to pay 5000 francs damages.
The suit against Professor Hoflfa, of Berlin, the famous ortho-
pedist, became widely known not only because of the prominence of the
defendant, but more so for the complicated etiology of the injury.
The patient suffered from ankylosis of his hip, presumably after
coxitis, for which he was treated by the Rontgen rays under the super-
vision of an X-ray specialist. Altogether he was exposed six times.
Xo change for the better occurring, the patient consulted Professor
Hoffa, who advised a diagnostic exposure in order to ascertain the con-
dition of the hip-joint. The distance of the tube from the abdominal
integument was 30 cm., the length of exposure twenty-five minutes.
Ten days later extensive dermatitis set in, which caused the patient to
bring charges of criminal negligence in the treatment. Professor Hoffa,
in defence, claimed that the exposure was made according to the prin-
ciples adopted by the medical profession, and that furthermore the sensi-
tiveness of the skin was increased by the previous irradiations. The
district attorney, after having called upon an expert, who sustained
Professor Hoffa, dismissed the claim.
1 Gazette des Tribuneaux, March 9, 1901 ; and La Semaine M(klicale, March 13,
1901, No. 6, p. xlii.
THE ROXTGEX BAYS IX FORENSIC MEDICINE. 387
At present, by our greatly improved means, Hoffa would not have
burned his patient, even in spite of the preceding irritation, because he
would not have been exposed for twenty-five minutes.
We may safely expect that damage suits for Routgen-ray burns,
caused during diagnostic exposures, will become more and more infre-
quent. But with the employment of the rays for therapeutic purposes,
burns have now become a rather common accident. In several instances
suits were brought against physicians on the ground that they did not use
the necessary means of protection ; in most of these cases the severe
character of the diseases demanded so severe a treatment that burning
had to be contended with. This fact alone is sufficient proof of the
perfidious nature of the suits. Where cosmetic considerations alone are
concerned, such heroic therapy is injudicious.1
A man suffering much distress2 in the early stage of locomotor ataxia
was sent by his physician to a firm of chemists for treatment with the
X-rays. The rays were applied ten or eleven times and the physician
was never present. The man who administered the treatment often left
the patient during the sitting. The machine emitted great sparks and
once or twice gave the patient a shock, but being quite ignorant he made
no complaint to his physician. His feet began to blister, for weeks
he suffered greatly, and his screams were such that lodgers left the
house. Eventually, the soles sloughed off and he became unable to
walk. He brought an action for damages against the firm. Mr. Chis-
holrn Williams, superintendent of the X-ray department of the West
London Hospital, was called as a witness. He said that it was evident
that the plaintiff had been placed too near the instrument — 12 or 18 inches
being the proper distance, not 2 or 3. In cross-examination he admitted
that the use of the X-rays is a recent innovation, and that even physicians
are burned at times. The plaintiff's physician said that he had never
administered the rays, and that he had only studied the subject from
books. He said that he thoroughly trusted the defendants, who had
often administered the treatment for him, merely telling them the part
to which the rays were to be applied. For the defence it was urged
that the defendants were not liable for mistakes of the physician. Wit-
nesses were called to show that it is essential that a physician should be
present as well as the person who administers the treatment. The
defendants stated that they had not studied the properties of the rays or
administered them from a therapeutic point of view. The jury returned
a verdict for the defendants.
Medico-legal Aspect of X-ray Sterility. — Destruction of the procreative
capacity by means of applications of the Rontgen rays may perhaps
'Quoted from an interesting article on "The Medico-legal Aspect of Accidents
caused by the Rontgen Rays," by Carl Beck, M.D., in American Medicine, April 16,
1904.
2 Journal American Medical Association, August 10, 1906.
;;,x> ELEOTRO-T 1 1 K I { A I >E \"V\ CS.
prove of frequent occurrence if the use of the apparatus by anybody and
everybody continues to be permitted. The matter was brought up by M.
Hennecart at the Rontgen Bay Congress recently held in Berlin.1 He
advocated legislation restricting to physicians the use of the rays on human
beings, arguing that it would be difficult to punish laymen in the event
of avoidable injury. He met with hearty support in his contention,
and, on motion of Dr. Becher, of Berlin, a resolution was adopted calling
upon physicians to employ only medical men in X-ray work, pending
legislation on the subject.
A committee was recently appointed by the Paris Academic de
M&lecine to report on the question whether the medical use of the Kont-
gen rays should be restricted. They emphatically advocate that the
medical application of the Kontgen rays should be legally restricted to
duly qualified persons. Their conclusions are based on the established
facts that the medical use of the Rontgen rays may lead to serious acci-
dents, and that certain practices may prove a social danger, while, on
the other hand, only qualified physicians or health officers, or regularly
licensed dentists (in the domain of odontology), are capable of interpret-
ing the results obtained from the point of view of the diagnosis and treat-
ment of affections.1
1 Presse nuVlicale, May 13, 1905.
J Arch. d'Electricite inedicale, February 10, 1906.
PART III
RADIOTHERAPY, RADIUM, AND PHOTOTHERAPY.
THE invaluable services rendered by X-rays in numerous affections,
notably in epithelioma and other cutaneous lesions, are too well known
to need elaboration. The action of the rays upon malignant disease
of the deeper structures offers to the profession less promise of marked
good than in the superficial variety. In tuberculosis, leukaemia, and in
diseases and affections of a systemic nature, time alone will be the deter-
mining factor. As assertions without proofs must weaken any statement,
the following portion of the work is devoted to the therapeutic action
of this agent, its uses, its limitations, its disadvantages, from which
the reader can glean more information and arrive at more decided
(•(inclusions, than by the recital of a number of theories, that at best
would be inexact, hypothetical, and abstract.
CHAPTER I
ACTION OF THE X-RAYS ON BACTERIA.
THE results obtained by investigators on the question of the bacteri-
cidal power of the X-rays seem coufusingly contradictory in many ways.
There are a number of authorities who, from clinical experience
with the action of the X-rays on bacteria, firmly believe that the action
of the rays upon certain of the micro-organisms is in the main detri-
mental to their development, and that destruction results from a few or
more applications.
In March, 1896, Dr. "VV. W. Keen1 reported the results obtained by
the action of the rays on the pink-hued streptococcus, bacillus anthra-
cosis, micrococcus prodigiosus, yellow sarcina, the tubercle bacillus, etc.
He asserts that after exposures, first, for half an hour, and then twice for
fifteen minutes, neither lethal nor inhibitory effects resulted upon the
cultures. Dr. Davis, a few months prior to Dr. Keen's report, published
exactly similar results, the latter's report confirming what had already
been stated by Dr. Davis.
Berton 2 reports that he exposed cultures of the Klebs-Loffler bacilli,
on bouillon, to the action of the X-rays for periods of sixteen, thirty-two,
1 The American Journal of the Medical Sciences.
'Bull. Gen. de Therap. November 8, 1896.
389
390 ELECTRO-THERAPEUTICS.
and sixty- four hours, but in no instance was he able to observe any
result on the vital manifestations of the various inicro-organisuis.
Wittlin, Wolff, Grumniach, and many others have made experiments
on various types of bacteria, the results on the whole being negative.
Muhsam l reports that general tuberculosis in the guinea-pig is not
affected by the X-rays, whilst to a certain extent a localized tuberculosis
is hindered in its development.
Sormani * reports that he exposed numerous cultures of bacteria
for six hours to the action of the X-rays, at a distance of from one
to two inches. No alteration in the rapidity or mode of development,
in the formation of gas, or in their color, fluorescence, or virulence
was noted.
J. Brunton Blaikie* concludes that the rays have no visible influence
on the growth of cultures of the tubercle bacillus, and that the chemical
constitution of diphtheria toxin, like the delicate chemical structure of
the retina, is not affected by their vibrations.
Gocht4 reports the results of Minck's experiments. In his investi-
gations Miiick found that sunlight, daylight, and arc-light caused a weak-
ened condition, amounting to injury to the bacteria in cultures. He
exposed agar plates of typhoid bacilli to the rays for thirty minutes, with-
out any injurious effects. By these experiments he proved that a fewer
number of typhoid colonies developed on that part of the plate exposed
to the influence of the rays than on that portion not so exposed. In
Minck's later reports he specifies that no bad effects were produced on
the typhoid bacteria when they were exposed to the action of the rays
for eight consecutive hours.
H. Rieder 5 reports the experiments performed by Schultze and Beck
upon bacteria with color-producing abilities. The micro-organisms were
planted in agar-agar soil on Petri dishes and exposed from thirty min-
utes to two and a half hours to the influences of the Rontgeu rays. It
was shown that after twenty-four hours' exposure, the bacteria had thrived
quite considerably, also that those shielded by lead, from the full action
of the rays, produced the same color as those that were subjected to the
full action of the rays. In the experiments a coil of 12 cm. spark length
was used, and the tube containing the bacteria was 25 cm. distant from
the source of the rays. He concludes that the rays are negative as
regards chromogenic or color- producing effect of micro-organisms, and
that they cause a more rapid sporulation of the bacillus subtil is, while
retarding that of the bacillus anthracis.
'Freie Vereining. d. Chir., 1898.
*<;iorno della v. soc. it. dig., May and June, 1896.
'The Scottish Medical and Surgical Journal, May, 1897.
4 Fortschritte a. d. Geb. d. Runtgenstr., B. L, 1897-1898, page 34.
'Munchener med. Wochenschrift, 1898, No. 4, 101-104.
ACTIOX OF THE X-RAYS ON BACTERIA. 391
Drs. Xorris "\Volfenden and Forbes Ross 1 conducted experiments
with the bacillus prodigiosus. They grew cultures on potato, carrying
the same to the fifth generation. When exposed to the rays for a period
of sixty minutes, there was a great increase of growth as well as of the
pigment production. An 18-inch spark producing coil was used, 16
volts, with an amperage from 8 to 10. The culture was placed 6 or 8
inches distant from the vacuum tube. The same investigators observed
only very slight changes in the protococcus.
Sabrazes and Riviere2 report the result of their experiments con-
ducted with the bacillus prodigiosus. The culture was placed 15 cm.
distant from the vacuum tube, the dishes being covered with black paper,
so as to exclude all possible light. They observed no changes in the
chromogenic ability of the bacilli ; the morphological characteristics,
growth in particular, remained undisturbed by a daily hour exposure for
20 consecutive days. They also performed experiments with the rays on
the heart of a frog and also upon the leucocytes, failing, however, to ob-
serve any important changes when the exposure lasted from 20 minutes
to one hour or even longer.
Schaudiim 3 experimented on various types of unicellular organisms,
showing that the protozoa differ greatly in their reaction to the rays.
These differences depend possibly on the varying conditions of the nuclei,
and on the presence or absence of capsules.
Dr. F. Robert Zeit, of the Xorth-Western University,4 gives the
result of experiments upon various forms of micro-organisms, and arrives
at the following conclusions :
"Bouillon and hydrocele- fluid cultures in test- tubes, or non-
resistant forms of bacteria, could not be killed by the action of the
rays after 48 hours' exposure, and at a distance of 20 mm. from the
X-ray tube.
" Suspensions of bacteria in agar-agar plates exposed for a period of
four hours to the rays, according to the plans carried out by Rieder,
were not killed.
' ' Tuberculous sputum, even when exposed to the Rontgen rays for
six hours, at a distance of from 16 to 22 mm. from the tube, caused
acute miliary tuberculosis of all the guinea-pigs so inoculated. Rontgen
rays have no direct bactericidal properties."
Lortet and Geuoud,5 Fiorentini and Liuaschi,6 report an arrest of
development of the bacilli in the guinea-pig.
1 Lancet, 1898, p. 1752.
1 Comptes-rend. Acad. d. Sc. Paris, 1897, cxxiv. p. 979-982.
'Pfliiger's Archiv f. d. ges. Physiologic, 1899 ; Archives d'Electricite Med., No.
80, 1900.
4 Journal of the American Medical Association, 1901, xxxvii. p. 1432.
5 Comptes-rendus, 1896.
•British Medical Journal, 1897.
392 KLECTRO-THERAPEUTICS.
Rieder1 has reported quite elaborately on this subject. He used
Volt-Ohm tubes, and a coil of 12 inches (30 cm.) spark length. The
distance of the anticathode from the cultures was four inches, and the
exposure was from one to three hours. The cultures were covered by
a leaden plate having a central aperture, so that the exposed part might
be readily compared with the unexposed area. An apir plate culture of
cholera vibrio was then placed in an incubator kept at a temperature of
37° C. after it had been exposed to the action of the rays for forty-five
minutes. In the incubator was also placed a control culture plate, which
had not been exposed to the rays. On the exposed plate, the colonies
were markedly fewer in number than on the unexposed plate. Similar
experiments were made with gelatine cultures of the bacterium coli,
staphylococcus pyogenes aureus, streptococcus, bacilli of anthrax, and
other bacilli. The tubercle bacilli, in meat extract, glycerin, and solution
of peptone, were similarly affected.
In consequence of the bactericidal action of the Rontgen rays on
plate cultures, he made further experiments on animals. Mice, rabbits,
and guinea-pigs were inoculated with the bacilli of anthrax, streptococcus,
and staphylococcus, and directly after injection they were subjected to
action of the rays. The results being negative, he believed that the rays
have no effect on acute infectious processes.
In order to study its action in chronic affections, Rieder experi-
mented on animals with tubercle bacilli. After subjecting them to the
action of the rays, uecrotic destruction of the skin was observed. This
came on very gradually, remained for a considerable period unaltered,
and showed little or no tendency to extend. The affected skin was covered
with seal >>. and slight swelling and encapsulation of the tuberculous foci
were likewise observed. In the control cases, the skin showed the pres-
ence of ulcers as if made by a therrno-cautery, and these had a decided
tendency to increase in area. Disease of the internal organs set in
later, in those animals which had been exposed to the rays. That local
tuberculosis was arrested by the rays, and in many cases the general in-
fection retarded, was proved conclusively, but nevertheless all the animals
succumbed.
Rieder's experiments proved that the bacteria, when grown on agar-
agar, blood serum, or gelatine, were killed when exposed to the action of
the rays for one hour or more. When bacteria developed in suitable media
outside of the body, their ability to develop further can be stopped, or at
least discontinued to a degree, or even killed, by exposing them to the
action of the rays. He proceeds to say that it may be unnecessary to kill
the various bacteria inhabiting the human body, but only to inhibit their
growth and reproduction.
1 Miineh. im-.l. Wochenschrift, 1898, No. 4, S. 101; and No. 25, S. 773 ; 1899, No. 10 ;
an«l No. 29, S. 250.
ACTION OF THE X-RAYS OX BACTERIA. 393
In experiments on developed germ colonies he found that cholera
micro-organisms were killed after they had been exposed to the rays for
a period of two hours or longer. Gelatine cultures of the bacillus coli,
which had previously been in an incubator for from IL* to 24 hours and
then subjected to the rays, showed colonies in the exposed portion of
the dish which proved to be quite as large as those which were pro-
tected during the exposure from the influence of the rays, though they
were diminished in number.
In another experiment Rieder employed eight dishes of extract of
beef, glycerin, and peptone solution, prepared with a thin layer of new
tubercle bouillon culture, exposing four dishes to the rays for a period of
a little over an hour. These dishes together with those non-exposed were
placed in an incubator at a temperature of 37° C. One week following
he observed a luxuriant growth of the tubercle bacilli in the unexposed
dishes, and in three of the exposed dishes he observed a diminished
growth, while in the fourth dish there was hardly any growth at all
discernible.
Rudis-Jicinsky ' states that his results are similar to those of Rieder,
hence he also favors the theory that the X-rays have a destructive action
upon various bacteria. In the following table are to be seen the results
he has obtained.
UNDER X-RAY IRRADIATION. MEDIA.
ACID. ALKALINE.
Bacillus anthracis Negative, Negative.
Bacillus tuberculosis (in sputum). . . .Destroyed in 48 minutes, Negative.
Bacillus tuberculosis (in flask) Destroyed in 50 minutes, GVowth accentuated.
Spirillum cholene (in flask ) Destroyed in 51 minutes, 55 minutes.
Bacillus diphtheria? (in flask ) Destroyed in 46 minutes, 48 minutes.
Bacillus typho-abdominalis Destroyed in 45 minutes, 49 minutes.
Streptococcus Negative, Negative.
Staphylococcus Negative, Negative.
Mierococcus pyogenes albus Negative, 40 minutes.
Micrococcus gonorrhoase 'Destroyed in 35 minutes, 40 minutes.
The destruction of bacteria in cultures studied by careful observ-
ers, if not due to the direct action of the rays, is, he believes, brought
about by electrical wave discharges. The effect of the X-rays on micro-
organisms in tissues endowed with life, is at present an unsettled question.
It is admitted that the effects here are different from those upon bac-
teria in cultures. That there is a decided effect upon streptococci,
staphylococci, and certain other pus-producing organisms when in living
diseased tissues cannot be doubted.
In the treatment of abscess, frequent irradiations cause the discharge
to become sero-fibrinous in character, and greatly relieved of bacteria,
1 New York Medical Journal, Ixxiii., 1901, pp. 364-385.
394 ELECTEO-THEEAPEUTICS.
with a consequent decrease in the virulence. This proves that the
X-rays must have an effect upon the bacteria when imbedded in living
tissues. Practically similar results may be observed in a superficial
ulcer, which upon close microscopical examination shows the gradual
disappearance of the pus micro-organisms. Ullman, Sambuc, Mougour,
and many others seem to be of one opinion, that the rays cause a phagocy-
tosis ; but it is now generally believed that the rays produce an electro-
chemic substance (an antiseptic) in each and every cell, which destroys
the germs and aids in the healing process.
CHAPTER II
THE HISTOLOGICAL CHANGES INDUCED BY THE ACTION
OF THE RONTGEN EAYS.
AMONG those who have studied most carefully tissue changes the re-
sult of the action of the rays are Gilchrist, Oudin, Bartheleniy and Dar-
ier, Unna, Gassmann, Salarnon, Scholtz, and many others. Dr. Kibbe,
of Seattle, perhaps the first investigator to report authentically upon
this subject,1 relates the histological changes occurring in a piece of
inflamed and discolored skin, removed without the aid of local anaes-
thesia ; the outer layers of the skin, «. <?., the rete mucosum, presented the
most striking alterations, particularly in the nuclei ; the latter were ob-
served to take hreniatoxylin and lithium carmin very feebly, and showed
in addition a peculiar granularity, first indicated by the formation of a
fine nucleolus, which was seen here and there in the process of division.
Near the stratum granulosuni, the bodies of the cells were apparently
becoming converted into keratin hyalin, as a first step to the increase in
bulk of the stratum granulosuni, by a development in their interior of
coarse granules, staining deeply with hgematoxylin and also with carmin.
The corium exhibited the ordinary changes found in mild dermatitis,
— i. e., capillary dilatation, with collections of round cells scattered
throughout its structure, particularly around the hair follicles. No
blood extravasations in any of the specimens had been noted under the
miscroscope or macroscopically.
Gilchrist2 gives the results of his examination from dry, red, exfoliat-
ing dermatitic areas. His report is as follows : "Two portions of skin
were removed for microscopical study, on the first day. One portion was
removed from the dorsum of the phalaugeal region of the third finger,
and the other from the lateral margin of the head, over the base of the
metacarpal of the little finger. Neither stained nor unstained sections
demonstrated the presence of any foreign particles, and only showed
chronic inflammatory changes. A decidedly large number of brown
granules of melanin were found in the desquamating or exfoliating por-
tion. The mucous layer did not appear to be thickened, though it was
more pigmeuted than normal. In the stratum corium, the blood-vessels
appeared irregular and dilated, and the pigment cells covering the
papillae were almost as numerous as are usually found in the stratum.
"It was suggested that particles of platinum might have passed
from the tube through the glass bulb and have been deeply imbedded
xThe New York Medical Journal, 1897, Ixv. p. 71.
* Johns Hopkins Hosp. Bui., 1897, viii. p. 17.
395
:*% ELECTRO-THERAPEUTICS.
in the tissue, giving rise to pigmentation. Portions of the exfoliat-
ing skin were accordingly submitted to Professor Abel for a chemical
analysis, who stated that no particles of platinum could be detected."
Gassmann and Schenkel ' made histological examinations of deraia-
titic areas, and found that the tissue was not necrotic but consisted of
easily stained elements ; degenerate forms were observed like those
found in pathological tissue, which readily took up the nuclear stains.
These presented peculiar aspects, some being drawn out into long
threads, others were branched, indented, and grouped into irregular clus-
ters, while there were also a few large lymph-vessels and capillaries dis-
tended with blood. Elastic fibres were plentifully distributed, together
with collections of crowded mononuclear leucocytes, and a general but
minute extravasation of erythrocytes. It is still undecided whether this
peculiar tissue may be regarded as an altered subcutaneous tissue or as
a newly formed tissue already undergoing degeneration. The healing
process, which was very slow, began at the peripheral margin of the
diseased area.
Oudin, Barthelemy, and Darier,1 in a study of alopecia in guinea-pigs,
found the prickle cell of the stratum granulosum ten to fifteen times
thicker than is normally the case, the individual cells being only
slightly altered. Xot a single hair root was visible, and there appeared
only slight traces of the previous hair follicles. All the hair papillae,
regeneration buds, and sebaceous glands were lacking.
The changes in the dermis were trivial, the white fibrous and yellow
elastic connective tissue network being normal in texture. The large and
smaller blood-vessels of both the cutis and subcutis were normal ; nor
were any changes in the structure of the nerve-fibres apparent. These
writers conclude that, as a result of intense irritation, the least differen-
tiated skin elements are apparently increased. On the contrary. Un-
modified elements, hair, nails, and glands, undergo retrogressive changes
and atrophy. They do not know whether these changes are due to
nervous influence or to obliteration of vessels or other circulatory
disturbances.
Unna* reports his investigations on a brown pigmented skin, obtained
from a woman who had been, previous to her disease, exposed to the
influence of the rays. He states that no increase of pigment was ob-
served in the epidermis, but that there was a decided increase of coloring
matter in the hair and in the connective tissue of the papillary layer;
this appeared to be especially pronounced in the immediate vicinity
surrounding the capillaries and the more superficial layers of the cutis.
1 Kortsdiritte. Bin Beitrag zur Behandlung der Hautkrankheiten mittels Ront-
genstrahlfii, vol. ii. p. 128.
- M«.natach.f. prakt. Derm., 1897, xxv. p. 417.
"Deutech. med. Ztng., 1898, xviii. p. l«.»7.
ACTIOX OP THE BONTGEN EAYS. 397
Scholtz1 says: ''In almost every field were cells with nuclei divided
into two or three parts without any attempt at karyomitosis. The evi-
dences of a beginning degeneration were apparently everywhere. The
outlines of the cells were hardly distinguishable, and their protoplasm
appeared blended into a homogeneous mass. The nuclei were merely
shadows. In the hair follicles and sheaths, the changes in the cells
appeared entirely analogous ; and the loosening and falling of the hairs
can be easily understood when taking into consideration this active cell
degeneration.
"The corium was oedematous ; the connective tissue fibres did not
stain well, and appeared somewhat swollen and homogeneous. The
basophilic reaction, of which Unna speaks, could not be demonstrated,
though the elastic reticuluiu was still intact. Xo appreciable changes
were apparent in the small vessels. Evidences of inflammatory reaction
were only slightly intimated. The connective tissue cells and the sweat
glands showed changes only to a slight degree. The cells of the intima
were swollen, projected into the lumen of the vessels, and in some places
showed evident proliferation, with a tendency to fall off into the blood
current."
Gassmann2 described the changes occurring in the larger and
smaller blood-vessels of a part subjected to the action of the X-rays, as
follows :
" Important changes are noticeable in the vessels. The walls of the
small vessels and capillaries in the upper zone of an ulcer are changed
into an irregular swollen mass, the lumen being sometimes entirely
obliterated, and sometimes filled with corpuscles, in which latter case the
vessel is surrounded by a collection of infiltrating cells. The intima is
thickened and the eudothelial cells are swollen, and often detached from
the wall.
"The small vessels of the deeper tissues show similar changes of the
intima, the lumen being entirely or partly obliterated. In the larger
an cries and veins of the subcutis the intima is thickened, there is
proliferation of the eudothelial cells, filling perhaps half of the lumen.
The intima shows numerous vacuoles and crevices. The muscular layer
also shows vacuoles ; the cells seem to be pressed together, are smaller,
and the fibres between them do not stain well.
"Leucocytes are present in the media, and more numerously in the
adventitia. Xeither the inner nor the outer elastic layers are compact,
but both are loose, the fibres separated from each other by spaces and
increased in number. Xot all, but many, of the large vessels show these
changes. The lumiua are sometimes empty, though not obliterated,
sometimes filled with blood."
1 Arcli. f. Derm. u. Syph. 1902, lix. p. 241.
"Fortschr. a. d. Geb. Runtgenstrahlen, 1899, 11, p. 199.
ELECTRO-THERAPEUTICS.
I. The Action of the X-rays on the Skin, or Rontgen Dermatitis.
That the X-rays have an effect upon normal as well as on pathologi-
cal tissues is to-day an established fact. They cause changes not only in
the superficial but also in the deeper structures. In the former we refer
to changes in the several parts of the skin and the subcutaneous tissue ;
in the latter we allude to possible changes produced in organs such
as the lungs, heart, kidneys, and other viscera.
Shortly after the discovery and application of the rays for diagnostic
purposes, it was noted that in some of the cases, a dermatitis of varying
severity, with epilation of the hair occurred. This untoward incident
was the genesis of X-ray therapy.
A. CAUSES OF X-RAY DERMATITIS.
Many theories have been advanced regarding the etiology of X-ray
dermatitis. Prominent among these are the following :
1. Flight of minute platinum atoms.
2. Ultra-violet rays.
3. Cathode rays.
4. Rontgen rays.
5. Electrical induction.
6. Ozone generation in the skin.
7. Idiosyncrasy.
8. Faulty technic.
1. This theory lacks confirmation and is not generally accepted.
2. Stine1 and Goldstein2 state that burns received on exposure of
the body to the excited Crookes tube are not due to the X-rays, but to
the ultra-violet light coming from the tube.
3. Freund maintains that the phosphorescent glow set up by the
impact of the cathode rays gives off a certain number of ultra-violet
rays. This view is endorsed by Gilchrist,3 and Foveau de Courmelles.4
Sir Oliver Lodge5 asserts that cathode rays do penetrate the tube and
accompany the X-rays.
4. By many it is believed that the X-ray radiations are directly re-
sponsible for the dermatitis produced. Among the authorities that favor
this view may be mentioned Gassmann, Schenkel, Rieder, Forster, and
Kienbock.
5. Rollins' exposed his hand to a tube whose resistance was so high
1 Electrical Review, November 18, 1896.
1 Sit/ungsbericht d. k. preuss. Akad. d. Wissenschaften, Band viii., quoted by
Holzknecht.
'Bulletin, Johns Hopkins Hospital, February, 1897.
4Congr. f. Neurolog., Brussels, 1897.
5 An hives of the Rontgen Ray, April, 1904.
•Electrical Review, Jan. 5, 1898.
ACTION OF THE RONTGEN BAYS. 399
that no current could be forced through it with the generator used ;
nevertheless, the hand was burned, in spite of the fact that no X-rays
were produced. He therefore believed that X-ray burns could be pro-
duced by electricity, but did not show that they could not also be
produced by the X-rays.
Those favoring the above theory are Schall, Leonard, Bordier,
Salvador, Gocht, and Apostoli.
6. Tesla l believes that burns are due to the ozone generated on the
skin and to a small extent to nitrous acid. He therefore interposed a
screen made of aluminium wire, connected with the ground, between the
tube and the person, and no burn was produced. Before he took this
precaution one of his assistants was burned.
Dr. F. J. Clendinnen has made some experiments on the action of
X-rays on the air. He found that air which had been irradiated for ten
minutes gave a slightly acid reaction with phenol-phthalein. Further
tests with diphenyl-sulphonic acid showed this to be due to the produc-
tion of nitric acid. He holds that the healing and stimulating effects of
the X-rays are partly due to this production of nitric and nitrous acids.
This would account for the bronzing and pigmentation due to X-rays,
since, when nitric acid comes in contact with any proteid matter it turns
yellow owing to the formation of xanthoproteic acid, which acid would
further be darkened by the action of the ammonia in the skin.2
The above theories are not accepted by Oudin, Barthelemy, and
Darier.
7. Some individuals show a marked susceptibility to the action of
the rays. All operators confirm this view. In some patients, X-ray
burns have been recorded where a single exposure of one minute duration
was given.
8. The principal factors in faulty technic are :
(a) Too close proximity of the tube to the part to be irradiated.
(6) The degree of vacuum of the tube, the soft tube being
most prone to produce X-ray dermatitis.
(c) Prolonged or repeated exposures.
The opinions held by various observers as to the etiology of X-ray
burn, as detailed above, may not be endorsed to-day by some of these
very scientists. As the study is being more and more unfolded, new
theories are from time to time being advanced to account for X-ray der-
matitis.
B. CLASSIFICATION OF X-RAY DERMATITIS.
It is customary to divide X-ray dermatitis into the acute and chronic
forms.
1 Electrical Review, December 2, 1896.
* Intercolonial Medical Journal, October, 1904.
400 ELECTRO-THERAPEUTICS.
The acute for tn may appear 24 hours after the irradiation, or may not
manifest itself for two or three months subsequently ; it is characterized
by the presence of an erythema. This erythema is attended with
intense itching, which in a few days may give rise to vesicle formation.
The erythema may be preceded by pigment formation.
As soon as the cutaneous pigmentation has taken place, an effect
upon the hair may be observed. The hair loses its natural lustre, the
individual hairs become brittle and break off close to the hair follicle
upoii the slighest friction or combing.
It should be remembered, when there is an erythema, that this in
itself is sufficient to cause a loosening and falling of the hair, without
injury to the follicle, hair papilla, etc. Hair rich in pigment falls out
more readily than hair of a sparser pigment. I have seen two <-a>cs
where the hair had been removed from the entire scalp by the X-rays, to
grow again, and more luxuriantly, in a short time.
In mild cases this is simply a transient erythema, lasting perhaps a
few days, followed by an exfoliation of the superficial epidermis. There
may be a hypenesthesia of the skin and a mild burning sensation, though
no real pain is experienced. In the hairy portions, epilation may occur
without any active inflammatory signs.
In cases of the second degree there is a formation of serous or puru-
lent blebs following the erythema, and bearing a close resemblance to a
scald, but differing from the latter, in that it is decidedly slower in heal-
ing and less acute in character.
In the worst cases, the process, instead of disappearing in a few
weeks, extends to the deeper layers of the skin and to the subcutaneous
tissue, resulting in the formation of a leathery slough, surrounded by a
brawny indurated swelling with ill-defined limits. The process is
exceedingly slow and obstinate, and possesses a tendency to progress
It is generally very painful, usually resisting all treatment in a most
remarkable way.
The chronic form, found most largely in the persons of operators
(Fig. 209), may be regarded as a long-continued form of the acute variety,
and produced by the constant irritation of the action of the rays. Follow-
ing the acute form, the nails become brittle and thinner, and show th*>
presence of linear striations, and later of furrows.
Still later onychia develops, and the nail is frequently shed. The
knuckles become sensitive from a chapping of the skin, serum exudes,
and an itching sensation develops, which is often followed by numbness
and anaesthesia. The skin becomes hard and leathery, warty excrescences
form, and from the base of these excrescences a clear serum issues. Fre-
quently these growths become detatched and offer a raw, sensitive sur-
face. While the operator's hands are most frequently ''burnt," the phe-
nomenon may manifest itself on any part of the body, especially the fare
and the chest
FIG. 209.— AUTHOR'S HAXDS.— Showing the result of chronic X-ray dermatitis.
(Began in 1899 and the above photograph taken in 1903.)
ACTION OF THE EONTGEX KAYS. 401
Kienbock1 classifies X-ray burns as follows :
Those of the first degree, which appear from twelve to sixteen or more days after
exposure. The hair loosens, falls out, and leaves the skin smooth, bald, and occa-
sionally pigmented.
Those of the second degree, where the exposure has been more intense and
appears after a briefer interval than in burns of the first degree. There is localized
or general swelling. The hypenemia, at first light, later assumes a darker color.
There is marked irritation. These symptoms are followed by loss of hair, and by
marked cutaneous pigmentation with subsequent scaling ; the skin is smooth and sen-
sitive, of a delicate hue, and devoid of hair ; after a time, however, the part again
u>sumes its normal aspect, a slight pigmentation perhaps remaining.
Those of the third degree. Blisters and extensive exfoliations are present, the
hair fails to grow again, changes in the pigmented spots are permanent, and there is
atrophy of the cutis and papilla-, with the formation of painful cicatrices.
Th<>-?e of the fourth degree. This is characterized by a superficial dry necrosis.
After a latent period of a fortnight, the skin is darkly discolored, and is the seat of
ulceration, which may be of an indefinite duration. The condition may be painless.
The above methodical classification is purely arbitrary. I have seen many cases
of dermatitis where the symptoms did not follow these typical stages.
C. THE LATENT STAGE ; FREQUENCY AND SUSCEPTIBILITY IN X-EAY
DERMATITIS.
E. A. Codinan* shows that the latent period in X-ray dermatitis
varies from an interval of 24 hours up to the fourth week after the
irradiation.
In 9 instances, signs or symptoms were noticed within 24 hours.
In 6 instances, signs or symptoms were noticed within 2 days.
In 6 instances, signs or symptoms were noticed within 3 days.
In 2 instances, signs or symptoms were noticed within 4 days.
In 5 instances, signs or symptoms were noticed within 5 days.
In 3 instances, signs or symptoms were noticed within 6 days.
In 3 instances, signs or symptoms were noticed within 7 days.
In 4 instances, signs or symptoms were noticed within 8 days.
In 2 instances, signs or symptoms were noticed within 9 days.
In 9 instances, signs or symptoms were noticed within 10 days.
In 8 instances, signs or symptoms were noticed within 10-14 days.
In 8 instances, signs or symptoms were noticed within 15-21 days.
In 2 instances, signs or symptoms were noticed within 22-28 days.
In 3 instances, signs or symptoms were noticed after the 4th week.
From this table we may observe that it is impossible to fix an exact
time when the first symptoms may be expected, but the majority of cases
of X-ray dermatitis make their first appearance from the 10th to the
13th day, the cases occurring later having really started previously, but
the symptoms were insufficient to attract the patient's attention.
1 "Hautveranderungen durch ROntgenbestrahlung bei Mensch und Thier,"
Wiener nied. Presse, 1901, pp. 874-879.
2 Philadelphia Medical Journal, March 8, 15, 1902.
402 ELECTRO-THERAPEUTICS.
Tii seven cases, two of which came under my care, a dermatitis had
been set up from two to eight hours after exposure. There are two cases
on record where dermatitis did not appear until the thirty-second day,
but I believe it questionable whether the X-rays were instrumental in
bringing about this belated condition.
In 1898 H. Gocht l stated that in the Hamburg-Eppendorf Hospital,
out of a total of over 2000 exposures, there was only one burn.
Albers-Schonberg, in the same year, was also of the opinion that the
probability of a burn is only very small. He, perhaps the most compe-
tent X-ray expert, says that, despite his frequent irradiations for diagnos-
tic purposes, up to that time (1898), he had never seen a burn; and that
was at a period when exposures of twenty minutes were customary, with
the tube very close to the body.
Hofifa 2 says that the occurrence of the burn is in the proportion of
7 to 10,000, which small figure (0.7 per cent.) is not obtained in the
statistics of even the most harmless operation.
It has been said, that the individual "disposition" is an important
factor in the relative frequency of X-ray burns, and that this disposition
varies according to the types of the pigments of the body. Different
parts of the body react variously to the rays, the hairy regions being
especially sensitive.
In an examination of 8000 patients for diagnostic purposes, I have
met with but three mishaps, — one case each of epilation, vesication, and
ulceration.
Sjorgen and Sederholm s are strongly impressed with the fact that
blondes and brunettes react differently to the action of the rays, as shown
in the following :
A— BLONDES.
Case 13, with 21 exposures ; reaction mild.
Case 4, with 19 exposures ; reaction mild.
Case 6, with 12 exposures ; reaction very mild.
B— BRUNETTES.
Case 1, with 22 exposures ; reaction strong.
Case 2, with 20 exposures ; reaction very strong.
Case 5, with 18 exposures ; reaction present.
Case 7, with 16 exposures ; reaction strong.
Case 7, with 15 exposures ; reaction ; second period, strong.
Case 8, with 15 exposures ; reaction medium.
Case 9, with 18 exposures ; reaction intense.
Case 10, with 29 exposures ; pronounced swelling.
Case 11, with 35 exposures ; very strong reaction.
1 American Electro-Therapeutic and X-Ray Era, May, 1903.
'Quoted by Scliiirmayer, Fortschritte a. d. Geb. d. Rontgenstr., 1901, 1902, v.
pp. 4K 51.
3 Ibid.
ACTIOX OF THE ROXTGEN RAYS. 403
Codman1 says: "Many assertions have been made that the static
machine is less liable to the production of injuries by the X-rays than any
other form of apparatus, because of the low amperage required ; this
statement, however, is not borne out by the present analysis.
"In the cases in which the kind of apparatus is recorded, 11 were
caused by static machines ; of these 3 were severe ; 11 were caused by
Tesla coils ; of these 5 were severe ; 42 were caused by forms of induc-
tion coils ; of these 18 were severe.
"On the other hand, coils have been far more commonly used than
static machines or the Tesla apparatus, probably in the proportion of 3
to 1. In the other cases in which the apparatus is not spoken of, it is
probable that a static machine would have been used and not mentioned.
I believe that X-ray dermatitis occurs with equal frequency both with
the coil and with the static machine."
Codmau further says : " Unfortunately, the quality of the tube is not
recorded often enough to give us effective data. Where it is recorded it
is usually stated to be 'soft.' It is the general impression of skiagraph-
ers that soft tubes have more therapeutic influence than hard. It is
probable that the distance from the skin and the time of exposure are
more important factors.
"Maximum recorded distance from tube to skin at which injury has
occurred, was 50 cm. (statement of patient). Minimum recorded distance
from tube to skin, 1 cm. Maximum recorded time of exposure, 20 hours
(ten exposures). Minimum reported time of exposure, 5 ruin, (other
data not given). Considerable inaccuracy probably exists in the ac-
companying reports of times and distances. One writer speaks of 'dis-
tance from tube to skin;' another from 'tube to plate,' or from 'platinum
terminal to skin,' still others say the ' tube was so many inches distant,'
or perhaps neglect the entire data."
Leopold Freund,2 whose experience in this field has been enormous,
says: "The dangers of Rontgen therapy are not confined to primary
Rontgen dermatitis, which may take months or even years to heal, but in-
clude permanent changes in the integument, atrophy, scleroderma, and
telangiectases, which may follow prolonged and repeated irradiations.
The most to be dreaded is the primary Rontgen dermatitis. Its pro-
tracted duration, its painful nature, and the comparative uselessness of
treatment, render these cases the bane of both doctors and patients.
"The question arises, What is the percentage of accidental burns in
all cases treated by Rontgen therapy! According to Codmau, up to the
year 1902, the total number of recorded cases of severe burns due to the
Rontgen rays is 172. He calculates that such accidents do not exceed one
1 The Philadelphia Medical Journal, March 8 and 15, 1902, ix. pp. 4-38.
2 An address delivered before the Wissenschaftliche Versammlung des Wiener
Medizinischen Doktorenkolleginms, February 12, 1906.
404 ELECTRO-THERAPEUTICS.
in 5000. In the hospitals of Boston there were only four cases of burns
in 20,000 radiographic exposures.
"Hahn has collected statistics from a number of sources :
Hahn treated 303 cases, and had 2 Rontgen ulcers.
Schiff treated 505 cases, and had 3 Rontgen ulcers.
Miiller treated 47 cases, and had 1 Rontgen ulcer,
de Nobele treated 42 cases, and had 1 Rontgen uk-er.
"Holzknecht gives the number of cases in which reaction occurred,
and not the total number irradiated. In 4872 cases of reaction, he got
44 cases of ulceration.
" Many other authors record cases of ulceratiou, but do not give the
total number of cases treated. All agree that unforeseen secondary
effects may include scarring, pigmentation, telangiectases, atrophy of the
skin and nails, keloid, and sclerodermic changes."
Between the years 1896 and 1904, Freund treated 369 cases, with a
total of 11,808 irradiations. In these 369 cases he had 3 intense
reactions.
D. PATHOLOGICAL PHYSIOLOGY.
Huntington l quotes Eudis- Jicinsky in that an X-ray dermatitis con-
sists of an acute, subacute, or chronic uecrobiosis. Eudis-Jicinsky, in a
later article, states that "the irritation of the peripheral extremities of
the sensory nerves causes a paralysis of the vaso- motors of the vascular
area affected, that spasmodic contraction of the arterioles and capillaries
follow, and the proper nutrition of the cells is impaired. With these
changes, which are directly dependent upon disturbance of the circula-
tion, there are changes in the parenchyma cells of the affected region.
The death of tissue follows, caused by permanent stasis in the blood-
vessels."
Lowe* mentions the fact (first demonstrated by Lord Kelvin), that a
bar of iron, electrified and insulated, can be discharged or de-electrified
by means of the X-rays. He seems to be of the opinion that an X-ray
dermatitis depends very largely upon a similar action on the trophic
nerves of the parts subjected to exposure.
E. A. Codman * supports the theory that attributes the lesions to a
primary action on the trophic nerves of the blood-vessels and the skin.
He says, "the delay in the appearance of the lesions after the exposure,
their progressive character, and their failure to react to stimulating
treatment, are the strongest reasons for this view." His reports of the
1 Annals of Surgery, December, 1901.
'British Medical Journal, January 18, 1902.
s Philadelphia Medical Journal, March 8-15, 1902.
ACTION OF THE RONTGEX KAYS. 405
microscopic examinations of the excised tissue agree in that the smaller
arterial branches are occluded, and the appearances are not unlike those
of necrosis and inflammation due to other causes.
Apostoli1 ascribes the cause of these burns to an electrical stream
of high tension issuing from the Crookes tube.
Oudin, Barthelemy, and Darier 2 believe that the changes in the skin
are not caused by the local direct action of the rays on the cells of the
cutis and epidermis, but that the influence is transmitted indirectly
through a tropho-neurotic action, having its seat entirely in the central
nervous system.
Destot 3 also regards these changes as having a tropho-neurotic origin.
Kaposi explains them by a paresis of the blood-vessels, whilst Bordier is
of the opinion that they originate in a disturbance of nutrition.
Kienbock believes in a chemical action leading to disturbances of
metabolism, by which the cells of the tissue are led to react in the form of
a Eontgen dermatitis.
Freund maintains that, through the destruction of tissue elements,
certain products arise whose absorption leads to constitutional symp-
toms. This would explain the appearance of fever at the commencement
of severe Eoutgeu dermatitis, before any excoriation or ulcer affords the
opportunity for local infection.
L. Jankau ' believes that an electrolytic analysis of the cells takes
place from irradiation, whereby the tissues are chemically affected, and
inflammation is provoked.
Gassmann and Schenkel5 have examined histologically this form of
dermatitis. They found that the tissue was not necrotic in the ordinary
acceptation of the term, but consisted of various characteristic elements
easily stained. The chief of these were bundles of collagen fibres
of normal appearances, their nuclei being readily stained by the usual
methods. Here and there were seen degenerate forms, like those found
in pathologically altered tissue, which readily received nuclear stains.
These were of peculiar aspect, some being drawn out into long threads,
others much branched, indented, or grouped in irregular clusters. There
were also a few large lymph -vessels, and capillaries distended with blood.
Elastic fibres were found in abundance, with here and there collections
of crowded mononuclear leucocytes or a slight extravasation of blood.
The adipose tissue was unaltered.
Unna6 alone has had an opportunity of examining microscopically a
dermatitis erythematosa set up by X-rays in the human skin. He found
*New York Medical Journal, October, 1897.
2 Monatschrift f. prakt. Dermatologie, 1897, xxv. p. 417.
3 Compt.-rend. Acad. d. Sc., Paris, 1897, cxxiv. pp. 1114-1116.
4 Internal, photog. Monatsschr. f. Medicin, 1898, vol. v. pp. 1-7.
5 Fortschritte, vol. xi. p. 128.
6Fortschritte a. d. Geb. d. Rontgenstrahl., B. xi., H. 3, pp. 118-119.
406 ELECTRO-THERAPEUTICS.
the elastiii altered, and the bands of collagen swollen, whence he concludes
that the Riintgen rays attack even the more resisting tissues of the skin.
He thereby explains their cumulative action.
Sequeira l speaks of a few cases where the scar tissue that remained
contained many vascular places, designating them as telangiectasrs. I
have seen three such cases, though I could not study the condition in
detail as I would have liked.
In a previous paragraph it is mentioned that the changes resulting
from the action of the X-rays are usually atrophic in form. On the
other hand, there is a hypertrophic tendency about the joints of the
phalanges and especially on the dorsum of the hand. The condition
spoken of as hyperkeratosis is characterized by an over-development
of the horny layer of the epidermis. These keratotic areas are nothing
more than elevations that have a broadened base, and which frequently
project above the outer surface of the skin in the form of small
"peaks."
Usually the bases of the keratotic peaks are not inflamed, though I
have seen three cases where the opposite condition was true. Cases are
reported where there have been three keratoses distributed over the en-
tire anterior surface of the thorax, the dorsal surface of hands and feet,
and over the thighs. Between the keratotic peaks, the skin was usually
atrophied and pigmented.
Johnston l speaks of the keratotic peaks as " precancerous patches,"
he believing that these points are very prone to undergo epithelioruatous
changes. He reports a case where a surgeon developed numerous kera-
toses on the back of both hands, the result of extensive use of the rays.
Two of the larger peaks were excised and studied microscopically ; the
first revealed the cutis in a state of subacute inflammation, accompanied
by an intense lymphocytosis with a proliferation of fibroblasts.
E. DURATION.
The duration of chronic dermatitis is often prolonged over months
and years, running an uninterrupted course. Cicatrices often remain
after the lesion has healed. In the cases of X-ray operators, chronic
dermatitis leaves the nails disfigured and deformed, and they never again
regain their normal appearance and condition. The skin of the hand
remains tough and indurated, with the subsequent occurrence of atrophy.
The bones suffer no change, though the knuckles are enlarged, and
there is hypertrophy of the periarticular tissues (as is evidenced in my
own hands).
Movements of the fingers, in flexion and extension, are painful and
limited. Itching, paraesthesia, and anaesthesia are present to a greater or
1 The British Dermatological Journal, 1902, xiv.
'The Philadelphia Medical Journal, February 1, 1902, pp. 220-221.
ACTION OF THE ROXTGEN BAYS. 407
lesser degree ; this renders the operator nervous, irritable, and generally
ill. Months and years of rest and change of occupation may fail to show
any improvement in the condition, the skin remaining thickened, dry,
and shining; there being present numerous red patches, with the joints
flexed and sensitive.
When the X-rays were first brought to the notice of the medical
profession, the number of experimenters in this fascinating field were
numerous. To-day, many of these enthusiastic votaries have become its
victims, and it is a painful duty to inscribe the names of the following as
among the more prominent workers who have perished, — martyrs to a
noble cause : Mr. Clarence Dally, Thos. A. Edison's assistant, of New
Jersey ; Mrs. E. Fleischman Aschheim, of San Francisco ; Dr. Louis
A. "Weigel, of Rochester, New York ; "NV. C. Fuchs, of Chicago ; Dr. A.
Barry Blacker, of London ; M. A. Radiquet, of Paris. The number of
operators that have been disfigured, maimed, and injured would form a
deplorable list of tremendous proportions.
F. PREVENTIVE MEASURES AGAINST X-RAY DERMATITIS.
As a prophylactic measure, the patient's susceptibility should be
carefully ascertained by interrupted small doses of the rays. The
character of the tube must be considered. Soft tubes produce a derma-
titis more readily than do hard tubes, because the latter afford less absorp-
tion. Another matter for thought, is the distance of the tube from
the patient. The more distant the tube, the less will be the danger of
burning the patient. In treating the deeper-seated structures, the sur-
rounding healthy parts should always be screened from the rays by thin
sheets of lead. For filtering off the soft and unnecessary rays, advantage
is taken of the use of a piece of leather or aluminium (grounded) applied
over the part to be irradiated. As a prophylactic measure the treat-
ment first employed by Dr. C. L. Leonard, of Philadelphia, may be
mentioned. He employs the compound stearate of zinc powder, with
ten per cent, ichthyol, in cases under treatment, believing that it not only
relieves the symptoms of acute dermatitis, but also allows a stronger
dosage to be employed.
THE PROTECTION OF THE OPERATOR.
For his own protection, the operator should never use his hand to
test the intensity of the rays. While the patient is undergoing treat-
ment or examination, the operator should be in a communicating room
or behind a lead screen or in a sentry box, where he can observe the
fluorescence of the tube from a mirror suspended at a convenient angle
from the ceiling. The best place for the operator to have his lead pro-
tection, is behind the anode. The absence of the operator from the room
is always advisable because its atmosphere becomes ionized by the rays.
408
ELECTRO-THERAPEUTICS.
To discover the presence or absence of the rays, the operator may
employ an electroscope or photographic plate, and wherever they are
detected that region is unsafe for the operator. (Fig. 210.)
The Crookes tube should be covered with an opaque rubber shield,
or, as some recommend, with lead glass containing an interval of ordinary
glass, for the passage of the rays. Miiller paints the active hemisphere
FIG. 210.— Author's scheme for the operator's protection.
with a black opaque material and employs diaphragms of various sizes.
The operator should still further protect himself by wearing special
opaque rubber gloves and an apron, the latter to prevent injury to the
testicles. Spectacles of lead glass are worn by some to protect the eyes.
It is far better, however, for the operator to be out of the room and dis-
pense with such protecting devices.
G. TREATMENT OF X-RAY DERMATITIS.
Treatment of the acute form may be similar to that employed in any
other acute inflammation of the skin.
Slight erythema may disappear within a few days, but when the
irritation is excessive and accompanied by intense itching, soothing rem-
edies, as, zinc oxide ointment, compresses of ice, boric acid, etc., may be
employed. When the vesicles burst and the skin resembles the lesion
of pustular eczema, a warm normal salt solution proved soothing and
efficient in one of my patients. Carbolic acid, bichloride of mercury,
and other antiseptics produce irritation. I used orthoform on my own
band, with the result that a general inflammation resulted.
ACTIOX OF THE RONTGEN EAYS. 409
Too much medication is dangerous. Dry dressings are to be pre-
ferred. My treatment of acute X-ray dermatitis consists in cleansing the
part with sterile water, covering it with sterile gauze, and in enjoining
absolute rest of the part. The general health should be inquired into,
and the patient's diet should be simple and uon-stimnlatiug.
For the intense itching, immersion in hot water and the employment
of dilute solutions of cocaine are to be recommended. If the operator
uses a dilute solution of carbolic acid for this purpose, he should remem-
ber that its too frequent application may increase the irritation and
even produce gangrene. Xormal salt solutions and sterile gauze dress-
ings brought about rapid relief in an acute case under my care in the
Philadelphia Hospital.
Treatment of the chronic form is the same as for the acute form, plus
other measures. The latter include the employment of picric acid,
various ointments containing boric acid, /inc oxide, calcium salts,
aristol, orthoform, etc., with lanolin, cold cream, vaseline, etc., as a base.
Some recommend powders of the above in place of ointments. Some
urge the use of a poultice as an analgesic. When the warty excrescences
appear, it is good practice to file them down with a small strip of sand-
paper. When the knuckles are thus involved, I advise the use of a
digital (palmar) splint, which, however, must not be worn too long,
lest ankylosis set in. I also advise touching the fissures in the skin with
a ten per cent, solution of argyrol. As salicylic acid is very stimulating,
its use is contraindicated. Continuous moist dressings should not be used,
as maceration of the skin is sure to ensue. When the skin appears dry
and parched, nothing is so valuable as the nightly application of lanolin.
It is worthy of remark that frequently a chronic X-ray dermatitis,
apparently cured, breaks out anew and with increasing severity. In
such cases I employ an application of twenty per cent, of zinc oxide in
lanolin for several days. If continued too long over-stimulation will
occur. The internal administration of arsenic and the iodides is most
valuable. Alcohol in all forms is strongly contraindicated.
The following treatments are appended :
F. Engman1 says that in acute cases of the second degree or milder,
where infection and ulceration are not complications, he has controlled
the intolerable itching, assisted repair, and kept the surface aseptic,
by the employment of the following formula, which has yielded him
excellent results.
R Boric add 12 drams (46J grammes).
Zinc oxide, starch, bismuth subnitrate, of each, 1 ounce
Olive oil 1 ounce
Lime water 3 ounces
Rose water 12 drams
1 Interstate Medical Journal, July, 1903.
410 ELECTRO-THERAPEUTICS.
The powder should be well triturated in a mortar and the lanolin
added. The olive oil and lime water are thoroughly mixed, and slowly
added to the powder and lanolin, keeping constantly stirring ; after
which the rose water is added, and the whole beaten up in the mortar
into a light creamy paste. If there is much pruritus, 1 or 2 per cent,
of carbolic acid can be added to the mixture. This creamy paste
should be spread on several thicknesses of absorbent gauze, and applied
to the surface, and a sheet of gutta-percha tissue placed over it, to
prevent evaporation. It is very soothing because of the great per-
centage of water it contains, and acts almost as a lotion without the
disagreeable effects.
Mr. H. Lyle, Senior Surgeon to the Liverpool Hospital, believes
X-ray burns to be reasonably amenable to treatment. The method recom-
mended is the free application of an ointment, composed of one dram of
lead oxide, two drams of carbonate of zinc, one drain of glycerin, half a
dram of olive oil, to one ounce of benzoinated lard.
Unna ! advises that the hands be bathed from one-quarter to three-
quarters of an hour in warm water with superfatted soap, to be followed
by the application of one of the following ointments :
R Ung. Hebraj rec. par 25.0 grammes (386 grains).
Sol. calcii chlorati 10.0 grammes (154 grains).
Glycerini 5.0 grammes (77 grains).
Adipia lanse 10.0 grammes (154 grains).
or
R Ung. Hebrae rec. par 35.0 grammes (540 grains).
Acidi ealicylici 2.5 grammes (39 grains).
Sap. kalini 2.5 grammes (39 grains).
Vaselini 10.0 grammes (154 grains).
Dr. Nogier * recommends for the burning, itching, and pain in acute
dermatitis :
R Water 3 ounces (90 grammes).
Gelose 20 grains (1.25 grammes).
Glycerin, oxide of zinc, of each 3 drams (12 grammes).
Norman Walker* uses the following :
R Prepared chalk 3 drams (12 grains).
Olive oil 2 drams (8 grains).
Prepared lard 1 dram (4 grains).
1 Fortschritte auf dem Gebiete der Rontgenstrahlen, vol. viii., No. 2.
'Archives dY'lectricit^ m£dicale, Sept. 25, 1906.
* British Medical Journal, 1901, ii. p. 852.
ACTION OF THE RONTGEX RAYS. 411
Dr. J. Hall Edwards1 advises the use of the following :
R Sulphate of zinc 5 grains (0.32 grammes).
Tincture of lavender 60 minims (4 c.c.).
Glycerin 60 minims (4 c.c.).
Water 1 ounce (30 c.c.).
Ft. lotio.
He likewise advises the application of olive oil several times daily to
the hands, to be followed with hot water and superfatted soap.
Since the above was written, I have been using EichhofTs superfatted
resorcin soap, but the results are unsatisfactory, as the soap removes
the epithelial layer and renders the irritated remaining layers most
tender. Oudin recommends a peroxide of hydrogen dressing in cases of
erythema and excoriations.
M. "VV. Brinkmann advocates Bier's method of inducing passive
hyperaemia, — i. e., by constrictiou of the venous circulation above the
diseased area.
Professor Lassar, of Berlin, applied radium over the ulcerated spots
of my hands, but I could derive no benefit from the treatment, as I could
not continue it. But I am doubtful as to its ultimate efficacy.
In passing, it is interesting to note that in the treatment of X-ray
burns advantage has been taken of the caloric power of the red rays and
of the absence in these rays of chemical properties. The experiments of
Finsen, Schenk, and Graber have abundantly proved that white light is a
stimulating agent of considerable power, and Bar and Boulle * describe at
length, the case of a pregnant woman treated at the Infirmary of Saint
Lazare, who suffered from bleuorrhagia, accompanied by abdominal pains.
She had been pregnant about three months, when the rays were applied
to the abdomen in the hope of producing a blister and thus allaying her
intense pains. An ulcer formed which baffled all treatment. Two months
after delivering two healthy infants the woman was placed in a sunny
corridor, and each day the rays of the sun were sent through red glass and
allowed to fall on the abdomen. Over the ulcerated area was placed a
transparent sheet of celluloid. At night the ulcerations were covered
with an inert powder. Gradually the crusts produced by the X-rays
sloughed off, and, fifty days after this treatment was begun, the healing
was hastened by cauterization with silver nitrate.
Freund and Huntington advise excision of the ulcer in obstinate cases
and that the operation of skin grafting be resorted to. I concur in this
advice. Apostoli and Oudiu recommend the effluve from a static ma-
chine and a resonator respectively. I do not believe that, at the present
day, there is any agent known for the cure of X-ray dermatitis. All of
the proposed measures are merely palliative.
1 The Archives of the Rontgen Ray, October, 1903.
2 Bulletin de la Socit-te d'Obstetrique de Paris, 1901, vol. iv. pp. 251-266.
4li> ELECTKO-THEEAPEUTICS.
II. Remote and Indirect Action of the Rays.
Peculiar sensations attending and sometimes subsequent to irradia-
tion are often complained of by the patient. These include nervous dis-
turbances,— /. e. dizziness, somnolence, and tinnitus. The circulatory
disturbances are increase in the pulse rate, palpitation, and cardialgia.
Digestive disturbances manifest themselves in nausea, vomiting, and occa-
sionally in diarrhoea. These symptoms may occur in both the patient and
the operator. It is my own belief that some of these symptoms may be
manifestations of psychical influences.
CKMTO-URINARY SYSTEM (STERILITY).
That the Rontgen rays are capable of inducing at least temporary
sterility should never be lost sight of. Long ago the possibility of this
unfortunate occurrence was emphasized by Albers-Schonberg.1
The experiments of Halberstaedter 2 disclosed the fact that marked
macroscopic and microscopic changes occurred in the ovaries of rabbits
exposed to the rays. " The histological change most in evidence was the
complete disappearance of the Graafian follicles, in about fifteen days.
Whether this loss is permanent and whether or not regeneration can take
place, has not yet been determined. It was also found that the ovaries
seemed more sensitive to the effects of the rays than the outer skin of the
abdomen, and, when compared with control experiments in male rabbits,
developed degenerative changes in shorter time and with fewer expos-
ures. How far these observations in animals apply to human beings can-
not be definitely stated, nor is it known how permanent the effect may
be. Of course the question of individual susceptibility must also be
taken into account, but since the wearing of an apron impervious to the
rays, or the encasing of the focus tube so as to prevent the escape of all
rays except those intended for a particular region under treatment, and
to avoid applying the rays to 'danger zones,' would seem to obviate all
danger in this direction."
Albers-Schonberg 3 called attention to the fact that in male rabbits
and guinea-pigs, in which the abdomen was exposed to the action of the
X-rays, azoospermia was gradually developed. Frieben4 found that this
was due to the disappearance of the epithelium in the seminal tubules,
which resulted in an atrophy of the testes.
Before the January (1905) meeting of the section for Geuito-Urinary
diM-ases of the New York Academy of Medicine, the statement was made
by F. Tilden Brown and Alfred T. Osgood that men, by their presence in
1 Munch, med. Wochen., 1903, i. 43.
* Berliner klin. Wochensch., January 16, 1905.
3 American Journal of Surgery, April, 1905.
4 Miinch. med. Woch., 1903, No. Hi. p. 2295.
ACTION OF THE KOXTGEX RAYS. 413
an X-ray atmosphere incidental to radiography, may, after a period of
time, be rendered sterile.
This statement was based upon discovering that ten X ray workers,
who had consulted them, were the subjects of total azoospermia, although
none of them had suffered from any venereal disease or traumatisui in-
volving the genital tract, none of them presented physical signs of abnor-
mality of these organs, and none was conscious of or gave a history of
functional derangement.
Since that time the number of cases has increased and there now are
records of eighteen cases in whom total azoospermia or oligo-necrosper-
mia has been demonstrated. All of those examined who have done ex-
tensive X-ray work for a period of more than three years show no sper-
matozoa in their seminal fluid, while a few of the men who have been
engaged in the work for a shorter time and have exercised care in avoid-
ing direct exposure to the active tube show varying states of oligo-
necrospermia. Several cases have been examined whose exposures have
been infrequent and short (once or twice a week, for from five to fifteen
minutes), whose seminal fluid presents normal characteristics, with
abundant actively motile spermatozoa.
These men are in robust health, and from 22 to 40 years of age.
Twelve of them have operated X-ray tubes for one-half to four hours
at least three times a week, for the greater part of each year during the
past two to six years. Six of them are the subjects of more or less
severe X-ray dermatitis of the hands.
This sterility has been produced without the slightest subjective or
objective sign, illustrating its insidious development. In no case has even
a transient erythema of the scrotum been noted, and in no case has there
been evidence of deterioration of sexual activity. One-half of these
men are married, and no one among them has had a child since he
undertook this work.
Philipp a reported the exposure of the testes of two men who recog-
nized the danger of producing sterility. One was a tuberculous subject,
and he was exposed for 30 days to the raj^s, duration of each seance 10 to
l.~» minutes. At the end of this time, the semen was apparently normal,
and the spermatozoa normal. Later a resection of the vas deferens of
each side was performed, and six months after no spermatozoa were found
in fluid withdrawn from the epididyniis. This demonstrated merely a
marked resistance of these organs, in this case at least, to the injurious
action of the rays.
The second case was treated for pruritus ani. Total time of expo-
sure 195 minutes. The patient then disappeared. After several months
he had a slight recurrence of pruritus. Seven months later, examination
1 American Journal of Surgery, April, 1905.
2 Fortschritte auf dem Gebiete der Rontgenstrahlen, 1904, B<1. viii., Heft 2, p. 114.
414 ELECTRO-THERAPEUTICS.
of seminal fluid showed complete azoospermia. Only one examination
seems to have been made.
Bergonie" and Tribondeau1 have extended their experiments on
the seminiferous tubes to the action of the rays on the spermatozoa
themselves. The result was entirely negative.2
In conclusion, let me remark, while many operators say that X-ray
workers after a time are permanently sterile, I am personally acquainted
with six well-known active specialists in this field who during the past
year became fathers of healthy children.
1 Arch, d' 6lectricit6 Medicale, November, 1906.
* For a comprehensive study of this subject, the reader is referred to the follow-
ing papers : Heineke — Mitteilung aus den Grenzgebieten der Medizin und Chirurgie,
1905, Bd. xiv., Hefte 1 und 2, pp. 21-94 ; Munch, med. Wochenschrift, 1903, No.
xlviii., p. 2090, and 1904, No. xviii., p. 785 ; Freund, Elements of General Radio-
therapy ; Senn, New York Medical Record, August 22, 1903 ; Krause, Fortschritte auf
dem Gebiete der Rontgenstrahlen, 1905, Bd. viii., Heft 3, p. 209 ; Halberstaedter, Ber-
liner klin. Wochenschrift, January 16, 1905 ; Selin, Fortschritte auf dem Gebiete der
Rontgenstrahlen, 1903, Bd. vii., Heft 6, p. 322.
CHAPTER III
CHANGES INDUCED IN VABIOUS DISEASED TISSUES BY THE
EONTGEN BAYS.
THE following are the changes noted in psoriasis by X-ray expos-
ures. We abridge the reports of Scholtz.1 The diseased area was ex-
posed to the rays from May 31 to June 6, five times, of ten minutes dura-
tion each, at 40 cm. distance. June 8, the scales had completely fallen
off and the affected area was completely smooth and colored with dark
brown pigment. The healthy skin in the vicinity was also slightly
colored. At this time a piece of the cutis was excised containing both
the healthy and the diseased tissue.
"Microscopically, the typical changes occasioned by the disease had
almost completely vanished. Only the horny layer and the stratum
gramilosuin were still somewhat thickened, and there was some infiltra-
tion of the papillae and also around the subpapillary vessels of the corium.
The epithelial cells themselves again showed the usual changes. The
healthy as well as the diseased tissues were peculiarly pigmented. In
one place in the corium, especially in the papillae, were cells, some long,
some stellate, with irregular nuclei, whose protoplasm was abundantly
filled with round, large, yellowish-brown particles of pigment. More-
over, the cells of the rete, especially in the deeper layers, contained in
their protoplasm fine particles of the same color ; while a fine network of
particles of pigment, lying close to each other, appeared interwoven
around these cells."
Scholtz also studied the changes taking place in lupus. A rather
deep area of lupus was on the breast, which was deeply infiltrated,
thickly set with tubercles, and covered with a thin crust. X-ray treat-
ment. February 8 to March 7, at intervals, in all ten exposures, at 35 cm.
distance. After a few weeks a severe dermatitis of the exposed surface
appeared, with subsequent superficial necrosis. Excision March 17.
" Microscopic examination showed the epithelium in a degenerated
homogeneous condition. The cutis, especially in the lupus area, was
infiltrated with round cells and pus cells. The form and typical structure
of the tubercles had disappeared, and were to a certain extent absorbed.
In their place were collections of numerous cells, single and multiple ;
nucleated with swollen washed-out protoplasm ; and among them mono-
nuclear and especially polymorphonuclear leucocytes in great numbers.
The giant cells contained an unusually large number of nuclei, and
1 Arch. f. Derm. u. Syph., 1902, lix. p. 241.
415
416 ELECTRO-THERAPEUTICS.
iiit-asured 100 to 200 microns in diameter. Most of them no longer
show regular outlines, but, instead, a pale, irregular mass of multi-
nucleated protoplasm. The altered epithelioid cells, which are often
poly nuclear, showed the same appearance.''
Grouven l gives a report of his studies of lupus of the cheek treated
by the rays. He studied sections of the diseased tissue which had been
continuously treated by the rays for a period of ten weeks. He noted a
very large production of connective tissue, some of the fibres running
through the tubercles themselves. In brief, Grouven speaks of the heal-
ing of lupus tissue as an active hypersemia giving rise to diapedesis
of the leucocytes, first observed at the periphery of the tuberculous
masses, gradually extending into the interior of the tubercles. There is
a conversion into spindle-cells, resulting in the complete production of
new connective tissue; i. e., the cells of the tubercles undergo fatty
degeneration, absorption, and finally are wholly replaced by connective
tissue newly formed.
Scholtz* speaks of the results of his investigations with leprosj- of
the nodular type, after having been treated by the rays. He exposed a
leprous area until sufficient hyperaemia was produced. He believes that
" some time after the disappearance of this reaction the part of the nodule
which had been treated seemed to be a little sunken, but no further
change appeared. Five weeks later the nodule was excised. Microscop-
ically, the leprous infiltration was slightly reduced. The numerous
bacilli seemed to show more granulations than the unexposed region, but
were well stained and undimiuished in number, the action of the rays
having no apparent influence upon them." He3 has also studied cases of
cancer treated by the X-rays, and found that in one case he was able to
obtain sections in the stage of commencing reaction, and also after the
formation of a superficial necrosis. Under the influence of the rays the
microscopic examination showed that the cancer cells degenerate and are
destroyed. However, the degenerative processes are recognizable, espe-
cially in the deeper carciuomatous points, only after a relatively more
intense action of the rays, and the appearances were very often difficult
to distinguish from the normal retrogressive processes.
Freund 4 states that in lupus and epithelioma the improvement
observed is due to cellular infiltration and proliferation, and to the influ-
ence of the rays in promoting the formation of connective tissue and
cicatrices. In his opinion the X-rays possess no bactericidal qualities.
Chas. Lester Leonard 5 is of the opinion that the X-rays have both
'Fortschr. a. d. Gebiete d. Rontgenstrahlen, 1002, Bd. v. p. 186.
'Arch, f. Derm. u. Syph., 1902, lix. p. 241.
8 Ibid.
4 Lancet, August 2, 1902.
'American Medicine, October 4, 1902.
CHANGES INDUCED IN DISEASED TISSUES. 417
stimulating and alterative effects on normal tissue. There may be
caused a retrograde metamorphosis, on tissues of low vitality, ending
in fatty degeneration. He adheres in general to the tropho -neurotic
theory.
The lesions in Shaud's l case were recurring superficial abscesses of 18
months' standing, the pus containing the staphylococcus pyogenes aureus.
Improvement began under X-ray treatment, a relapse occurring when
treatment was discontinued. Irradiation was again begun and continued
until a permanent cure resulted.
Kinehart,2 after stating that he gets no results from X-ray treat-
ment unless inflammatory action is induced, says: "It then remains
to be decided whether the inflammation causes the death of the
cancer and tuberculous deposits, or whether the effect is produced by
the light itself. My own experience is, that it is the light. Simple
inflammation has often been caused by caustics, in and around these
sores of lupus and epitheliouia, without producing the death of the
process. A light sufficiently strong to produce an inflammation of the
healthy cells of the part treated is of sufficient strength to destroy cells
of lower vitality, as cancer cells are known to be. Whether the effect
upon the skin is produced by the ultra-violet rays remains to be proven.
That the low-vacuum tube produces more effect upon the skin than
the high-vacuum tube, might help to substantiate the statement that the
effect is from ultra-violet rays, as they are given off more freely from the
low-vacuum tube."
Hallopeau and Gadaud3 call attention to the sclerogenic action of
the X-ray, to which they properly attribute the ungual dystrophies and
the vascular dilatation produced thereby.
Herzog4 treated transplanted sarcomas in two rats. The skin over
the tumor became necrotic in each case. In one, the tumor changed
to a cyst filled with a perfectly clear fluid material, and after the fifth
exposure the whole tumor came away, leaving a clean surface.
Walker5 has studied sections of rodent ulcer healing under
treatment by the X-rays, and describes the new growth as undergoing
fibro-myxomatous degeneration.
Blackmar6 concludes that the X-rays cause a breaking down of
malignant and non-malignant growths, the disintegrated material being
absorbed. He considers the waste products from a rapidly disintegrating
cancer exceedingly dangerous when thrown into the general system,
unless the patient is in vigorous health.
1 Australasian Med. Gazette, May 20, 1902.
2 American Journal of the Medical Sciences, July, 1902.
3 La Presse Med., July 16, 1902.
4 Journal of Medical Research, June, 1902.
5 British Med. Jour., May 10, 1902.
'American Electrotherapy and X-Ray Era, May, 1902.
418 ELECTEO-THEEAPEUTICS.
Morton * believes that the effect of the X-rays in the cure of disease
is due to a primary chemical reaction, affecting in turn the metabolic pro-
cesses. He claims that under proper conditions the X-rays build up tis-
sue, in proof of which he cites the case of a young woman suffering from
enlarged axillary glands. In six weeks, the neck, shoulders, chest, and
breast of that side had developed so markedly that the patient afterward
desired the opposite side treated in order to restore symmetry.
Beck * states that an adeno-carcinoma, subjected to the X-ray treat-
ment, showed beginning colloid degeneration, changes of the same nature
being observed in the epithelium of the skin covering the tumor. Speci-
mens of the affected skin showed thickening of the intima of the small
blood-vessels ; fibrous tissue in reticular arrangement being deposited.
The same observer elsewhere states that he regards as most important, the
nutritive changes in the walls of blood-vessels and the results incident to
such changes.
Loeb,s after seven exposures of ten minutes each during eleven days,
transplanted sarcoma in a rat and found mitoses in the cells. The tumor
continued to grow, and pieces from it were successfully transplanted into
other rats. Degenerative changes were present in the centre of the tu-
mor, but Loeb believes that these changes occur in many tumors without
exposure to the rays.
A. G. Ellis,4 in regard to tissue changes, occasioned by the X-rays,
reports upon the findings in four cases, which were carefully examined.
He observed necrosis of cells and trabeculae of a varying degree. There
was also marked fatty degeneration . In three cases there was increase of
elastic tissue before and after exposure. In one case there were fewer
areas of lymphocytic infiltration after exposure, and about equal numbers
before and after in others. A tendency to occlusion of the vessels, by
deposits on their inner surfaces, was marked in some cases. Entire absence
practically of infiltration of polymorphonuclear leucocytes was noted.
These findings, he remarks, hardly warrant conclusions, but a few
thoughts suggest themselves. The blood-vessel changes, on which Beck
and others lay stress, seem hardly to account for the accompanying
tissue necrosis, though endarteritis is probably induced by the X-rays.
He thinks the possibility is suggested of their being similar lesions from
the same influence instead of standing in relation of cause and effect.
The presence of immense numbers of cocci and bacilli in the tissues in
one case after twenty exposures, would argue against the bactericidal
power of the rays. It should be said, however, that the pathogeuicity of
these organisms was not proven.
1 Medical Record, May 24, 1902.
* New York Med. Journal, May 24, 1902.
s Journal of Medical Research, June, 1902.
4 A. G. Ellis, in American Journal of the Medical Sciences, January, 1903, from
which many of the above statements have been taken.
CHANGES INDUCED IN DISEASED TISSUES. 419
Yose and Howe,1 from a study of the effects of X-rays on cancer,
believe that, " Cutaneous cancer treated by the X-rays undergoes degene-
ration not peculiar to this form of treatment or distinguishable histologi-
cally from degeneration from other causes. The vascular changes are
limited to an endarteritis ; new formation of blood-vessels occur, if heal-
ing takes place, as in the process of repair elsewhere ; there is an increase
of elastic tissue. Taken as a whole, the clinical cases show that the only
cure of cancer by the X-ray is by destruction and exfoliation. This at
once limits its value to superficial cases. This destructive process is a
slow one, and acts very superficially .''
Journal of Medical Research, Boston, January, 1905.
CHAPTER IV
TECHNIC OF EONTGEN RAY THERAPY.
THE production of a dermatitis, the result of the use of the X-rays
as a diagnostic measure, early suggested the possible value of the new
agent for therapeutic purposes. Treatment with the X-rays depends
largely upon the character of the lesion. Thus the same method of treat-
ment would be of no avail if applied indiscriminately to the malignant
and benign, to the superficial and to the deeper tissues, etc. Effective
technic in treatment is dependent not only upon a good understanding of
how to use effective apparatus accurately, but also upon the experience
and ability of the operator to apply, to each individual case, the quality
and dose that that particular case demands.
In observing the progress of disease, so far as a cure is concerned,
and also for comparative study of several diseases, a life-sized photograph
of the affected area should be taken before the actual treatment is com-
menced. The plate employed should be isochromatic in type, in order
that the color value of the tissues may be recorded as exactly as possible.
To be accurate all these photographs should be taken in precisely the
same manner. The prints made from the resulting negatives should be
of equal density.
"When an open wound is to be treated, care must be exercised not to
infect it ; if it is well protected by a sterile dressing, this should not be
removed, unless ointments are smeared thereon which might offer ob-
struction to the rays, such as zinc oxide, boric acid, bismuth, iodoform.
etc. I would urge that all lesions be covered with several layers of gauze
while treatment is in progress.
I. Apparatus and Method of Treatment.
The apparatus necessary for intelligent and effective treatment is
practically the same as that employed for skiagraphic purposes. The
current for exciting a tube is generated by a static machine, an induction
coil of the Ruhmkorff type, or a Tesla high-frequency apparatus. Some
operators prefer the static machine, believing that it does not produce a
dermatitis, but this has been proved a fallacy. Regarding the size of the
coil for therapeutic purposes, one that is of seven or eight inch (18 to 20
cm.) spark producing power will suffice.
When using a coil for therapeutic purposes, the frequency of pro-
longed exposures, often required, is liable to injure the insulation of the
coil. It is considered advisable to switch off the current and allow the
coil and the tube to cool every ten or fifteen minutes, during prolonged
420
TECHtfIC OF EONTGEX RAY THERAPY.
421
W&B.MFG.CO.N.Y
FIG. 211.— PIFFAED TREATMENT: TUBE.— The whole tube is made of lead glass, except at the lower
opening, to permit the passage of the rays for therapeutic purposes. This is a protective measure for
the operator, and also limits the area irradiated.
FIG. 212. — THE BI-CATHODE TUBE OF KOCH OF DRESDEN. — Koch asserts that where much in-
verse current must be overcome, this tube acts both as an X-ray and a ventril tube. He believes that,
the anode being of a heavy design, a large quantity of current may be employed with a shortened
exposure. (Kny-Scheerer Co.)
H«T VH
: ' -— -j; .- SH^S
THE: KNY-SCHEERER co. M.Y.
FIG. 213. — THE KNY-PCHEEKER TTBE.— The anode is placed into the tubular extension, the latter
being encased by a cylinder of lead-flux glass. A set of two specula of lead glass further serve to
localize the X-rays.
422
ELECTKO-THEEAPEUTICS.
treatment; but, the current being of small amperage, the injury to the
coil at most would be slight. The mechanical or the liquid interrupter
may be employed, but the mechanical, being the cleaner and easy of manip-
ulation, is commonly used. The electrolytic interrupter has met with
little favor, as the enormous current transmitted to the primary is totally
unnecessary, and is detrimental to the life of the tube and the coil.
CKOOKES TUBE.
The tubes employed for therapeutic purposes (Figs. 211, 212, 213,
and 214) are practically similar, in degree of vacuum, to those employed
for diagnostic purposes. They are self-regulating, or those in which the
vacuum can be altered by automatic appliances. Tubes are also classified
according to their degree of vacuum, as "soft," "medium," and "hard."
The rays coming from a tube of low vacuum produce an early and rapid
Fio. 214.— Dr. J. Ronsenthal's tube for therapeusis, as employed by him in the hospitals of Munich.
tissue change. When a softer tube is employed more tissue change
results, because under such conditions the rays are considerably less
penetrating and more readily absorbed by the tissues, than with a hard
tube. This is the accepted view of most X-ray operators. When the
suspected lesion is deep-seated, as in cases of carcinoma of the uterus,
stomach, or abdomen, a "medium" tube should be used. The connec-
tion of the Crookes tube with the oscilloscope is explained at Fig. 215.
PROTECTION OF HEALTHY PARTS.
Prior to the application of the rays (as in cases of superficial
ulcers, epithelioma, etc.) the surrounding normal tissue should be pro-
tected against the influence of the rays. This may be accomplished by
shielding the surrounding integument by leaden sheets, & of an inch
(1 mm.) in thickness, covered with adhesive plaster, and grounded, in
which an aperture has been cut, to permit the passage of the rays.
The aperture should be of the same size as the superficial lesion. This
TECHXIC OF BONTGEN BAY THEEAPY.
423
precaution, however, does not apply to lesions that are deep-seated, the
risk of setting up an integumentary inflammation weighing but little in
comparison with the gravity of the condition.
An ingenious device is the protective tube shield, which conforms to
FIG. 215. — CONNECTION OF THE TUBE AND VILLARD VALVE WITH THE OSCILLOSCOPE. — Piffard, of
New York, uses the oscilloscope as an index of the inverse current. When the inverse current is exces-
sive, a violet glow will appear on both terminals of the oscilloscope ; if the current is unidirectional the
glow will be manifest only on one terminal of the oscilloscope. The oscilloscope is in reality a Geissler
bulb.
the size and shape of the Crookes tube, and is provided with different
sized cylinders, or localizers, allowing either a large or small surface to be
acted upon by the rays.
424 ELECTRO-THERAPEUTICS.
POSITION.
The position of the tube is of little importance, except that the
anodal field must face the lesion. The satisfactory application of the rays
to such conditions as carcinoma of the cervix uteri, diseases of the oral
cavity, the larynx, stomach, and rectum is a matter of much difficulty. If
the tube is placed within a cavity, or in such a position as to send the
rays directly to the seat of the lesion, better results are to be expected
than if the rays need penetrate some intervening tissue. For this reason
tubes of special shape have been designed by Caldwell of New York,
and Cossar of London, for the express purpose of treating diseases of
the rectum, vagina, and oral cavity. The tube devised by Caldwell
has a long cylindrical projection which fits into a metallic protector.
The latter has an opening which corresponds to the area undergo-
ing treatment. The Cossar tube is constructed of lead glass com-
paratively opaque to the rays, except at the end of the projection,
which is made of ordinary glass, and permits the rays to reach the
diseased area only.
DISTANCE OF THE TUBE.
The distance of the tube from the part depends upon the quality of
the tube, upon the size of the area to be treated, and whether a rapid
reaction is desired or not. It is measured from the target of the tube to
the exposed surface. The nearer the tube, the more intense the action.
Theoretically, some claim that the distance of the tube from the part
should be directly as the height of its vacuum and inversely as the
distance of the part to be affected is from the surface. Some operators
prefer a short distance with short or less frequent exposures. This I
believe to be a matter of personal experience, and can only be deter-
mined by a most careful study of each and every case seeking treat-
ment. The anode of a hard tube should usually be placed from
twelve to fifteen inches (30 to 38 cm.) from the surface, and a soft tube
from six to eight inches (15 to 20 cm.). On the other hand, the tube
should l>e placed nearer to the body, the farther the diseased part is from
the surface.
Dr. "William S. Xewcomet l has devised a frame covered with lead,
containing openings in three of its sides, and employed by him for X-ray
therapeusis. The sizes of these windows may be modified by the insertion
of few or many lead diaphragms. The Crookes tube is placed within the
frame, with the active hemisphere directed towards the openings. As
three patients can always be treated simultaneously, much time is sav«-d
by this device. But patients must be selected that demand the same
quality of the rays, as exemplified in large hospitals.
1 American Medicine, March 5, 1904.
TECHNIC OF RONTGEN BAY THERAPY. 425
Dr. H. P. "Wells, of St. Louis, has very kindly sent me the following
description of his ingenious method, for the multiple connection of
Crookes tubes in series, as a means of economy of time and current.
''It has been found practical," he writes, "to connect in series more
than one Crookes tube to be operated from a single coil or static machine,
and thereby increase the usefulness of such equipment to meet the needs
of those doing much clinical work and with whom the question of time
and expense are matters of consideration.
"The tubes are connected so as to maintain the proper direction of
flow of current in both of them, that is, the anode-terminal of one tube
is connected to the cathode-terminal of the second, etc.
"It is hardly practical to use more than two tubes on the average
coil or static machine, as the resistance and consequent strain on the
machine increases by arithmetical progression with the number of tubes
in the circuit.
"It is possible to maintain each tube at any desired resistance by
adjusting the shunt spark-gap on the regulating device of the tube, each
tube regulating itself independently of its fellow.
"The only apparent difficulty in the way of the multiple connection
of the tubes, is the strain thrown on the interrupter, especially of the
mercury jet type. I believe that a perfected form of mechanical inter-
rupter will prove least troublesome and give the best results under the
higher resistance in the secondary.
"Economy of current is effected, because we use the latter in the
second tube, which ordinarily is dissipated in the form of heat in the
rheostat when only one tube is used."
This method has also been employed in the London Hospital, where
they also run a series of coils from the same interrupter and on the same
primary current.
THE DURATION OF EACH EXPOSURE.
This depends on whether a coil or static machine is used, and upon
the patient's susceptibility and the character of the case. Operators differ
in the length of time of exposure. Some resort to frequent but short
exposures with ascending doses, others employ longer but less frequent
exposures. If the integument remains normal, the stances are length-
ened, twenty minutes being the maximum. All other things being equal,
the usual time of exposure with a coil is less than with the static
machine.
FREQUENCY OF THE EXPOSURE.
This depends upon the character of the lesion, the rapidity of action
desired, the length of each exposure, the susceptibility of the patient,
and on the distance of the tube. At the very beginning of treatment,
426 ELECTEO-THEEAPEUTICS.
it is advisable to expose the patient two or three times a week for the
first two weeks, and then to discontinue treatment for a similar period,
watching in the interval for the development of any untoward symptoms.
Some prefer to give a treatment every other day, asserting that this pro-
cedure is productive of the best results. This necessitates very close
watching of the patient's susceptibility, but if caution is observed not to
over-expose the seat of disease, then the applications may be brought
more closely together for almost an indefinite length of time. Periods
of rest for tissue restoration, other than that just mentioned, should
never be attempted, as under this plan all is lost that may have been
gained through the treatment of the previous days or weeks.
FILTERS.
Concerning the law of the absorption of the Eontgen rays, "\Valters *
finds that, after these rays pass through silver, palladium, cadmium,
zinc, and antimony, they are soft instead of hard. In other words,
these metals absorb the hard rays, while aluminium, copper, and the
metals at the extremes of the scale of atomic weights absorb the soft rays.
The second layer of any specified substance absorbs less rays than the
first. This principle, he believes, can be applied practically in inter-
posing a substance similar to the skin in the treatment of deep-seated
growths without sacrificing the skin.
Drs. G. E. Pfahler and J. F. Schamberg* conducted a series of
experiments upon rabbits, in which use was made of silver, leather, and
aluminium, for the purpose of establishing their values as filters. They
found leather of decided advantage for filtering out the soft, medium, and
hard rays. They were impressed with the fact that the susceptibility to
the rays varied in different animals, which doubtless is also true of man.
It has been my practice for some time past to employ aluminium and
leather filters, but I decidedly prefer the former.
THE DOSAGE.
By " dosage " is meant the quantity and quality of the Eontgen rays
used during each exposure. This depends upon whether the condition is
superficial or deep, malignant or benign. Some believe in exposing the
part until tanning or bronzing occurs, but in dark-skinned individuals,
in negroes, and in mucous membranes no tanning is observed ; hence in
these instances this sign cannot be depended upon. I have noticed that
itching often indicates the beginning of a reaction within the tissue.
If the treatment is continued after the development of these signs,
erythema, vesication, or dermatitis may develop, whereupon the
! Fortechritte auf dem Gebiete der Rontgenstrahlen, Berlin, April 13, 1905.
* Journal of the American Medical Association, September 15, 1906, p. 888.
TECHNIC OF RONTGEN RAY THERAPY. 427
operator should cease treatment. These effects do not necessarily mean
carelessness on his part and may occur in most skilful hands.
Although the clinical manifestations are a guide in determining the
amount of reaction obtained, yet they do not indicate the exact amount
of the X-rays used. The possible methods of determining the " dosage"
are fully detailed and discussed in a special section.
II. Methods of Measuring X-Ray Dosage.
Since Rontgen' s discovery, scientists have lacked a practical and
oxact unit of X-ray dosage. The establishment of a standard unit is
difficult, because of the idiosyncrasy of the patient, and because no one
can make any positive statement as to the number of treatments that
any one case may demand, the personal equation entering so largely into
the consideration. We cannot deduce the amount of physiological and
biological action of the rays on the tissues by the measurement of their
chemical and physical properties. The question arises : What standard
shall we adopt, so that the unit may be accurate, practical, and precise !
Recently the Rontgen Ray Society of London appointed a committee for
the purpose of formulating a standard unit for the measurement of all
radiations ; they arrived at no definite conclusion and asked for the
earnest cooperation of American scientists.1
A. MEASUREMENT OF ELECTRIC CURRENTS.
The Current going to the Primary Coil. — The voltage and amperage of
a current that goes to a coil depends upon the variety of the interrupter
and the construction of the primary coil. The secondary or induced
current depends upon the variety of the current or winding of the coil,
because the same coil and interrupter may give a different quality of the
rays, depending upon the make and the vacuum of the tube. Wertheim
Salomouson's experiments show that electric energy is absorbed in the rhe-
ostat and in the interrupters. "Wehnelt considers that 30 to 80 per cent, of
the energy derived from a battery is absorbed by the electrolytic break.
Salomouson's wattmeter showed that 61.2 and 65.4 per cent, of current
was lost. Since this percentage of lost energy evidently varies under
different conditions of operation, it follows that the induced secondary
current is not proportional to the primary current when an electrolytic
interrupter is used.
Milliamperaye of the Secondary Induced Current. — The milliampere-
meter was first advocated by D' Arson val, who used it with a Yillard
tube, and proved that the production of X-rays is proportionate to the
intensity of the current, and has shown photographs in support of this
1 At a meeting of the American Rontgen Ray Society held at Niagara Falls, August,
1906, I urged the appointment of a committee to confer with a like committee of the
Rontgen Ray Society of London, which was agreed to.
428 ELECTRO-THERAPEUTICS.
assertion. The milliampererneter measures the current passing through
a tube ; but does not tell us how much energy is expended in the
production of the rays.
Salomonson asserts that X-ray production is a function of watts ex-
pended in the tube rather than of the current traversing it. If his theory
is correct, and I believe that it is, then we should know the amount
of energy or watts expended in heating the anode.
The niilliamperemeter measures the resistance of the tube. There
are degrees of vacuum where no X-rays are produced, yet the mil Hani -
peremeter indicates a passing current. The resistance of a tube often
depends upon the shape and angle of the anode (platinum), upon the
surface of the cathode, and upon the focal distance of the cathode. A
valve tube makes the current unidirectional, as shown by the ossilograph ;
the latter also shows absence of constant movement in the needle, whilst
the milliamperemeter shows the slight changes in the vacuum by the de-
flection of the needle. It should never be forgotten that the reading of
the milliamperemeter is not necessarily an absolute index of the amount
of X-ray production in the tube. Thus, we read the milliamperage and
we know that the current is passing from the secondary into the tube ;
but how much of the current going through the tube is expended in the
production of the X-rays? So much depends upon the make, shape, size,
etc., of the tube and upon the relation existing between the cathode and
anode that the answer is difficult, if not impossible. However, Salo-
monson ' described and exhibited a new instrument for measuring the
energy of a variable current of high potential. The milliamperemeter
usually used for measuring the current in the secondary circuit indi-
cates the mean current, whereas what we really require is the mean
square value, and with an oscillating current these two values are not
proportional.
The dilatometer devised by Professor Saloniouson measures the
energy expended in the secondary circuit directly. It consists of a
paraffin oil thermometer, which is heated by the current passing through
a slate resistance. Slate has a high and fairly constant electric resistance.
The heating effect of even a small current is therefore readity apprecia-
ble. The heat is communicated to the surrounding paraffin, and the con-
sequent expansion in the paraffin is shown in a capillary tube attached to
the vessel. The rise of the meniscus in this tube will therefore be a
measure of the total energy expended in the circuit during the time the
current has passed through the resistance. The dilatometer sums up the
values of the energy for each instant since the current was started ; its
readings will therefore be proportional to the mean square of the current,
and the rise of the meniscus per unit time will give the mean square
intensity of the current. The dilatometers are standardized by means of
1 Archives of the Rontgen Ray, April, 1906.
TECHX1C OF ROXTGEX RAY THERAPY. 429
an electro-dynamometer and a stop-watch, a small steady current being
passed through the two instruments.
Experiments with these instruments showed that the efficiency of a
Ruhmkorff coil is the same for all intensities of current in the primary,
that the rexixtance in the secondary circuit remains unaltered.
/netrr. — Measuring the length of the spark-gap (parallel) on
the secondary coil or induced current was the earliest method employed.
The length indicates the internal resistance of a tube to the passage of
the current ; the longer the spark-gap the higher will be the vacuum.
But it is a fact that the variation in the supply of current in the primary
coil or interrupter will change the length of the spark-gap, with the same
tube in circuit. The pointed rods of the electrodes, the composition of
the rods, the atmospheric conditions, such as moisture, etc., the construc-
tion of the coil, interrupter etc., the source of current and also the
amount of the current, will alter the length of the spark-gap. Two
different tubes with the same current and same spark-gap may give
different degrees of radiation, because the size of the electrodes may be
different and different metal may be used, etc. Beclere, of Paris, em-
ploys a graduated rod capable of sliding to and fro. On this scaled
bar he observes the number of inches or centimeters. This is a
convenient form of measurement, and every coil is thus supplied and
is universally employed. This method is often misleading, as I have
seen a tube with 3- or 4- inch (7.5- or 10-cni.) spark-gap, where the
rays were far less penetrating and in some instances cathodic rays were
produced.
The data given by the spinterineter holds good only for the special
apparatus that the operator employs and not necessarily for other forms
of this apparatus.
B. THE PENETRATION METHOD.
By this means we measure the penetrative property or quality of the
rays directly outside of the tube.
The Itadiochromometer of Benoist (Fig. 216). — M. L. Benoist devised
this instrument, which is based upon the principle that different metals
possess different degrees of transparency as regards their penetration by
the X-rays. A silver disk in the centre of this device having a thickness
of 0.11 of a millimeter, is used as standard. Around this disk are placed
layers of aluminium, beginning with one layer and up to 12, like the dial
of a clock. These 12 sectors are designated by lead numbers, so that one
can recognize them by their position without seeing the number. This
apparatus can be used either with the fluoroscope or on a photographic
plate. One of the sectors will match the tint of the central disk. A
lead diaphragm is provided for bringing one sector into view, and the dia-
phragm is then rotated until the tint of the sector corresponds to the tint
430
ELECTRO-THERAPEUTICS.
of the centre. M. Benoist1 improved upon this apparatus. His device
resembles a telescopic arrangement, whereby the numbers and the tints on
the screen appear enlarged ; it is also furnished with a glass to protect
the operator while testing the rays. By rotating the lead diaphragm one
can examine each sector successively. Dr. Geo. Pfahler 2 places a mirror
FIG. 216. — Benoist's radiochromometer.
at an angle of 45 degrees, utilizing the principles of the reflecting fluoro-
scope (Figs. 217, 218), thus preventing the rays being directly projected
upon the face or hand, and in this way minimizing the danger of burns.
Dr. Lacaille* has devised an apparatus which is simply a Benoist radio-
chromometer associated with a lunette, of similar disposition to that used
1 Archives d'electricite" medicale, April, 1906.
1 Archives of Physiological Therapy, June, 1906.
3 Bulletin Officiel de la Socie'te' Fran^aise d'Electrothe"rapie et de Radiologie,
July and August, 1905.
Ku;. 217.— The improved benoist radiochromometer.
FIG. 218.— The same, with its parts connected.
FIG. 219.— The skiameter.
TECHNIC OF RONTGEX RAY THERAPY.
431
by Brandt in his posometer. Such a lunette is formed of two parts : a box
6 x 8 x 10 centimeters and an eye-piece placed close to it at an angle of 45°.
The box in his apparatus presents two interesting points : (1), on the
bottom and placed at an angle of 45° is a mirror in which, when looking
through the tube, one can see the inferior surface of the upper wall of the
box ; on said inferior surface is affixed a pasteboard disk covered with
barium platino-cyanide ; (2), on the superior surface of the same upper
wall, exactly above the platino-cyanide disk, is the radiochromometer, the
shade of which is projected by the X-rays on the little screen, and reflected
in the mirror. With such a disposition the operator is not directly
exposed to X-rays.
All radiochromometers give only penetration power, but we know
that there is a great difference between the penetration and fluores-
cence, and also between photographic (chemical) and physiological (ther-
apeutic) effects.
Skiamcters and Penetrometers. — The principle of these devices consists
in the use of an obstacle to the passage of the rays. (Fig. 219.) Many
different metals have been used to determine the penetrative power of the
rays, but as with Benoist's de-
vice these forms of apparatus
do not indicate the intensity
of the rays. Two different
tubes which have the same
penetrative power may differ
in their chemical and physio-
logical effects.
Crypto-radwmeter of Weh-
nelt. — This apparatus (Fig.
220) consists of a fluoroscope
with a sliding or telescopic
arrangement and provided
with a sheet of lead to pro-
tect the hand of the operator
and a single "V "-shaped
piece of metal which grad-
ually increases in thickness.
It is claimed by Wehnelt that his apparatus is more accurate and allows
of a wide range of comparison because of the wedge-shaped character of
the piece of aluminium.
FIG. 220.— Crypto-radiometer of Wehnelt.
C. THE PHYSICO-CHEMICAL METHOD.
Because of its accuracy and precision, I believe that physico-chemical
measurement more nearly approaches the ideal than the other procedures
in vogue. This method has been ably illustrated by Holzknecht. He
432 ELECTKO-THERAPEUT1CS.
based his theories and constructed his apparatus upon the principle that
certain salts suffer a change of color when exposed to the cathode rays.
Other substances, when heated and irradiated, undergo a change of color,
as the chloride of lithium, which becomes a greenish-yellow, and carbon-
ate of potassium, which changes to a heliotrope. On exposure to the air,
or at a high temperature, the colors of these salts are seen to disappear.
He also proved that X-rays and Becquerel rays possess this property, and
that they are all transformed into ultra- violet rays at the point of impact
with the surface.
Chromoradiometer of Holzknecht. — Guido Holzknecht, of Vienna, pre-
sented this device for the consideration of the profession in 1902. Holz-
knecht's studies on this subject led him to fuse certain salts and to
expose them to the action of the rays. He employs a small capsule con-
taining the reagent covered with celluloid. This reagent, which is color-
less and whose composition has heretofore been kept a secret, has been
analyzed by a French chemist, Mr. Lind,1 and M. Bordier describes it as
follows : " The reagent consists of 99.77 per cent, potassium sulphate, the
remainder being potassium sulphite or hyposulphite, or possibly potassium
tri-, tetra-, or penta-thionate. The mixed mass is impregnated and held
together with copal varnish. This capsule (which is placed over the cuta-
neous area to be treated) has a dirty-yellow color due to the copal varnish,
and under the influence of the X-rays the color changes to a greenish tint,
gradually becoming deeper as the quantity of the rays is increased. After,
or often during, the irradiation this capsule is brought near to a standard-
ized scale which is graduated in Holzknecht units, from 1 H. to 24 H., the
color scale being graduated from a greenish-yellow to a deep green, which
serves as a standard of comparison for j udging the color of the capsule
after irradiation. The unit is indicated by H. This method has certain
disadvantages : The treatment is interrupted in order to compare the color
of a reagent with that of the scale, and this-is repeated until a tint is ob-
tained which corresponds to the precise dose required. As more than one
sitting may often be necessary (in the interval between the two exposures),
this reagent must be kept in darkness. This graduated scale holding
the numbered capsule is kept in a light-proof box. Although this method
would seem very correct in theory, nevertheless, in practice we meet with
many difficulties. The standard scale suffers changes in color, or it may
fade in the course of a year. Subsequent to exposure the capsule gets
darker and must be compared immediately. The comparison of the cap-
sule with the scale is very difficult. Different individuals and different
parts of the body exhibit different degrees of susceptibility, and the
various diseases display individual peculiarities to the action of the rays.
Radiometer of Sabouraud and Noire. — In 1904 Drs. Sabouraud and
Noire" introduced a method largely employed in France. It consists of a
1 Archives of the Rontgen Ray, June, 1906, p. 6.
TECHXIO OF ROXTGEX RAY THERAPY. 433
small disk of paper over which is spread a layer of platino-bariuin cya-
nide ; this salt assumes a brown color under the action of the X-rays. M.
Yillard pointed out that under the influence of increasing doses of the rays,
plantino-cyanide passed from a bright green to brown, and at the same
time the fluorescence gradually decreased. Upon a two-page leaflet is the
standard-color pastille, marked " A " (which is an unchanged green color),
and another one marked UB," which is brown, and indicates the maximum
dose the skin can tolerate without producing dermatitis, and causing
only epilation. The comparison should be done in a dimly lighted room,
because, if the pastilles are exposed for too long a period to the light, they
regain their original green color. The pastille should be placed in a pas-
tille-carrier, 8 cm. from the anode, and midway between the part under
treatment and the anode. The standard color pastille UB" corresponds
to a dose of 10 X, or 5 H in Holzknecht units. Sabouraud himself ad-
mitted that the test, however, is less sensitive than by the Holzkuecht
method, and that the color may change by the action of heat, light,
moisture, etc. It is asserted by some that the location where the
pastille is placed under the active hemisphere may not be equally
irradiated, because the rays are unequally distributed over the active
hemisphere.
The Cliromoradiometer of Bordier. — Bordier1 describes a new method,
based on the principle that when platiuo-cyanide of barium is exposed to
the rays, it undergoes a change of color due to the dehydrating action of
the X-rays, also that the same discoloration occurs when this chemical is
placed in an atmosphere artificially dried by sulphuric acid or when ex-
posed to a gradually increasing temperature. Under the action of light
dehydration may also occur. He describes his apparatus and reagent as
follows: " The Bordier chromoradiometer differs from its predecessors.
The barium-platino-cyanide, suspended in a thin layer of collodion, is
placed on the skin itself, or at all events in the same plane as the part
to be irradiated. The pastilles are square, with a diameter of 6.5 milli-
metres. The back of the square is adhesive, to facilitate its attachment
to the skin. A scale of colors is supplied with tints Xos. 1, 2, 3, 4, cor-
responding to the principal reactions required in radiotherapy.
"Tint No. 1, a pale yellowish-green, is the shade that the pastille
takes when exposed to the maximum dose of rays compatible with the
complete integrity of the normal skin. "NYith this dose of X-rays the hair
falls out some twenty days after exposure, and grows again within the
succeeding twenty days. This is the weak normal exposure of Kien-
bo'ck's, corresponding to a skin reaction of the first degree, accompanied
by temporary loss of hair.
"Tint No. 2, of a sulphur-yellow shade, is that color the pastille
assumes when the skin has been exposed to an irradiation calculated to
1 Archives of the Riintgen Ray, June, 1906, p. 9.
434 ELECTRO-THERAPEUTICS.
produce a strong reaction, viz. erythema, tumefaction, and at the end of
the reaction marked desquamation. This Xo. 2 tint corresponds to a mild
form of Kienbock's reaction of the second degree.
"Tint No. 3 is almost of the color of gamboge. It corresponds to a
reaction of the skin of the second degree ; it is a true dermatitis. Latent
period is eight to ten days. This is Kienbock's strong normal reaction.
"Tint No. 4 is of a chestnut color, and corresponds to a reaction of
the third degree, which is accompanied by necrosis and ulceration of the
skin. This is the strongest dose ever required and should never be
applied to the normal skin. He obtained tint No. 4 after irradiation of
a specimen of radium of a radio-activity of 100,000 for a week, at a
distance of a millimetre from two pastilles."
Very soft tubes are not desirable for these reagents, as they produce
ultra-violet rays which will be confused with the X-rays. He reports
cases that were cured at a single seance. He believes in giving one
massive dose rather than fractional doses, so common in this country.
This method is also subject to the same objections that I have mentioned
before.
Quantimeter of Kienbock. — In 1905 Dr. R. Kienbock introduced this
new method of direct dosimetry, and asserted that, in 1900, he demon-
strated that the changes noted on a photographic plate are an accurate
measure of the therapeutic dose ; admitting,1 however, that Stern2 pub-
lished a paper on photo-radiornetry, and suggested the use of photo-
graphic films, to be compared with a " normal scale ;" but at that time
(1905) Kienbock was unaware of the fact. He describes his instrument as
follows : s "My quantimeter (Fig. 221) consists essentially of two parts, a
strip of photographic paper, which is easily applied to the irradiated
skin, and a normal scale of graduated tints, with which it is to be com-
pared. The paper is covered with a sensitized film of chloro-bromide of
silver in gelatine. After exposure, the strip may be developed in a dark
room or by means of a small light-proof box. The development can be
carried on in daylight in the consulting room. The film is then compared
with the standard scale, either at once or after drying. The developing
solution is of constant composition, and should be used at a temperature
of 18° C., or 64° F., for a period of exactly one minute. After fixation,
the strip of paper may be immediately compared with the scale." The
unit of Rontgeu light which we call X is equivalent to one-half of a Holz-
knecht unit and to one-tenth of the Sabouraud-Noir6 maximum dose.
The formula is as follows : 1 S-N maximal dose = 5 H or 10 X.
This reagent enables us to measure the penetration or the degree
of hardness of the Rontgen light. In comparison with other dosimetric
'Archives of the Rontgen Ray, June, 1906, p. 17.
2 Journal of Cutaneous Diseases, December, 1903.
8 Archives of the Rontgen Ray, June, 1906, p. 17.
TECHNIC OF RONTGEN RAY THERAPY.
435
methods, the quantimetric method has the advantage of greater exact-
ness and the possibility of estimating small differences of dosage. This
method gives a permanent registered record. The disadvantage of this
method is the difficulty which is encountered in comparing and distin-
guishing the slight differences of tint on the scale. Careful development
is necessary and always tedious. When massive doses are given the
color will be darker and will be more difficult for making comparison
with the scale. The degree of the sensitiveness of the emulsion of the
paper may frequently differ.
The New Radiometer of Freund. — Freund's method was used in 1904,
and is based on the color changes occurring in a two per cent, solution of
FIG. 221.— Kienbock's quantimeter.
pure iodoform in chloroform. This solution normally retains its color
unchanged for 48 hours, and is so very sensitive that a difference of tint
may be observed between two portions of the solution, one of which is
exposed to the rays for three minutes, while the other portion is screened
from the action. Slight heat and light will alter the color of the solution,
and, although this method is most accurate and sensitive, the solution is
too unstable for practical and clinical purposes.
The iodoform (CHI3) is decomposed by the X-rays, with the libera-
tion of free iodine, imparting a claret-color to the solution. Freund's
solution shows a change of tint in six minutes, equal to that attained in
ten minutes by the use of Holzknecht's pastilles.
436 ELECTRO-THERAPEUTICS.
Precipitation Test. — Schwartz,1 of Vienna, demonstrated a method
of measuring the strength of the Rontgen rays, based on the precipita-
tion of calomel in a mixture of ammonium oxalate and corrosive subli-
mate. This mixture is a clear fluid which, sheltered from the light, keeps
indefinitely. Exposure to daylight or to the Rontgen rays causes the
precipitation of calomel. The amount of precipitation is determined by
centrifuging in a graduated capillary tube. Three millimeters of the
precipitate in the capillary tube correspond (approximately) to the
strength of a Holzknecht unit. This technic with the usual methods
of testing the strength of the latter has the disadvantage of being a
subjective test of color.
D. THE IONIZATION METHOD.
Prof. Rontgen, in his second announcement, stated that he had already
made this discovery, and, probably prior to this, J. J. Thomson found that
the X-rays would discharge both positively and negatively electrified
bodies, by experiments on Hankel's electroscope or electrometer. Thom-
son stated that the discharge varied somewhat with the intensity of the
rays by the relative luminosity of the fluorescent screen, and in several
instances by the relative darkness produced upon the photographic plat*-.
This method is based on the principle that X-rays have the power to
ionize the gases through which they travel.
The lonization of Confined Gases. — Milton Franklin* states that, "so
far as I have been able to ascertain, this method has not been system-
atically used to measure the intensity of the X rays. This method has
been commonly employed to measure the radio-activity of radio-active
substances. Air is rendered a conductor of electricity by this ionizing
agent, and the measurement of the amount of current flowing through
it, under given conditions, gives an absolute index of the activity of the
radiation. It is necessary only to charge the electroscope by applying a
rod of vulcanite, sealing-wax, resin, or other suitable material, which has
been previously electrified by friction, and then to time the transit of
the filament under the influence of X-rays. The rate of discharge will
vary directly as the activity of the radiation."
The working of the instrument is as follows :
" The electroscope is charged by having brought into contact with
the knob, a rod of vulcanite which has been electrified by friction. The
knob is brought into communication with the filament while the vulcanite
is in contact, and released as soon as the filament has assumed a horizon-
tal position. The electroscope is brought to the same distance from the
tube as the plate or patient (in any position), and, while the tube is run-
ning, the shutter is opened, and the time, in seconds, occupied by the
1 Wiener klin. Woch., May 31, 1906.
1 New York Medical Journal, April 22, 1905.
TECHXIC OF KOXTGEX BAY THERAPY. 437
filament in transit, is noted. The number of seconds is the exact
coefficient of energy of the rays, and when compared with any other
reading made, under any circumstances whatever, with a similar
instrument, the ratio of energy of the two radiations will equal that of
the two times.
"In this method, with an electroscope of the gold-leaf pattern,
the relative activities of two radiations may be compared with great
accuracy and expedition, and if one of them is the standard unit of
activity or bears a known ratio to the standard, the value of the other,
in terms of the standard, will be readily deducible. Atmospheric
variations must be taken into consideration. The number of seconds
which it requires for the filament to traverse the field, is the coefficient
of the strength of the rays. All calculations and variations due to
the atmospheric absorption must be eliminated at once."
Tfie Radio-active Standard of Phillips. — Phillips1 utilizes the principle
of Franklin's method of ionization, and suggests radium as the standard
unit. He describes the modus operandi as follows: "The method con-
sists in attaching two similar discharge vessels one to each of the plates
of the electroscope. The needle, a thin strip of silvered mica, is only
electrified inductively, and the forces acting upon that end of it which
comes to rest above the centre of the gap are able, Avheu. the rods are
electrified equally, to produce a condition of equibirium. The horizontal
rods are connected with the standard radium ; when the rods are equally
charged, the needle is steady, but gives no deflection. * * * We
may also conveniently compare the activities of various substances, by
noting the time taken for a gold-leaf electroscope to discharge between
certain potentials. To do this with anything approaching accuracy,
however, the motion of the leaf must be observed with a reading tele-
scope." He calls the absolute unit the Becquerel, or one Curie, while
the commercial unit might be appropriately known as one "ray."
Dr. Henry G. Piffard* takes a brass ball, about one and one-
quarter inches in diameter, and supports it about four inches from
the wall of the tube just within the circle of rays issuing from the ante-
rior hemisphere. The ball is then connected by a cord about eight feet
long to the charging device of the electroscope. As soon as the current
passes through the tube the aluminium needle or foil indicates the
charge, and the angle is easily read off on the scale. For this purpose
he found Brauirs electroscope (which is graduated in volts) or his
own (which is graduated in degrees of an arc) very convenient. The
angle varies directly with the current passing through the tube, and
also shows whether the tube is running steadily or not, and indicates
any notable change in the vacuum.
1 Archives of the Rontgen Ray, June, 1906, p. 27.
2 Journal of the American Medical Association, Sept. 15, 1906.
438 ELECTRO-THERAPEUTICS.
E. THE PHOTOMETRIC METHODS.
These methods consist in comparing the fluorescence of a platiuo-
barium cyanide screen with an artificial light, either with a fluorescence
produced by radium or a radio-active salt.
The Radiometer of Courtade. — This instrument consists of a lead shield
containing two similar openings, and covered by a fluorescent screen. The
radium, which serves as a standard of fluorescence, is placed behind one
aperture. The degree of fluorescence on the second screen, produced by
the X-rays, is equalized with that of the standard by altering the dis-
tance of the Crookes tube. This distance will be a measure of the amount
and the quality of the radiation. This method is not thoroughly or ab-
solutely correct, because the intensity of the fluorescence of all the
platino-barium cyanides is subject to great variations, when exposed for a
long time to the action of radium or the X-rays.
The GuiUeminot- Courtade Method. — Founded on the same principle as
the radiometer of Courtade, Guillemiuot employs a sample of radium as
his standard of comparison, whose activity is 50,000. He considers the
unit of quantity of the X-ray is, that quantity falling on one square centi-
metre of the surface in one minute of time. This unit he calls the unit
"M." For example, if the Crookes tube has to be placed at a distance
of 3 metres, in order to produce an equal illumination of the screen,
then the intensity of irradiation of the field at 3 metres from the tube is
said to be unity. From this it is easy to calculate the number of units
"M" absorbed per minute at a distance of 10, 15, or 20 centimetres.
Thus, in the above example the number of units absorbed per minute at
10 centimetres distance is 900, "M" = 3 metres (300 cm.) ; then 3(*> cm- =
10 cm.
30 cm., therefore 30 cm. x 30 cm. = 900, while at 15 cm. it is 400, etc.1
This is open to the many objections mentioned before, the platino-
barium-cyanide changing its color of fluorescence, etc. This does not
give us the amount of absorption in the tissue, but we infer that from
calculations deduced.
The Fluorometer of Williams. — This instrument* depends upon the dis-
tance that a tungstate of calcium screen must be held from a given
vacuum tube, in order that the illumination from it may equal that from
a radio-active substance which has been measured by a standard source
of light. "I found," says Williams, "that when a tungstate of calcium
screen with the radium (Curie) lying upon it was placed over a vacuum
tube in a dark room, and the X-rays allowed to strike it, the radium was
less bright than the luminous screen ; but that as the screen was moved
farther away from the vacuum tube, the brightness of the screen diminished
until a point was reached at which the screen was less bright than the
1 Archives of the Rontgen Ray, June, 1906.
2 The Rontgen Rays in Medicine and Surgery, 1903, p. 640.
TECHNIC OF EONTGEN BAY THEKAPY. 439
radium, and that then by gradually approaching the screen nearer the
vacuum tube a point was found at which the radium and screen were
about equally bright.
"I experimented with several tubes in this way, and found that the
distance at which the screen and the radium were about equally bright
was different with different tubes, the limit of variation being between
10 and 41 centimetres ; and the distance was constant for the same tube
under the same conditions. As, by means of a photometer, the amount of
light given off by the radium can be measured in terms of a known stand-
ard, so the amount of fluorescence produced on a tungstate of calcium
screen by a given tube and the brightness of which a given screen is
capable may both eventually be referred to the same standard. The
fluorometer may serve as a basis, with a given apparatus, for determining
the length of exposure when X-rays are used as a therapeutic agent, and
likewise when they are employed for taking radiographs."
This instrument has the objection that the durability of tungstate of
calcium varies with different tubes, and also because the vacuum of the
tube changes during exposure and requires constant attention.
The Method of Contremoullns. — With this method, instead of employ-
ing radium, the standard fluorescent screen is illuminated by an acetylene
light. This is open to the same objection as stated above.
Selenium Photometer, — In 1905 Euhmer Levy presented, at the Berlin
Congress, a new instrument for measuring the X-rays. A selenium cell is
clamped in position at a fixed distance from the anode, a current from a
couple of dry cells is passed through the selenium, and its intensity is
read off on a millianiperenieter. The X-rays alter the resistance of the
selenium, and the variation of the current is therefore a measure of the
quantity of the rays.
Dunham's instrument1 consists of a selenium cell, which is placed
inside of a wooden pill-box and surrounded by tungstate of calcium.
This and a voltmeter are placed, in series, in a direct current of not less
than 60 volts. When this is placed before an X-ray tube, the tungstate of
calcium is caused to fluoresce and the light derived from the fluorescence
causes the resistance of the selenium cell to be reduced. The fluorescence
is much less powerful than a 15 -candle-power lamp. This lowering of
resistance in the cell allows the current to flow more readily, and this can
be directly measured by a very sensitive voltmeter. The next instru-
ment depends for its action on the fact that a 2-per cent, solution of iodo-
forni in chloroform is very easily and uniformly affected by the X-rays.
Its appearance when so treated varies from a light pink to a very dark
reddish brown. The second instrument is as follows : The selenium cell
and voltmeter are put in series as before, but no fluorescent salt is used.
The wooden box is removed and the cell placed in a light, tight box. The
'Lancet-Clinic, Cincinnati, August 25, 1906.
440
resistance of the selenium cell is reduced by the electric lamp beyond a
partition. The light must pass from a lamp to the cell through the bottle
because of the small aperture. To make this doubly certain the opening
is fitted with a small cylinder so that the rays must pass as desired.
When it is desired to measure a given dosage, all that is necessary to do is
to fill the bottle, place it in the box, and make the reading. The solution
is clear and practically all the light passes to the cell. The resistance
drops and the voltage as read on the meter goes up. The bottle is now
removed and laid on the surface of the patient near the part to receive
the irradiation. After the treatment it is quickly placed in the box and
the reading taken. The quantity of X-rays will be read by the difference
of the voltage before and after the exposure.
Dr. George G. Johnston1 takes advantage of the fluorescence pro-
duced on the tungstate of calcium or other screen as indicating the
quantity of the X-rays emitted. The fluorescing screen is placed in a
light, tight box, and facing it is a selenium cell. Such a cell, when kept
in total darkness, may have the resistance of several hundred ohms, yet
on permitting light to strike the cell resistance falls almost instantly,
and this alteration bears a direct relation to the intensity of the light. If
there is placed, in series, with such a cell a galvanometer or ammeter of
sufficient delicacy, a series of current such as an ordinary dry battery
and a variable rheostat providing a means of introducing more or less
ohmic resistance into the circuit, and the rheostat, the measuring instru-
ment, and the selenium cell be balanced, the point will be found at which
the ohmic resistance of the rheostat, the communicating wires, the
selenium cell, and the measuring instrument will exactly balance the
electro-motive force of the battery.
If, however, the container, having within it the screen and cell, be
placed in the path of the X-rays, the screen will become luminous in pro-
portion to the distance from the source of the rays and the quality of
rays striking it. The container will be illuminated ; the selenium cell
under the influence of this light will change its ohmic resistance in pro-
portion to the light, and the current flow will be measured and indicated
on the dial of the galvanometer.
Fluorescence of the Tube and the Appearance of the Electrodes. — This
method does not afford a reliable means of determining the penetrability
of the rays, as the fluorescence depends upon the kind of glass composing
the tube. In a dark room this fluorescence will be more clearly discern-
ible. Behind the anode there may often be noticed annular patches of
fluorescence, indicating a high vacuum. In studying the appearance
of the electrodes, a phenomenon sometimes noticed is, the emission of a fine
smoky stream around the edge of the cathode ; indicating a high degree
of vacuum. A low vacuum in the tube can be recognized by a conical
'Journal of the American Medical Association, September 15, 1906.
TECHNIC OF RONTQEN BAY THERAPY. 441
stream of cathode rays of a blue color. The appearance of a cherry-red
heat at the anode indicates that the tube is working properly, and that
rays of a high degree of penetrability are being produced. However,
this will vary according to the thickness of the platinum anode and the
strength of the current. It should not be forgotten that the same tube
will fluoresce differently with the different amounts of current, which
will produce more or less penetrating rays.
The Thcrmomelric ^^(iho(L — Kohler places a thermometer into a
depression in the Crookes tube, whereby he gauges the variation of
temperature as indicative of the quality and quantity of the rays.
III. Natural Fluorescence in the Human Body and its Artifi-
cial Production.1
Fluorescence may be defined as a property possessed by certain sub-
stances of absorbing visible or invisible rays and emitting visible light.
Fluorescence and phosphorescence are not, however, synonymous, in that
the former is evidenced only when the exciting cause is acting, and that
the latter continues after the cessation of the exciting force. Long ago it
was asserted and proved that a natural fluorescence existed in the tissues
of the human econonvy. The crystalline lens, the cornea, the aqueous
and vitreous humors are all fluorescent. Again, it has been demon-
strated repeatedly that the liver, heart, lungs, spleen, kidneys, brain,
muscles, nerves, etc., contain a fluorescent material, in many respects
resembling quinine, to which the name of lt animal quinodin " has
been applied. Half a century ago the view was advanced, and still very
largely obtains, that an intimate relation exists between the decrease of
animal quiuodin and malarious affections ; therefore the apparent wisdom
of exhibiting quinine to augment the fluorescence of the devitalized tis-
sue to its normal point. Based upon these views, experiments were
instituted and malarious patients were treated in darkened rooms with
purple hangings, in the belief that the sporulation of the plasmodiuin of
malaria could not occur in the absence of light, and especially red light,
corresponding to the Finsen treatment of smallpox. Thus, from the de-
ductions of various observers and experimenters, the administration of
fluorescent substances has been tried, and the blood thus affected has been
the subject of an interesting study both by the X-rays and with radium.
The fluorescent substances must of course be harmless, and a radiation
employed capable of offering a fluorescence deep within the tissues.
Sunlight, electric discharges, the ultra-violet rays, the X-rays, and the
1 This subject has been most exhaustively and elegantly investigated by Dr.
"William James Morton, of New York City. For a clear exposition of the study, the
reader is referred to Morton's original paper, " Fluorescence Artificially Produced in
the Human Organism," Journal of the American Medical Association, April 1, 1905,
from which parts of the above article have been taken.
442 ELECTRO-THERAPEUTICS.
Becquerel rays are all capable of exciting fluorescence and phosphores-
cence within the human body. For a study of the physiological action
of light upon animals and plants, the reader is referred to the chapter
devoted to " Phototherapy."
APPLICATION IN DISEASE.
As a therapeutic agent, Dr. Morton says : " I employ quinine bisul-
phate in doses of from five to fifteen grains daily, according to the
natural physiologic tolerance of the patient ; fluorescin, a 1 to 30
aqueous solution, from six to twenty drops, three times daily, one hour
after meals ; esculin, from five to fifteen grains daily.
"In treatment of an extremely obstinate case of lupus, one patient
has now taken ten drops of the fluoresciu solution three times daily dur-
ing the last three months and, employing the X-ray, not only has his
lupus healed over large areas, but he also has gained thirty pounds in
weight in the three months. Both in hospital and in private practice my
cases of lupus heal more rapidly and get permanently cured by this
method and in less time than by any other method I have used.
' ' I have ready to report six patients with tuberculous glands of the
neck, two already subjected unavailingly to numerous surgical operations
for removal, who are now perfectly well. One case of tuberculosis of the
hip -joint is making marked improvement.
11 In tuberculosis of the lungs the method is giving good results, not
yet ready to be reported on in extenso.
"In from one to three days after beginning treatment a reaction
occurs. The afternoon temperature in a recent case rose from, normal to
103° F. The cough, night sweats, and lassitude increased. Examination
of the sputum at this time revealed an enormous increase of the number
of tubercle bacilli. This reaction lasted about a week and then the tem-
perature gradually fell to normal, with corresponding improvement in
the other symptoms. The patient then entered on a stage of steady
gain in weight and comfort and personal appearance. The case is
under most rigid observation by skilled consultants and will be reported
on later."
Morton asserts that the fluorescence is much increased if radio-
active water is used to prepare fluorescent solutions. He administers
a half ounce of radio-active water in the morning, and again in the
evening, believing that this liquid absorbs and holds the emanations of
radium, becoming a secondary source of radiation ; the charged water
exciting the fluorescence. He successfully combats those scientists who
deny the possible existence of a radio-active fluid.
As is usual in such studies, the mass of literature, good, bad, and
indifferent, upon the subject in hand is most confusing. I append Dr.
Morton's resum6 : "The excitation of fluorescence within tissue is a
TECHXIC OF BOXTGEX EAY THEEAPY. 443
species of phototherapy and dependable on the same basis for curative
effects. The term sensitization is not accurate, for it is not known what
the term means. There is no proof that fluorescent substances make
the cells or other micro-organisms vulnerable to the exciting radiation.
•• \\liat the fluorescent light lacks in intensity is compensated for by
propinquity to tissue.
"The method here outlined consists of a medicinal saturation of
the entire blood system with a fluorescent solution, and submission of
parts or of the whole of the patient to the Boutgen and Becquerel
radiations, and to electric discharges.
"The method naturally includes filling cavities with fluorescent
solutions, as well as using these solutions medicinally.
"The curative effects obtained by this method are probably due
to the fluorescent light. This method permits of an improvement in
skiagraphic effects and of fluoroscopic examinations.
"Following the suggestions of the use of fluorescent solutions in
diagnosis and treatment, the method has proved of value in determining
the position and size of the stomach and other cavities of the body.
"The thoracic cavity presents on the fluoroscope a degree of illumi-
nation greater than that produced by the X-radiatiou alone.
"The method is useful in tuberculosis of the lungs, and in other
cases of tuberculous deposits, as well as in cancer."
Influence of Photodynamic Substances on the Action of X- Rays. — Kothe1
is enthusiastic over the enhanced action of the X-rays after the tissues
have been previously injected with a one per cent, or per thousand solu-
tion, of eosin, an hour before exposure. He describes experiments on
animals, and with lupus and warts in the clinic. The injection of eosin
enables the course of X-ray treatment to be much shortened, the expo-
sure need not be so long, and the reaction occurs sooner and is more
intense than without the eosin. The eosin injections also permit the ener-
getic reaction to be restricted to a circumscribed area, while the unin-
jected, sound tissue around or above scarcely feels the action of the rays.
Theoretically this method of treatment seems very plausible. Prac-
tical tests of its value have fallen far short of the early expectations.
This is probably due to the fact that such quantities of fluorescent salts
as can be absorbed are so widely distributed and diluted in the fluids of
the body that no appreciable effects can be produced. The same dilu-
tion, approximately, employed experimentally outside the body fails to
give any reaction on photographic plates. The effects produced on the
patient by the administration of quinine are probably due to its anti-
toxic action, counteracting the toxins resulting from efficient Bontgen
treatment and the consequent break-down and absorption of diseased
tissues.
1 Deutsch. me«l. Woch., Berlin, vol. ix., 1904.
CHAPTER V
THEKAPEUTIC VALUE IX DISEASE.
I. Cutaneous Affections.
LUPUS ERYTHEMATOSUS.
IN the first case of lupus erytheniatosus treated with the X-rays,1
the method employed was precisely the same as that used in cases of
lupus vulgaris. The result was a rapid disappearance of the cellular
infiltration in those areas exposed to the direct action of the rays. Im-
mediately surrounding this area a ring of pigmentation forms, which,
however, quickly disappears. The skin remains perfectly flat, regular,
and practically normal after the rays have been discontinued.
Jutassy * reported a case of lupus erytheniatosus in which he effected
an absorption of the infiltrating cellular elements, deposited by the capil-
laries of the coriuin and of those of the corpus capillare. A partial recur-
rence of small extent was observed in those portions which the rays had
difficulty in reaching.
Hahn and Grouven s report successful results obtained in cases of
lupus erytheniatosus, as do likewise Sjogren,4 Sartin,s and Torok and
Schein.'
LUPUS VULGARIS.
That the X-rays are most beneficial in the treatment of lupus vulgaris
is to-day the consensus of opinion among dermatologists. Freund
and Schiff were the first to give a detailed account of the favorable
influence of the X-rays in this disease. The rays seem to have a
selective action on the tubercles, and in continued treatments cause
a sloughing off of the hardened, gummy masses, which in time are
replaced by healthy scar tissue. The deduction of Freund in two cases
treated by him as early as 1897 is, "that there is primarily set up an
inflammatory reaction within the already discovered diseased tissue by
the rays/'
After irradiation there results a specific reaction, causing the tubercles
to become visible ; this is followed by a loosening of the tubercles with an
1 Fortechritte der Rontgenstrahlen, vol. ii., by Dr. E. Schiff.
1 Wanderversammlung Ungarischer Aerzte, Aug., 1899.
'Aerztl. Verein, Hamburg, 1900.
'Fortschr. a. d. Geb. d. Rontgenstrahlen, 1901, v. p. 37.
* Lancet, 1901, ii. p. 144.
•Wiener med. Wochen., 1902, lii. p. 847.
444
THERAPEUTIC VALUE IX DISEASE. 445
increase in their size, due to an augmented blood supply, which is suc-
ceeded by a shedding of the masses. With the swelling of the tuberculous
nodules there is set up a swelling of the already infiltrated lymphatic
glands in the vicinity of the tuberculous area.
Birkett ' treated a boy, aged 15, with a family history of tuberculosis,
who had two distinct primary lupus growths in the oro-pharynx, each
situated partly on the lateral and partly on the posterior pharyngeal
wall. The growths were distinctly nodular in appearance, about the size of
a swollen sago grain. Medical and surgical measures were inefficient,
and resort was made to the X-rays. A regulating tube with a vacuum
equal to a 3-iuch (7.5-cm.) spark-gap was employed. Twenty-three daily
exposures were given. A recurrence was treated in the same manner,
and the results at the present time are most satisfactory.
In cases of lupus the reaction always runs a similar course, the
tubercles gradually swelling, turning dark red, and becoming turgescent ;
at the same time irregular dark spots develop in regions previously unaf-
fected, which subsequently take on the character of lupus nodules. These
nodular masses subsequently drop out, leaving behind cavities with a
circular punched-out appearance about the size of a pin-head.
The results are on the whole as satisfactory as those obtained by
Finsen's method. The latter may give better results, but the procedure
is more or less tedious, the apparatus is expensive, and often fails to
work satisfactorily. With the X-rays a larger field of affected skin can
be treated at one exposure than with the Finsen light.
M. Morris and S. E. Dore2 state that "the X-rays have a sphere of
usefulness, but in cases of lupus they are much inferior as a curative
agent to the treatment advanced by Finsen. However, the rays can be
applied to cavities which are inaccessible to the Finsen light."
E. Smith3 reports a case of lupus vulgaris, of fifteen years' standing,
successfully treated and apparently cured by X-ray irradiations. The
patient was a man of eighty, who had been told that he was suffering
with a cancer of the right side of the nose, the inner can thus of the right
eye, and the inner thirds of the lids. Twelve treatments were given,
marked improvement being noticeable on the second treatment, which
was interrupted until the affected area was entirely healed. After the
second treatment, healthy granulations appeared and healing promptly
followed.
The following case came to me for treatment. The patient was a
young man in whom lupus had developed very slowly upon the side of
the nose, extending over the bridge to the inner cauthus of the opposite
eye. There was no pain and little or no exudation. Small nodules
1 New York Medical Record, December 24, 1904.
2 British Medical Journal, June 16, 1903.
5 Buffalo Medical Journal, January, 1901.
446 ELECTRO-THERAPEUTICS.
distinctly separated from oiie another were noticeable on palpation.
Microscopic examination of the diseased tissue confirmed the diagnosis.
After twelve treatments he was permanently cured.
Dr. H. W. Van Allen l reported fifteen cases of lupus vulgaris, with
80 per cent, cures. The average time since treatment was discontinued
is from one year to eight months. The average time of treatment is six
months, the shortest period being three months, and the longest nine
months. The most recent case was treated three months ago. The
longest time that has elapsed since treatment is three years. Eleven
cases were cured ; in one there was an apparent cure ; one is returning,
and two cases were not benefited.
X^vus.
The removal of hair from hairy naevi was successfully accomplished
by Freuud2(iu his first case of hypertrichosis treated by this method)
and likewise by Pusey.3
Vascular Na?vi. — Jutassy4 has given a very interesting report of the
successful treatment of an extensive vascular naevus of the face. Over
part of the area involved the naevus was flat, but on the cheek and nose
there were dilatations forming angiomata from the size of a hemp-seed to
that of a bean. The exposures were carried to the point of producing a
very acute dermatitis with free vesication ; as a result the growth was
practically destroyed. There remained over the area a smooth scar of
almost normal color. Xo trace of the angiomata remained. A year and
a half later the improvement had been maintained.
Pusey believes that "it is possible that, by setting up an acute
reaction in a vascular naevus, there may be produced scar tissue which
will be of such a character as practically to destroy the lesions. Of
course, the likelihood of so doing is greater the less the dilatation of the
blood-vessels. It is surely true that where there are large angiomata the
method will not be very effective, though Jutassy's case seems to show
that it may be possible to deal with superficial angiomata."
Lassar, of Berlin, states that applications of radium give better
results in cases of naevus than do the X-rays. I am using radium and the
X-rays alternately, with apparently good results. At present I am
treating a young boy who has a naevus covering most of one cheek.
For a control test, one-half the growth below the eye is exposed to the
rays, the upper part being shielded by lead. Xo dermatitis has resulted ;
the exposed area is changing from a deep red to a brownish hue, and
offers as a result of lessened vascularity a lighter color on pressure.
Journal of the American Medical Association, September 15, 1906.
MVien. med. Wochens., 1897, xlvii. p. 428.
8 Ri'mtgen Rays in Therapeutics and Diagnosis, p. 339.
4 Pest. med. chir. Presse, 1900, xxxvi.p. 73, quoted by Pusey.
THERAPEUTIC VALUE IX DISEASE. 447
ALOPECIA AREATA.
Ullmanu treated a patient by two exposures of fifteen minutes each,
on alternate days, the tube being " medium soft,"' at a distance of 15 cm.
The hair in the vicinity fell out ; but at the end of three months it began
to grow, but was of a darker color. The treatment had evidently stimu-
lated both the growth and pigmentation of the hair, and this result has
been permanent.
The treatment of alopecia areata by the X-rays has been reported by
Kienbock ! and Holzknecht.2 Kienbock reported a case of a young man
in whom the affection had existed for three years. After two months of
X-ray treatment dark-colored normal hairs appeared, while upon the
affected surfaces the growth of hair did not occur.
Holzknecht used the method with some success in several cases. In
one case of alopecia areata that had progressed steadily for five months,
after six months' treatment with the rays there appeared a fine growth
of hair.
Parasitic Alopecia. — In alopecia areata of mycotic origin it is possible
that the X-rays may prove of use, and in cases of tinea tonsurans simu-
lating alopecia areata this treatment would probably be successful. That
X-rays, however, cause temporary atrophy of the follicles is not a valid
reason for believing that they would be contraindicated in alopecia
areata, for unless a reaction is produced several times, the healthy hair-
follicles regenerate.
In treating certain cases of epilepsy, I observed in one bald-headed
patient that the application of the rays was followed by a growth of
short, stiff hairs.
HYPERTRICHOSIS.
Freund was the first operator in the field who employed the X-rays
in dermatology with success. He artificially produced an alopecia in a
case of hirsuties. The patient had previously undergone the usual course
of treatment when Freund experimented on the case with the rays. In
the beginning, the field was exposed two houi'S each day, and within
twelve days the hair commenced to fall out in large, thick tufts, and a
few days later the part was completely bald. This was the first case of
this kind cured by the X-rays. It is recommended that any tj'pe of
hirsuties should be given more numerous but less intense exposures.
Jutassy 3 states that he has employed the treatments as outlined by
Freund and Schiff with similar results. In the process of epilation there
are four stages prominently defined. 1. In the stage of exposure nothing
of any importance is discernible. 2. During the hyperasmic stage there
1 Wien. klin. Wochens., 1900, xiii. p. 1053.
»Ibid., 1900, xiii. p. 1177. "Orvosi Hetilap, 1898.
448 ELECTRO-THERAPEUTICS.
may be a scattered or even a complete shedding of the hair, but this is
only temporary, as the hair roots are not destroyed. 3. In the inflamma-
tory stage there is an acute inflammatory process, with an accompanying
slight, transient hyperaemia. Xot infrequently this process advances to a
pustular stage, and falling of the hair is in many cases complete and per-
manent. 4. Regeneration of the hair occurs after a period of from two to
three months and in those insufficiently treated. The absence of any
signs of recurrence after a period of about three months indicates that the
treatment has been satisfactory, and a prognosis of a permanent alopecia
may be rendered. In one case there was produced a permanent alopecia
in less than three weeks ; seven treatments were given with a 20-minute
exposure at each sitting.
Barthe'lemy and Oudin1 remark that their conclusions are directly
opposed to those arrived at by Schiff, Freund, and a number of noted
American and English observers.
Two series of experiments were conducted on women, the hairy field
of the pubic region being the part selected. The hair of each of the
patients presented dissimilarities in color and thickness. In the first
series the exposure was of short duration, while in the second series the
exposure was of long duration. In the first two cases, with exposures of
ten minutes each, and repeated daily or every other day for a period of
from two to four weeks, no satisfactory results were obtained. The third
case, frequently exposed for a long time, was followed by an erythema
and a profuse shedding of hair. The exposure of the cases of the second
series extended from ten to thirty minutes. The results were negative in
three of the cases, while in the other three cases there was only a slight
loss of hair, which came out very readily upon combing or by pulling upon
it. In only two of the cases treated as above was there a complete falling
of the hair, one of these cases being accompanied by a wide-spread
erythema.
Schiff and Freund* reported that in three cases a slight erythema
was the sole visible result of the exposures. Prior to the falling out of
the hair, the skin was visibly undergoing the process of bronzing. The
pigment continued to accumulate until the hair fell out, followed by its
rapid disappearance. Previous to shedding, the hair turned snow-white,
lost all its pigment, and microscopically exhibited vacuoles. In a single
case this phenomenon had been repeated three times, when the recurring
dry hairs were again submitted to the action of the rays.
Sjogren8 observed a rapidly disappearing pigmentation in a brunette
of 25 years who was subjected to treatments similar to those outlined by
Schiff and Freund.
1 La Radiographie, 1900, xxxix.
* Wiener med. Wochenschrift, 1898, xlviii. p. 1058.
3 Bibliotheca medica, Heft 8.
THERAPEUTIC VALUE IN DISEASE. 449
After the treatment all the cutaneous roughness and unevenness dis-
appear, and likewise the scarring resulting from a previous folliculitis.
The integument becomes smooth and free from all blemishes. Occasion-
ally there may be noted a few flat, colorless depressions, very similar to
those following a treatment by electrolysis. The shedding of the hair
after a long series of exposures would indicate accumulative action of the
X-rays. Forster1 also expresses a similar belief.
Grunmack has conducted experiments to ascertain the epilatory
effects of the rays, but with varying results, due to lack of necessary
precautions.
I have treated several female patients who were disfigured with
growths of superfluous hair. One woman presented a growth of hair on
the neck and forearm. I treated the forearm first, to determine the
dosage and the patient's susceptibility, and after ten treatments of 5
minutes each, covering a period of ten months, the hairs were removed,
without even a vestige of erythema. In one patient the growth of hair
returned, but subsequent treatment permanently eradicated the growth.
This X-ray treatment obviates the pain of electrolysis.
FAVUS AND TINEA TONSURANS.
The use of the X-rays in the treatment of tinea tonsurans and favus
was suggested by Freund.2 Cases of tinea tonsurans successfully treated
by the X-rays have been reported by Schiff and Freund,* Torok and
Schien,4 and others. Cases of favus successfully treated have been
reported by Schiff and Freund,5 Hahn and Albers-Schonberg,6 Torok
and Schien, Kienbock, and others. One case of Schiff and Freund
has remained cured for a year. In these cases the reaction needs to be
carried to the point of causing complete alopecia and slight cutaneous
inflammatory reaction. Theoretically the treatment is ideal. It causes
a falling out of the diseased hairs, at the same time destroying the organ-
isms upon which the disease is dependent. The alopecia which it causes
is temporary unless accompanied by a greater reaction in the skin than
is necessary.
The objections to the method lie in the fact that the process
is a tedious one, and that the exposure of a large part of the scalp in
tinea tonsurans or favus is a procedure of some risk unless carried out
with caution. All that is said of the treatment of tinea tonsurans applies
equally well to the treatment of favus.
1 Wiener klin. Wochenschrift, 1897, No. 3.
1 Wien. med. Wochens., 1897, xlvii. p. 856.
s Fortschr. a. d. Geb. d. Rontgenstrahlen, 1899, iii. p. 109.
* Arch. f. Derm. u. Syph., 1901, Ivi. p. 132.
5 Wien. med. Wochens., 1902, Iii. p. 847.
6 Munch, med. Wochens., 1900, xlvii. pp. 284, ,".24, 363.
29
450 ELECTRO-THERAPEUTICS.
Batten ' proved that with X-rays we can make the hairs fall from the
bottom of their follicles, thus overcoming the difficulty of treating this
disease. His method of treatment is as follows : A boy's ordinary close-
fitting cap is covered on the outside with a continuous, fairly thick layer
of white lead, and the latter with linen or muslin ; holes are then cut in
this white-lead screen to correspond with all the ringworm patches to
be treated ; through these holes the scalp is exposed to X-rays from a
medium or moderately hard tube for ten or eleven minutes, six times
within a fortnight. The scalp should be six to eight inches from the
anticathode, and the ears, neck, and face protected from the rays by the
white-lead cap or similar shield, or by a diaphragm over the tube. Next
a simple, penetrating parasiticide lotioii should be applied morning and
night over the whole scalp, during the period of the treatment. AVhen
the patches are quite bald, a mild parasiticide ointment should be rubbed
into the scalp once a day, applying the lotion also to the entire scalp.
The hair usually begins to grow within seven or eight weeks from the
commencement of treatment, and by the end of the third or fourth month
it is fully grown.
Adamson * states that, when the X-rays are used for the treatment of
ringworm of the scalp, the hair of the part exposed to the rays may be
made to fall, leaving a smooth, bald area, entirely free from stumps, and
when this grows again, after an interval of some weeks, the new hairs are
found to be free from ringworm. The fungus has not been killed, but
has come away with the old hairs, and by the time the new hair grows
not a trace of it is left. Those using this method have, however, always
been chary of its application, fearing burns or baldness. But now, by
means of Sabouraud's radiometer, such accidents can be readily avoided.
The hair begins to fall about fourteen days after the application, and
continues to do so for a few days longer. It begins to grow again in from
six to eight weeks, and is fully grown at the end of three months,
provided that the length of exposure is not allowed to exceed the limit
set by the right use of the pastille, that no area or part of any surface is
exposed more than once, and that the part exposed is kept at the proper
fixed distance from the anticathode of the tube. By this method there
is no danger of permanent baldness or injury to the tissues.
Concerning the value of the X-rays in the treatment of tinea, Sabou-
raud 3 says that ambulant treatment is to be recommended, and instead of
the two years formerly required, the cure is complete in three months.
The tube should be fifteen centimetres from the diseased area, and at the
same time a scrap of platino-cyanide paper should be exposed to the
centre of the tube (equal to five Holzknecht's units), but at a shorter
1 Archives of the Rontgen Ray, August, 1905.
1 Lancet, June 24, 1905.
s La Presse M6dicale, Paris, No. 98, Dec. 7, 1904.
THEEAPEUTIO VALUE IX DISEASE. 451
distance (eight centimetres). "When the thin sensitized paper has
changed to the tint •' B'' of the radiometer, the exposure is terminated.
By observing that the shade of the sensitized paper is below the tint
"B" on five Holznecht's units, the operator can be confident that there
is no danger of an erythema, burn, or permanent baldness. After the
exposure the part is treated with an ointment containing the oil of cade,
which is washed off each morning. The entire scalp is then rubbed with
a ten per cent, alcoholic solution of tincture of iodine, to prevent reinfec-
tion from the hairs as they drop out of the exposed patch. Each patch
requires a separate exposure.
ECZEMA.
Dr. R. Halm claims priority in radiotherapy of eczema, especially
the chronic type. At a meeting of the Medical Society of Hamburg,
July, 1898, he reported two such cases that he successfully treated. Both
patients suffered from eczema of the thighs for periods of two and four
years respectively. In the first case a cure was effected after twelve
applications of the rays. In the second case, after four exposures, the
hypercemic condition of the affected part appeared, followed by a slight
dermatitis, which, however, disappeared in three days.
Dr. Margaret Sharpe l reported a case that affected a small area of
the hand, following a burn, which occurred three years previously. The
part had been exposed eleven times, each irradiation consuming fifteen or
twenty minutes. The lesion faded away gradually, the part appearing
more and more pallid as the result of each exposure. There was abso-
lutely no soreness or any inflammatory reaction.
Drs. Montgomery and Orinsby 2 state that several cases of chronic
eczema treated by the rays had given most excellent results. In one case
of eczema which was exceedingly stubborn and of many years' standing,
located in the skin of the scrotum, in which a vitiliginous condition had
appeared on the infiltrated skin, ten daily treatments gave the patient
relief from the itching ; the infiltration gradually disappeared, and later
the normal pigment returned.
Hahn * believes that if eczema is a gerin disease, then, as demon-
strated by Rieder, we may expect the X-rays to influence the bacteria
directly. If, on the contrary, it is a nutritional disease, the action of the
rays in setting up a dermatitis leads us to hope that the reactions of the
tissues will cause alterations in the circulation and nutrition with conse-
quent healing. The point of most interest is the rapidity with which the
lesions improved (usually after ten to twelve exposures). The effects
immediately observed were a decrease and in some cases an absolute
1 Archives of the Rontgen Ray, February, 1900, p. 5260.
2 Journal Amer. Med. Assoc. , Jan. 3, 1903.
3 Fortschritte a. d. Geb. d. Rontgenstr., 1901, 1902, v. pp. 39-41.
452 ELECTRO-THERAPEUTICS.
cessation of the secretion. In all Halm had fourteen cases, ia nine of
which he was able to effect absolute cures. Of the remaining cases three
failed to materialize after three, four, and eight exposures respectively ; of
the other two cases, one died of pneumonia, and the remaining one was
treated eighteen times with apparently no improvement.
In cases of eczema I usually give short and frequently repeated
exposures — i. e., every other day — for the first two or three weeks. After
this period I expose the parts every third or fourth day. By this pro-
cedure I have in some cases attained very good results. For a further
discussion of cases of eczema successfully treated by the rays, the reader
is referred to articles by Albers-Schonberg,1 Meek,2 Scholtz,3 Sjogren and
Sederholm.*
ACNE.
Dr. R. R. Campbell5 reports fifteen cases more or less completely
cured by the X-rays. He used a medium soft tube, moderate illumina-
tion, about fifteen centimetres from the patient, with exposures of ten
minutes each, usually every other day.
"MissE. R., age 20, had been under constitutional and local treatment
for three months, without any appreciable improvement in the local
condition. Early in January, 1902, X-ray exposures were begun. She
was given three exposures weekly of ten minutes each, with the tube
fifteen or twenty centimetres distant. After two weeks there was mani-
fest improvement, and the exposures were reduced to two sittings weekly j
by the end of February no active lesions or comedones could be detected,
and the exposures were further reduced to once weekly until the end of
March, when all treatment was discontinued. No relapse has taken
place. No dermatitis or erythema was produced in this case at any time."
Altogether I have treated ten cases of acne. In one patient, a girl of
nineteen, whose face was covered by the eruption of eighteen months'
duration, I succeeded in completely curing the patient in thirty-two treat-
ments. These applications were made three times weekly for two weeks
and thence once weekly. The tube was fifteen inches from the face, three
inches spark-gap, duration of each treatment, two minutes. The applica-
tions were just stimulating enough not to produce an erythema. I do
not believe in the production of an erythema in the facial region. Seven
of the other cases are apparently permanently cured, and recurrences
occurred in the other two, after a period of two years. In one case an
atrophic condition of the pitted area resulted.
1 Munch, med. Wochens., 1900, xlvii. pp. 284, 324, 363.
1 Boston Medical and Surgical Journal, 1902, cxlvii. p. 152
s Arch. f. Derm. u. Syph., 1902, lix. p. 421.
* Fortechrit. a. d. Geb. d. Rontgenstr., 1901, iv. p. 145.
5 Journal of the American Medical Association, August 9, 1902, p. 343.
THERAPEUTIC VALUE IN DISEASE. 453
Acne Yulgaries. — This chronic inflammatory disease, which involves
the sebaceous glands, usually appears in the form of papules, tubercles,
or pustules, simple or combined, and chiefly affecting the head, face, and
neck, and occasionally the chest.
Dr. Joseph Zeisler1 reports thirty-four cases of acne of different vari-
eties and of different degrees of severity. Five of these were instances
of acne rosacea and four were indurated cases with pustules of the back
and chest.
"The bulk of them were, of course, of the ordinary type of acne
of the face, many of them of the very severest and most rebellious na-
ture. The exposures were rather mild in character, the distance of the
tube, according to its light, being from twenty to forty centimetres.
"I usually start in these cases with three treatments a week for from
two or three weeks. After this exposures are given twice weekly only
for a time, and later about once a week. A beneficial action can usually
be noticed during the second week, when few new pustules are noted and
the comedones seem to shrink and dry up. The accompanying seborrhosa
oleosa of the face is very promptly influenced. Some of the severest
cases which I have ever treated were cured in from four to six weeks,
and have so far remained well."
A minimum reaction to the rays is not always accompanied by the
cure of acne, but a moderate degree of dermatitis should be aimed at.
The disadvantages of the treatment are the pigmentation liable to follow
in brunettes, occasionally the slight cutaneous atrophy, and the excep-
tionally severe dermatitic reaction. The X-rays cause the hairs to drop
out, and evidently check the secretion of sebum. The parenchyma of
the sebaceous glands becomes more indurated, and this explains the
lasting benefit derived in nearly every case from X-ray treatment.
Dr. Gautier,2 of Paris, reported sixteen cases of acne vulgaris and
acne rosacea which had been successfully treated by X-rays.
In hospital and private practice I have had numerous cases of this
disease. In general the results of radio-therapy were successful when
combined with other remedial measures. I have noted that frequent five-
minute exposures are more satisfactory than longer and less frequent
applications. The tube should be of ''medium vacuum," so that the
most beneficial results may be obtained.
Acne Rosacea. — Jutassy was the first to treat acne rosacea by the
X-rays. Hahn 3 reports two cases of acne rosacea in which he obtained
satisfactory results. The redness of the nose and of the adjacent parts
disappeared, and had not returned after an interval of several months.
'Journal of the American Med. Asso., February- 21, 1903.
'Compt.-rend. du xii. Congres international de MM., Moscow, vol. iv., August,
1897, pp. 385-386.
'Aerztl. Verein, Hamburg, 1900.
454 ELECTRO-THERAPEUTICS.
Hyde and Montgomery and Ormsby ' state the following: "In a
few cases of acne rosacea our use of the X-rays Las been followed by a
very marked improvement. In two very extensive and very severe cases
of acne, which had resisted for months all our efforts at treatment, the
eruptive symptoms disappeared completely under the use of the X-rays.
In other cases a few exposures have seemed to materially aid the other
treatment employed.
"The cases of acne in which radio-therapy is of unquestionable
value are those in which the disease is limited to a small area. Here the
treatment may be pushed, if necessary, to the point of producing atrophy
of the affected glands and follicles. When many scattered glands are
involved and new lesions are constantly forming, radio-therapy gives
temporary benefit, but could not be expected to prevent recurrence of
the lesions unless the treatment be carried far enough to produce general
atrophy of the sebaceous glands of the face. But the sebaceous glands
have a function to perform, and to produce a general atrophy of these
glands of the face must be a questionable procedure until we can deter-
mine what effect such a course would have on the skin ten, twenty, or
forty years later." (Figs. 222, 223.)
SYCOSIS.
J. F. Rinehart * speaks of the advantages of the treatment of these
cases by the X-ray. The treatment is thorough, painless, and there is
but little scar tissue left after healing. He reports a number of illustra
tive cases, and urges that too much haste to obtain reaction is often
productive of marked inflammation.
The treatment of sycosis by X-rays was suggested and first carried
out by Schiff and Freund,' and there are numerous reports in the litera-
ture testifying to its success. Successful cases have been reported by
Hahn,4 Spiegler,5 Rinehart,6 Scholtz,7 Gassman and Schenkel,8 Torok
and Schein,9 and others. The treatment has proved equally efficacious in
parasitic and non-parasitic sycosis. In some of the cases the patients
have remained well a year after the cessation of treatment. A typical
successful case of parasitic sycosis is that reported by Zechmeister.10 In
1 The Journal of the American Medical Association, January 3, 1903.
2 Philadelphia Med. Jour., 1902, ix. p. 221.
s Wien. med. Wochens., 1897, xlvii. p. 856 ; Fortechr. a. d. Geb. der Rontgenstrah-
len, 1899, iii. p. 109.
*Deut. med. Wochens., 1901, xxvii. V. B., p. 29.
6 Arch. f. Derm. u. Syph., 1901, Ivi. p. 131.
•Philada. Med. Journal, 1902, ix. p. 221.
'Arch, f. Derm. u. Syph., 1902, lix. p. 421.
8Fortschr. a. d. Geb. d. Rontgenstrahlen, 1899, ii. p. 121.
•Wien. med. Wochens., 1902, Iii. p. 847.
10Monatsheft f. prakt. Derm., 1901, xxxii. p. 329.
THERAPEUTIC VALUE IX DISEASE. 455
this case the face was covered with deep follicular pustules. Hyphomy-
cetes had been demonstrated around the roots of the hair. After five strong
exposures there was a slight reddening and scaling of the pustules. Ten
days later the pustules had vanished, and in two weeks more the disease
had entirely disappeared. Three months later there was no recurrence.
Dr. J. Zeigler1 reports very good results with the X-rays in four
cases of sycosis ; after two or three radiations, pustules ceased to form,
where epilation had taken place new hairs began to show after two
months, and no relapse has since appeared.
Schiff and Freund * speak of X-ray treatment of sycosis as follows :
"When the rays were applied seven times, complete recovery was
obtained, leaving the skin smooth and free from all inflammatory con-
tractions. The action of the rays seems to be anti-parasitic, as no
recurrence had appeared after the second month."
PRURITUS ANI AND PRURITUS VULV.K.
Dr. J. Rawsoii Penuington 3 has treated several cases of pruritus ani
with the X-rays. In one case, after the third treatment he began to
notice a change for the better. The exposures were continued, and the
tough, leathery condition soon began to disappear. As it passed away
the itching subsided. There has been no itching for the last four months,
and the skin is normal to the touch.
In another case the patient had previously undergone treatment for
hemorrhoids. Pruritus followed the operation and had been very
obstinate since. A few exposures to the X-rays eliminated the trouble.
He also reported a series of thirteen cases of pruritus ani wherein
most of the cases were cured by the rays and, though still under treat-
ment, all improved. The skin is left smooth, soft, clean, and pliable.
While there is no objection to the use of other procedures in conjunction
with the X-rays, none was employed in these cases, proving that the
successful results were entirely due to radio-therapy.
Scholtz4 has seen improvement in a case of pruritus vulvae, and
Sjogren and Sederholm 5 have reported seven cases of pruritus vulvse
which were decidedly relieved by this means.
XERODERMA PIGMENTOSUM.
At the Edinburgh Medico-Chirurgical Society, Dr. Allan Jameson 6
exhibited a little girl suffering from xeroderma pigmentosum which had
1 Journal of the American Med. Asso., February 21, 1903, p. 513.
2 La Presse Medicale, May 27, 1899.
3 New York Medical Journal and Philadelphia Medical Journal, February 20, 1904.
4 Arch. f. Derm. u. Syph., 1902, lix. p. 421.
5Fortsch. a. d. Geb. d. Rontgenstr., 1901, iv. p. 135.
6 Journal of the American Medical Association, February 14, 1903; Lancet,
London, 1903.5. p. 105.
456 ELECTRO-THERAPEUTICS.
been treated by the X-rays. At the age of twelve months she began to
develop freckles at the side of the nose. Later telangiectases and whitish
spots appeared on her face. The disease had extended to the hands and
wrists. When first seen, there was an epitheliomatous growth the size
of a sixpence on the tip of the nose and numerous warty excrescences
on the face. Thirty-four exposures to the rays, of five minutes each for
the face and thirteen minutes for the right hand, were given. The growth
on the nose and the warty growth both disappeared. The nose is now
whiter than the rest of the face, and there is a marked improvement in
the right as compared with the left hand.
PSORIASIS.
Attempts to employ radio-therapy in the treatment of psoriasis have
thus far given positive results in the hands of Ziemssen and Albers-
Schonberg. Jutassy has also made experiments in this direction, but his
results are as yet incomplete. Grouven and Hahn * have reported most
favorable results.
Hyde and Montgomery and Ormsby8 report their experiments with
this disease as follows : "We have treated thirty-two cases of psoriasis
with radio-therapy, causing in each case a temporary disappearance of
the lesions. From four to ten treatments on a given group of lesions were
usually sufficient to cause them to disappear entirely, except for a certain
amount of pigment. In lesions in which the thickening was but moder-
ate, the scales often disappeared after the second or third treatment.
Relief from itching, when such is present, occurs about the same time.
" In the treatment of psoriasis we use a fairly soft tube and very
short exposures, at a distance of ten or twelve inches. It has not been
necessary in any case to produce any visible evidences of reaction, not
even in erythema or pigmentation. The influence of the rays on psoriasis
is in keeping with the fact demonstrated by one of us (Hyde) twelve
years ago, and frequently since, that some psoriatic patients can free
their skin of all lesions by prolonged baths."
F. S. Burns 3 states that the treatment of this disease by means of
the Rontgen rays has been thoroughly tested, and no lesion has failed to
disappear under this form of treatment, even though the cases have
resisted all other forms of treatment for a considerable period of time.
He bases his conclusions on a series of 150 cases.
Morris and Dore * state that they have seen good results in chronic
patches of psoriasis. From four to ten treatments were usually sufficient,
in a given group of lesions, to cause them to disappear entirely.
1 Niederrheinische Gesellschaft fur Natur- und Heilkunde in Bonn, 11, ii., 1901.
1 Journal of the American Medical Association, January 3, 1903, p. 4.
1 Boston Medical Journal, October 23, 1903.
4 British Med. Journal, June 6, 1903.
FK;. -JJJ.— Profile and full view of a patient at the Philadelphia Hospital with acne rosacea.
FIG. 223.— The same after fifty irradiations, which I employed tliri<-«. weekly. Distance of tube (soft),
15 inches (38 cm.). Secondary current 2 ma., equivalent to No. 2 scale of Benoist.
FIG. 224.— Epithelioma of the nose, before irradiation.
KM;. ±i->.— The same after I irradiated the growth at the Philadelphia Hospital.
FIG. 226.— Epithelioma of 1"> years' standing, in which radium therapy was employed as a control
test, by shielding half the growth with lead. The protected half was subsequently treated with the
X-rays. The X-ray treatment brought about a marked improvement. Treatment with radium was
negative.
FID. ±27.— Epithelioma of the dorsum of
the hand, before irradiation.
FII;. -'is.— The same after irradiation.
THEKAPEI7TIC VALUE IN DISEASE. 457
Dr. E. S. Ferris 1 relates the following case : Patient, age 50, has had
psoriasis as long as he can remember. At intervals he has undergone
both local and constitutional treatment, the only result of which was an
apparent lessening of the scales for a short time. Occasionally, even
while under treatment, there was diminished activity manifested by dis-
appearance of scales and a pallor of the red patches, but the papules
never disappeared. On October 1, 1902, he presented himself for treat-
ment. "I found the disease involved the skin covering almost the entire
body. After trying various treatments and brush discharges, I gave him
sixteen X-ray applications to his back only, consisting of three expo-
sures of ten minutes each. On the day following the sixteenth sitting, I
found the skin tender and of a dusky hue ; later a more marked reaction
was manifested. After ten days all traces of the disease except slight
redness had disappeared from the part treated. Even this redness was
gone in another week, and the lesion on the chest vanished at the same
time. This success encouraged me to apply the X-rays to the other
parts involved, with the same happy results. At present there is
absolutely no trace of the former trouble ; the skin is smooth and soft
and of normal color."
Drs. Sjogren and Sederholm, of Stockholm,2 state that two cases
of psoriasis treated with the X-rays were not in the least benefited
thereby.
SENILE LEG ULCERS.
In 1904, in the service of Dr. Ernest Laplace at the Philadelphia
Hospital, I exposed twenty senile leg ulcers to the action of the rays.
The patients' ages varied from 50 to 65. Before treatment the ulcers had
an angry appearance and an offensive odor, with no granulations. They
were treated through sterile unmedicated bandages.
In most of the cases, after several months' treatment, a slight der-
matitis resulted, and the applications were discontinued. The secretion
was checked, the odor disappeared, and granulations began to sprout.
The areas, which previously had been measured and photographed,
showed a decrease in size. Three of the patients are still at the hospital
and are almost cured. Of the other seventeen some have since died and
others have disappeared from observation.
VARICOSE VEINS.
McGuire 3 reports two cases of varicose veins. The first patient was
a woman, aged 45, with eczema of both legs, complicated with varicose
1 American Electro- Therapeutic and X-Ray Era, May, 1903.
* Fortschritte auf dem Gebiete der Rontgenstrahlen, June, 1901.
'Medical Record, September 1, 1906.
458 ELECTRO-THERAPEUTICS.
veins and an ulceration on the right leg. The ulcer resisted all treatment
until the application of the X-rays. This caused inflammation of the
skin, which extended over the whole surface of the leg. The treatment
was stopped for four days, when it was again tried. Inflammation
resulted, but during the next five days, without the application of the
X-rays, the dermatitis gradually subsided and by the end of the week had
disappeared. The ulcer completely healed and the varicose veins disap-
peared. The second patient was a man, 50 years of age, with a large
bunch of varicose veins on the right leg. Treatment by the X-rays is
gradually reducing the tumor and without causing any great reaction of
the tissues. The rays cause contraction and atrophy of the tissues and
those of low vitality easily break down.
HYPERIDROSIS.
Dr. J. T. Dunn1 has treated a number of cases of hyperidrosis,
and asserts that it is necessary to produce reaction, by short repeated
treatments, until complete destruction of the sweat follicles has
occurred.
In treating cases of hyperidrosis involving the palmar surface of
the hands, it is necessary to be exceedingly cautious, as the reaction is
usually easily produced and pain is very severe in such cases. It is his
experience that reaction appears after six or eight treatments of ten
minutes each when applied to the palms of the hands ; and on account
of the density of tissue involved, pain is severe if the reaction is
excessive.
KRAUROSIS VULV^:.
Dr. G. H. Stover1 reports the case of a woman, aged 50, who had
suffered severely from kraurosis vulva3 for several years. She was told
that we knew nothing whatever of the effect of the X-ray in this
condition, and with that understanding an exposure was made, a
tube of medium vacuum being employed. The exposure was made
at 2 P. M. in March, 1903 ; that evening her suffering was so great
that her family physician was called. Some hours after the raying
he found the diseased area redder than common, swollen and osdem-
atous, the appearance being much like that of erysipelas. Further
radiation was decided against, and after a week or two, when the
inflammation had subsided, the affected tissue was excised. Possibly
the rubbing and cleansing which the patient had given the parts may
have had an unfavorable influence.
1 American Electro-Therapeutic and X-Ray Era, December, 1903, p. 450.
1 New York Medical Journal, February, 1904.
THERAPEUTIC VALUE IX DISEASE. 459
LEPROSY.
H. B. Wilkinson,1 who has had the good fortune to study exten-
sively the subject of leprosy, reported upon a series of thirteen cases
to the Manila Medical Society, October 12, 1905.
He began the treatment of leprosy with the X-rays during January,
1904, with a ten-inch spark machine, with which he used a bifocal tube.
That portion of the patient which presented the greatest amount of infil-
tration was exposed to the direct rays of the tube at a distance of about
ten inches. The exposure lasted about ten minutes and was repeated at
intervals of several days. His object was to approach as near as possi-
ble to the burning point without actually producing a burn. He called
particular attention, however, to the fact that a cure resulted in the two
cases which were accidentally burned. After two or three successive treat-
ments, a blushing of the skin is often observed, which is later followed
by scar formation. A tabulated statement of the thirteen cases treated
showed that three were cured, seven improved, and three not improved.
He is inclined to believe that, when a local lesion of leprosy is treated
with X-rays, the organisms there localized are killed and their bodies
absorbed by the system, thereby producing an immunity against the
living organisms. This, as may be seen, would be practically analogous
with the immunization of individuals against bubonic plague by injecting
into them killed cultures of plague organisms. In his cases he simply
grew the culture of lepra bacilli in the human body as a culture medium
and then killed them by the use of the X-rays. In support of this theory,
he cites the following facts : 1. The treatment of one leprous spot on a
patient produces improvement in spots at a distance from the one actually
treated. 2. The cure in the distant spots seems to progress parallel to —
and to be just as complete as in — the one treated. 3. The best results
seem to be obtained only when treatment is pushed to the point of killing
or beginning to kill the tissues, which would also probably be to the
point of killing the organisms. 4. Cases in which there are massive
localized leprous deposits are most rapidly improved. There is an abun-
dance of culture on which to operate and thereby produce immunity
more rapidly. 5. In diffuse general involvement of slight degree or
atrophic character, where there are only a few scattered organisms, little
success is to be expected.
Sequeira * reports a nodulated form of leprosy of the skin which has
shown marked improvement ; the hard masses became soft and flat.
Scholtz3 treated two cases of leprosy with X-rays without results;
de la Camp also obtained negative results.
114 Some Observations on Leprosy in the Philippine Islands, with an Account of
its Treatment with the X-ray," Medical Record, December 9, 1905, reported by a
special correspondent at Manila.
* British Medical Journal, September 28, 1901, p. 851.
3 Arch. f. Dei-mat, u. Syphilis, vol. lix., 1902, pp. 443-444.
460 ELECTRO-THEKAPEUTICS.
II. Malignant Growths.
A. EPITHELIOMA.
lu the X-ray treatment of epitheliomata a number of circumstances
must be considered, — the rapidity of the growth, its character, location,
and glandular involvement, age of the patient, and the state of health.
When the epithelioma has grown rapidly, I advise an immediate
operation and subsequent X-ray treatment. In cases of slow growth I
am in favor of X-ray treatment only. (Figs. 224, 225, and 226.) The
severity of an epitheliomatous growth is largely dependent on the proxim-
ity of the lymphatic chain of glands. Thus, such an ulcer of the upper lip
is far less likely to produce metastases than one of the lower lip, and con-
sequently irradiation of the former will yield the better results. Likewise
the anterior portion of the tongue aifords better results in treatment than
the posterior part. Again it is easier to irradiate the external than the
internal canthus of the eye, because of the excess of lachrymation pro-
duced when the latter is treated. In making a prognosis it is essential
to differentiate between the forms of epithelioma very carefully, since
these neoplasms vary in their malignancy according to their locality and
the depth of the tissues involved.
The results obtained in the treatment of epitheliomata by the Ront-
gen rays have more than satisfied its most sanguine advocates. That
these malignant cutaneous growths can be made to disappear entirely has
been the common experience of Eontgen therapeutists.
Carl Beck, of New York,1 and others make a statement which is
slightly at variance with the views of certain noted investigators in this
line. They deem it essential to remove surgically all such diseased areas.
This they regard as the most valuable form of treatment ; notwithstand-
ing this fact, they assert that it is proper to employ the rays after the
gro\vth has been excised. It is my belief, and which I have abundantly
confirmed, that the X-rays should be applied without any surgical
intervention.
W. Merrill and W. Johnson2 were the first in this country to report
the results obtained in malignant diseases by treatment with the X-rays.
Their first case, one of cutaneous cancer of small dimensions, was cured
in October, 1899. The discharge soon ceased, pain was relieved, and in
general the result was satisfactory.
Another case reported was an epithelioma affecting principally the
nose and involving the nasal septum. The case was carefully watched,
and one year later no apparent sign of recurrence was demonstrable.
In the third patient the cutaneous cancer affected the lower part of
the bridge and tip of the nose. The treatment was the same as was
1 Medical Record, February 7, 1902.
1 Philadelphia Medical Journal, December 8, 1900, vi. p. 1089.
THERAPEUTIC VALUE IN DISEASE. 461
applied in the other two cases, except that the exposures were shorter
in duration and more frequent. After an interval of three years the
patient has no sign of a recurrence.
They also reported sixteen additional cases l regardless of their length
of existence, extent of tissue involved, and previous treatment received ;
ten patients, or 62.5 per cent., are apparently cured ; four other cases, or
25 per cent., show improvement, and three of these give promise of
ultimate recovery under further treatment.
Sjogren 2 states that in nearly all his cases of epithelioniata treated
by means of the rays, a change for the better might be observed even
though apparently no inflammatory reaction developed. He seems to be
convinced that in order to bring about an absolute cure one must set up
an inflammatory reaction of intense severity. This causes a degenera-
tion of all (or at least the majority) of the embryonic cellular elements,
which is the aim.
Wni. Sweet, of this city,3 reports most satisfactory results obtained
from his treatments in three cases of epithelioniata involving the tissues
surrounding the eyeball.
William Allen Pusey 4 reports having treated several cases of epi-
thelioma, in which there was no involvement of the deeper orbital tissues,
and all resulted in cures where sufficient treatment was permitted. No
relapses have occurred, and some of the cases were treated about three
years ago.
"Win. M. Sweet 5 believes that it is no longer right to resort to plastic
operations in cases of epithelioma in ocular affections, basing his judg-
ment on the successful results of eighteen out of twenty cases treated.
Allen6 treated five cases of Jacob's or rodent ulcer, which were
entirely cured by the application of the X-rays. Two of these involved
the lower eyelids, two the nose, and one the centre of the cheek. All
these were of long standing and very slow development : one of them, at
the side of the nose, had been developing for fifteen years. When once
cured by the X-rays, these lesions seldom recur.
De Schweinitz 7 has had four cases of "entire and rapid cicatriza-
tion," with no relapse. In two additional cases the results were entirely
negative, or possibly the condition was aggravated. In one of the latter,
excision was practised with subsequent application of the rays, without
1 American Medicine, August 9, 1902.
1 Fortschritt. a. d. Geb. d. Rontgenstrahlen, 1901.
3 American Medicine, December 13, 1902.
4 Chicago Medical Reporter, April, 1902.
5 Medicine, April, 1904.
•Trans. Amer. Derm. Asso., 1903.
T Personal statements made to Dr. G. Oram King and embodied in an article,
"The Value of X-rays in Ocular Therapeutics," Journal of the American Medical
Association, September 29, 1906.
462 ELECTRO-THERAPEUTICS.
recurrence. De Schweinitz concludes the rays should be tried for a cer-
tain period, and, if the results are not good, then excision with or without
plastic operation should be practised.
Charles Lester Leonard,1 whose experience has been extensive in
treatment of epitheliomas and various skin lesions involving the eyelids,
regards it as uniformly and permanently successful. Baker 2 writes that
he has had five cases of rodent ulcer, with perfect recovery. One case
of special interest had been under observation for ten years ; all this
time the disease was slowly progressive ; not only the eye, but the cheek
and temple were involved. The eye was enucleated and, later, X-ray
applications were made for a year or more less regularly, resulting in
complete cicatrization, with no evidence of recurrence at the end of four
years. In a sixth severe case, in which both X-rays and radium were
used, a complete cure has been effected, the curative agent being, in
Baker's judgment, the Rontgen rays. In eight cases of epithelioina the
results have been entirely satisfactory, although in most of the cases the
knife was used and followed by the X-rays. There have been no recur-
rences. Baker had two cases of lupus involving the eyelids, that have
been "very greatly improved if not entirely cured by the X-rays."
Hermann Knapp* has seen "four temporary results in epithelionia
and the like." Stevenson 4 has used the X-rays with success in treatment
of lupus of the eyelids only. Xewcomet5 advises me that he has treated
about thirty cases, few of which have shown any disposition to recur.
The names of a host of foreign and home workers in ophtha.1 mo-
logic lines or electrotherapy could be added if additional testimony
were needed.
J. F. Schamberg6 treated a case of marked interest, — an epithelioma
involving not only the lids, but the conjunctiva as well. A perfect cure
was effected, and after two years Schamberg reports no recurrence.
Drs. Hyde, Montgomery, and Ormsby7 have been very successful
in treating fifty-five cases of epithelioma ; in a number of the cases
the major part of the growth disappeared, in twenty-five cases the
lesions have been entirely replaced by scar tissue, and there has been
no evidence of recurrence during periods varying from two to nine
months.
In surface carcinoma involving deeper tissue their results have not
been uniformly satisfactory.
Dr. W. B. Coley8 reports that out of forty-four cases of epithelioma
of the various regions of the face and head only four cases were cured.
'Personal statements made to Dr. G. Oram King and embodied in an article,
"The Value of X-rays in Ocular Therapeutics," Journal of the American Medical
Association, September 29, 1906.
2 Ibid. "Ibid. 4 Ibid. 5Ibid. 6Ibid.
7 Journal of the American Medical Association, January 3, 1903.
8 Annals of Surgery, August, 1905.
THERAPEUTIC VALUE IX DISEASE. 4G3
Dr. A. D. Rockwell1 treated two cases of epithelionia, giving
forty five and forty-seven exposures respectively ; recovery occurred in
both cases.
Dr. G. G. Burdick2 reports 80 cases of epithelioma, involving the
skin only, treated by the X-rays. There were no recurrences. In cases
of epithelioma situated at the muco-cutaueous junctions, he advises
removal of the glands in the vicinity. After an interval of two years,
this method was in 23 cases followed by no recurrence.
Dr. Chas. L. Leonard3 reported a case of epithelionia of twelve
years' standing, which has remained healed for two years.
Dr. Russel H. Boggs4 treated 12 cases of primary epithelioma ; 9 of
them were apparently cured, 1 almost cured, 2 very little improved.
Dr. G. P. Girdwood 5 reports 8 cases of typical rodent ulcer ; 4 of
them completely healed and the other 4 did not. He treated all with the
same apparatus and technic. He asks, "Is it simply the difference of
constitution, or is there some difference which the microscope does not
reveal that should make so great a difference in the result?"
I have had similar failures, and am of the opinion that previous
surgical treatment and the special location of the growth are important
governing factors. French pathologists believe that different epitheliomas
present different histological characteristics.
In the above reports we notice a great diversity of opinion. Some
prefer the soft and others the hard tube. Views also vary as to the dura-
tion of the seances and their frequency. It is asserted by some that a
slight dermatitis is always to be aimed at, in order to obtain the proper
action. The great variety of cases encountered will allow of no special
technic ; the peculiarities of the epitheliomas themselves will frequently
dictate the method to be pursued.
Sequeira.6 who treated 45 cases of rodent ulcer since June, 1901,
states that the ulcers healed rapidly and large cavities filled up, but that
he had had difficulty with the hard, raised edges. He also observed
slight recurrences.
He likewise reported 83 cases of rodent ulcer, 34 of which were
healed, and the majority of the remainder were still under treatment.
He found that when cartilages of the nose and bones were involved,
the condition was unfavorable.
He observed, microscopically, a destruction of the epithelial cells,
and in some of them a fatty change occurred and the connective-tissue
elements were also stimulated, and this stimulation caused the filling of
1 New York Med. Journal, April 7, 1906.
1 Transactions of the American Rontgen Ray Society, 1905.
s Ibid.
4 Ibid.
5 Transactions of the American Rontgen Ray Society, 1906.
6 British Medical Journal, September 28, 1901.
ELECTRO-THERAPEUTICS.
cavities and the formation of healthy scar tissue. He also recommends
the use of the actual cautery when there is difficulty in causing the hard
edge of the growth to disappear.
Joseph T., aged 63, with a negative family history, presented an
epithelioma of the dorsum of the hand the size of a half-dollar. (Figs.
227, 228.) Two months before, — i.e., in October, 1902, — after two years
of apparent cure, the lesion became painful, ulcerated, and began to
spread. The trouble began twelve years ago, with a small papule on the
back of the right hand. This grew steadily and slowly, and defied local
measures. Patient was subjected to X-ray irradiation, and about two
and a half or three years later I reported the lesion healed, but it subse-
quently reappeared, and at the beginning of the last treatment the ulcer-
ation had reached the size of a fifty -cent piece. Surface appears clean,
devoid of granulations, with rough and thickened edges. After thirty
irradiations the patient improved, but slight dermatitis forbade further
treatment. Subsequently the growth was again irradiated, and, at the
expiration of sixty treatments in all, the patient made a perfect recovery.
The technic that I usually employ is to irradiate thrice weekly for
three weeks, duration of each stance about eight minutes. Crookes
(soft) tube, 10 to 12 inches (25 to 30 cm.) distance.
B. CARCINOMA.
The results sought for in X-ray treatment of carcinoma depend upon
several factors :
Depth and rapidity of growth, age and health of the patient, and
technic employed.
The deeper the growth the fewer the rays that will reach the cancer-
ous part, most of the rays being absorbed by the skin. We cannot push
the treatment as we should desire, for to do so would be to cause a
dermatitis that would eventuate in gangrene and necrosis.
In cancers of rapid growth the knife should precede irradiation.
To do otherwise is to sacrifice needed radical treatment arid perhaps life.
After operation I advise irradiations through the dressings, in order
to destroy the cancer cells left by the surgeon. If small subcutaneous
nodules should appear four or more months after the operation, they
should be irradiated. I have seen very many of these nodules com-
pletely removed by this means. Of course the younger and the more
robust the patient, the better will be the results of treatment.
I cannot agree with those physicians and pathologists who assert that
the X-rays hasten cancerous inetastases ; their statement, that the rapid
disintegration of the cancer-cells (that cannot be eliminated by natural
means) must invade surrounding tissue, I believe to be faulty.
Reports of X-ray therapeutists are widely divergent as to the value
of X-rays in the treatment of cancer. I believe that this is largely due
THERAPEUTIC VALUE IX DISEASE. 465
to the use of inefficient apparatus aud to errors in diagnosis (benign
growths being mistaken for malignant ones), which point to the impera-
tive necessity of examining microscopically, before, during, and after
irradiation, sections or scrapings of the growth.
The vacuum of the tube is a matter of prime importance, especially
in treating the deeper-seated cancers ; — i.e., the vacuum should be high in
order to allow of a deeper penetration. In the body cavities, — as the
mouth, rectum, vagina, etc., — I believe in the direct application of the
rays, and not by special cavity tubes.
Probably we err too much on the side of safety ; apparently the
stances are too brief, we too often fearing the production of a severe type
of dermatitis. An erythema or slight dermatitis is unavoidable; per
contra, it is advisable as indicating the particular individual tolerance.
I do not endorse the Continental method of massive single doses, but in
common with our own operators, I strongly advise and always use short
and frequently repeated exposures.
I do not confine treatment to the involved area, as the disease may
have invaded surrounding territory. Thus, in treating a mammary
carcinoma I irradiate the axillary and subclavian glands on the diseased
side and also the opposite breast. This applies to cancer of the tongue,
with its associated cervical lymphatics, etc.
Cancer of the Breast. — Perhaps, as far as violent malignant disease is
concerned, cancer of the breast is more favorably influenced by the
X-rays than the same disease occurring in any other part of the body.
Personally, I have encountered quite a large number of cases of
carcinoma in various regions. The results obtained varied considerably.
Some of the cases showed absolutely no effects under the most persistent
treatment, others showed slight improvement, while in only four cases of
mammary carcinoma I succeeded in bringing about changes for the better
which might be designated absolute cures. I shall report only the cases
which gave very good results.
CASE I. — A woman, aged 34, had rapidly developed a carcinoma of
the left mammary gland. She readily consented to undergo an operation.
Upon palpation we could not discover any enlargement of the axillary
glands. The patient's wound granulated rapidly, so that it was appar-
ently healed in the course of four weeks. The pathologist diagnosed the
malignant portion as an adeno-carcinoma. Two months after the opera-
tion three small nodular masses developed within the old scar ; they
increased in size and ultimately ulcerated. The patient was advised to
undergo X-ray treatment. She was brought to me three months after
operation. I exposed the diseased area once daily for one week, in-
ducing by these frequent applications intense inflammation, and from
general appearances the area was growing rapidly worse. The exposures
lasted for eight minutes each, the tube being twelve inches (30 cm.)
distant. The second week all treatments were discontinued. I started on
so
466 ELECTEO-THEEAPEUTICS.
the third week giving a six-minute exposure every third day, the tube
being fourteen inches distant in the beginning, and gradually brought
down to eight inches (20 cm.)? until the last exposure had been given.
The wound had been treated sixteen times before we were able to note
any changes. These changes were a lessening of the discharge and the
formation of a scab from the drying exudate. The patient suffered abso-
lutely no pain in the beginning of the treatments, but about three weeks
subsequently she experienced most excruciating agony. This would
lessen considerably after each treatment, and again become worse, when
it would subsequently be relieved, and so on. When the discharge had
all discontinued, the pain almost entirely subsided. The ulcers seemed
to be healing at the edges and the intense induration present also gradu-
ally disappeared. In all I gave forty-five treatments and effected a cure.
I have watched the patient for nearly sixteen months, and up to the
present time no signs of recurrence have been noticed.
CASE II. — The patient was a woman of 62, from whom carcinoma
of the breast had been removed. On operation no tuberculous glands
could be detected. Six weeks after operation, before the wound had
fully healed, the disease recurred, near the seat of the former nipple.
The patient received in all thirty-three treatments ; irradiation was given
every fourth day, lasting six minutes. The disease has not recurred now
for eleven months.
CASE III. — A multiple carcinoma occurring in a woman 63 years of
age, affecting the breast. The involvement had not been extensive,
though sufficient to cause alarm. The tissue between the ulcerated
nodules was normal, though the skin was slightly inflamed. The patient
had an epithelioma of the lip, fourteen or fifteen years before, operated
on, with no signs of recurrence. The patient had been actively treated
for four months, and occasionally for the four succeeding months. At
first the treatments were given every fourth day, each one lasting from
three to eight minutes. By the end of the first four mouths the carcinoni-
atous field had entirely disappeared, leaving small scars very difficult
of detection.
CASE IV. — Mrs. B. , carcinoma of the right breast. She was operated
upon by Dr. M. P. Warmuth, on September 29, 1903, and X-ray treat-
ment was instituted January 1, 1904. I gave her twenty-five treatments,
thrice weekly. Up to the present time there has been no recurrence.
CASE V. — Miss J. L., age 24, a nurse, with cancer of right breast ;
her mother died of mammary carcinoma. Dr. Warmuth operated in
November, 1904, and I instituted X-ray treatment in January, 1905. In
the meanwhile she married. On October 10, 1905, she noticed a swelling
on the left breast. I gave her ten treatments before the operation and
subsequently the left breast was also removed. Post-operative tn-at
ment was given for a period of three weeks. She is now in good health.
CAKE VI. — Mrs. C., was operated upon by Dr. John B. Deaver, on
THERAPEUTIC VALUE IN DISEASE. 467
November 27, 1905, for cancer of the right breast, and referred to me by
Dr. Taylor. I began X-ray treatment one month after the operation, and
gave her three exposures weekly for three months, duration ten minutes.
Anodal distance ten inches. Both breasts and axillary regions were
irradiated. At present I treat her once monthly. She is perfectly well
and there is no sign or symptom of a recurrence.
CASE VII. — Mary Moore, age 51, single, housewife. Family history
negative. Duration of the present disease ten months (secondary).
The trouble began as a small white papule under the left axilla. Three
months later the patient was operated upon for the growth, which had
increased greatly in size and extent ; surgical measures were only partly
successful. The patient was treated for three months, thrice weekly.
Eventually the part healed, but the patient died from metastatic
involvement.
CASE VIII. — Kate Quiun, age 61, married, housewife. She was run
down by a bicycle eleven years before coming to me, and a year later
there appeared over the site of the trauraatism a small growth, that
increased in size until it involved nearly all of the right breast ; ulcer-
ation occurred and spread rapidly. There was no apparent involve-
ment of the adjacent lymphatics. Treatment was instituted June 22,
1904 ; forty-five exposures were given, each of ten minutes duration.
The pain, discharge, etc., disappeared, but four months later the patient
expired. Death was due to general infection.
II. Gocht 1 reported two cases of carcinoma of the breast exposed to
the influence of the rays. Both of these cases had been regarded as
inoperable. No cures, however, were effected, though in one of the cases
pain was almost entirely relieved. The other case died before any
improvement had been discerned.
George G. Hopkins2 reported two cases of carcinoma of the mam-
mary glands treated by the rays. The first case was entirely cured after
thirty-two treatments had been given. The second case only showed
improvements, such as lessening of discharge and pain and partial
healing of the ulcer.
Ayers 3 also reported the results obtained in two cases of mammary
carcinoma. The first had been operated on, and, before healing had been
completed, areas of recurrence of the disease were noticeable. These
areas were exposed daily for four minutes during three and a half
months. Healing was absolutely complete, with no symptoms. The
second case had a great deal of induration, ulcerating at three areas. The
axilla had also been much involved. The results obtained were a
decrease in size of the induration, considerable lessening of the ulcerating
discharge, and the disappearance of all pain.
1 Fortschr. a. d. Geb. d. Rontgenstrahlen, 1897, i. p. 14.
'Philadelphia Medical Journal, 1901, viii. p. 404.
5 The Kansas City Medical Index-Lancet, 1902, xxiii. p. 18.
468 ELECTRO-THERAPEUTICS.
Chisholm Williams1 reports a woman, 42 years old, single, having a
scirrhous form of recurrent ulcerative carcinoma of the breast treated by
X-rays, twice a week, five minutes each sitting; in all 28 exposures
were given. There has been no recurrence during the past four and a
half years, and the patient is still in excellent health. He also reports
a similar case in which lumps in the axillary region disappeared and
remained cured for three years.
Dr. S. M. McCollin1 reports a recurrent carcinoma of the breast
with an ulcerated surface five by eight inches. The patient was relieved
of all pain, skin formed over the ulcer, and life was prolonged for nearly
one year.
Dr. G. H. Stover* says that in his own experience prophylactic
treatment has resulted in failure. He believes that this may be due to
the treatment not being sufficiently vigorous or continued long enough.
He thinks anti-operative treatment is of benefit. Kor is Stover alone in
this view, a number of skiagraphers sharing the same opinion.
Dr. R. H. Boggs * observed 23 cases of carcinoma of the breast ; 15
of these patients were operated upon and a recurrence had taken place
when they came for X-ray treatment. Up to the present time, 8 patients
have died, 2 have been lost sight of, and the other 13 are living ; 7 of
these are apparently cured, 2 are under treatment, and the other 4 are
gradually becoming weaker. Some of them were treated three years ago,
but, of course, this is still too short a time to say that there will be no
recurrence.
Dr. Joseph F. Smith5 says that in carcinoma of the breast he has
seen small recurrences along the line of incision or small nodular involve-
ments disappear under the use of the rays. He has not seen any patient
in whom a large primary carcinoma of the breast disappeared under the
use of the X-rays.
Dr. G. G. Burdick6 reports a cure of 18 cases of carcinoma. In 14
cases the tumor and enlarged glands disappeared.
Dr. W. B. Coley7 treated 36 cases of carcinoma of the breast. In
only one instance did the tumor disappear, while in every other case
there was a recurrence.
Dr. A. D. Rockwell8 reports that in a case of scirrhus of the breast,
after 24 post-operative exposures there was no evidence of return three
years later.
1 Archives of the Rontgen Ray, October, 1906.
1 Proceedings of the Philadelphia County Medical Society, October 31, 1904.
8 Transactions of the American Rontgen Ray Society, 1906, p. 150.
4 Ibid.
& Ibid.
•Ibid.
T Annals of Surgery, August, 1905.
• New York Med. Journal, April 7, 1906.
THERAPEUTIC VALUE IN DISEASE. 469
Dr. Lassar1 stated that he had had only three failures out of
hundreds of cases of cancers that he submitted to the rays.
He recognizes2 the limitations of treatment, stating that one-fifth of
an inch is the extent of its effective therapeutic penetrating power.
Comas of Listen has had similar favorable results.
\Vohlgemuth 3 witnessed the disappearance of a cancer of the breast
in a woman of 75 after 72 exposures thrice weekly.
Unger, of Berlin, and Sjogren, of Stockholm,4 know of no case of
cure of mammary cancer.
Djemil Pasha 5 treated six cases of cancer ; three cases were cured
and three improved.
W. Johnson and "VV. Merrill 6 treated seven cases of carcinoma, all
of which were inoperable ; none showed any improvement beyond relief
from pain. They all ended fatally.
Cancer of the Sternum. — Ferguson7 reported a case of scirrhus of the
sternum, which had been declared inoperable. The Rontgen rays were
applied nineteen times, each exposure lasting twenty minutes. Three
weeks after the last treatment the growth had almost entirely dis-
appeared. After the sixth treatment the excruciating pain wholly
ceased. Following the healing of the ulcerated field, there was noticed
a slight involvement of the axillary glands.
Cancer of the (Esophagus. — Pusey 8 records the following case of
carcinoma of the oesophagus, treated by the X-rays: "Man, age 56,
referred to me by Professor "VV. S. Halsted, of Johns Hopkins University,
May 7, 1902. An obstruction in the oasophagus had been located nine
inches from the teeth. At first a clinical diagnosis of carcinoma
was made. Subsequently, Dr. Halsted informs me, a piece of tissue
was removed through the ossophagoscope and the diagnosis of adeno-
carcinoma was made microscopically. Vigorous X-ray exposures were
begun over the upper part of the chest May 7, 1902, and from that
time to the present he has had exposures daily except Sundays, either
over the chest or back, the exposures being changed as erythema devel-
oped. There was prompt disappearance of the discomfort and pain
in the chest, and there was a gradual improvement in his swallowing.
Six weeks after beginning the exposures, he had gained nine pounds
in weight, his pain had disappeared, and he was having no difficulty in
swallowing."
1 Rontgen Congress, Berlin, 1905.
'Journal of American Medical Asso., p. 79.
'Rontgen Congress, Berlin, 1905.
4 Ibid.
5 Revue de Chirurgie, Paris, xxv., No. 1.
6 American Medicine, August 9, 1902.
7 British Medical Journal, 1902, i. p. 265.
8 The Rontgen Rays in Therapeutics and Diagnosis.
470 ELECTRO-THERAPEUTICS.
Cancer of the Larynx. — "W. Scheppegrell l reports a case of carcinoma
of the larynx in which a complete cure was obtained by the rays alone.
The growth involved the left wall and left vocal cord. A high-tension
coil was employed, and a tube of medium vacuum was selected in order
to gain some penetration. The face and chest were protected, but the
neck was freely exposed in the hope that any involvement of surround-
ing glands might be influenced by the treatment. At first the exposures
lasted ten minutes and were repeated daily for twenty days. The anode
was brought to a dull-red heat, and the vacuum was maintained about
the same, from the beginning to the end of the treatment. At the end of
three weeks, congestion seemed more marked and the tumor unchanged ;
pain, however, had disappeared after the second exposure. Ten days
later it was found that the tumor and most of the symptoms had dis-
appeared. Treatment was carried on for ten days, by which time the
ulcers were healed. The patient, when seen three months later, seemed
in good condition ; the aphonia had been practically overcome by
compensatory over-action of the other cord.
Dr. D. Bryson * believes that not a single case of laryngeal cancer
has been reported cured, but few cases have been thus treated. In one
case treated by Dr. W. J. Morton for the author, apparently good results
were produced on the growth, but the patient died of Bright' s disease
after twenty applications of the rays.
Cancer of the Stomach and Bowels. — Dr. P. M. Pilcher* reports an
inoperable carcinoma of the stomach in a woman of 56. Three treat-
ments of fifteen minutes each were given weekly ; they began August 1,
1903, and at the time of the report the patient was able to eat and was
free from pain.
Dr. S. M. McCollin 4 reports a case of carcinoma of the stomach in
•which the swelling entirely disappeared and the patient was relieved of
all clinical evidence of the disease.
Dr. Finley R. Cook5 reports that in carcinoma of the intestines,
where life had been threatened with intestinal obstruction, all symptoms
of obstruction have been relieved, the tumor reduced in size, and life
prolonged for variable periods.
Pusey says that in carcinoma of the rectum the only hope in the
application of the rays lies in the decrease of pain, the checking of the
discharge, and the shrinkage of the growth.
Cancer of the Herns. — In applying the rays for cancer of the uterus,
I introduce a speculum and protect the thighs and lower abdomen with a
sheet of lead, exposing only the vulva. I employ a medium tube, at
1 New York Medical Journal, December 6, 1902.
1 The Laryngoscope, December, 1902.
1 Brooklyn Medical Journal, April, 1904.
4 Proceedings of the Philadelphia County Medical Society, October 31, 1904.
6 International Journal of Surgery, October, 1903.
THEKAPEUTIC VALUE IN DISEASE.
471
a distance of eight to ten inches (20 to 25 cm.), thrice weekly, exposure
ten minutes' duration. The Crookes tube with the speculum attached,
encased in a shield (Fig. 229), is far superior to cavity tubes (Figs. 230,
231), as the latter lack the effective quality of the Crookes tube. X-ray
workers, however, employ these tubes. If vaginal dermatitis is threat-
ened, the rays may be passed on alternate days through the lower abdomen.
Dr. James P. Marsh,1 of Troy, X. Y., cited a case of a woman, aged
55, referred to him for hysterectomy because of an extensive carcinoma
FIG. 229.— TUBES AND RUBBER TUBE SHIELDS *OK THERAPY OF THE BODY CAVITIES.— A, the
rubber tube shield, encasing the tube and tied to it ; B, showing the size of the opening governed by
the diaphragm ; C, showing speculum attached. (R. V. Wagner Co.)
of the cervix. He applied the rays alternately over the suprapubic
region and the vagina, using a very soft tube. The treatment was given
for ten minutes. After twenty or thirty treatments there was a marked
improvement in her condition. All of the symptoms had disappeared ;
she was feeling well and gaining in weight.
Therapeutic Action of the X-rays in Cancer. — Dr. John G. Clark,2 at a
meeting of the Medical Society of Pennsylvania, said :
"During the
Journal American Med. Association, Jan. 17, 1903.
2 The Pennsylvania Medical Journal, April, 1904.
472
ELECTKO-THEKAPEUTICS.
last year Dr. Matthew D. Mann, in a personal recital of his own experi-
ence, first directed my attention to the possibilities of Eontgen-ray
OUTER TUBE
AIR SPACE
INNER TUBE.
OUTEf? TUBE
A IP S PACE
/NNER TU&E
CR05S SECTION
FIG. 230.— Pennington's treatment (cavity) tube. (R. V. Wagner Co.)
FIG. 231.— Cavity tube applied. (R. V. Wagner Co. )
treatment in inoperable cases and in those in which there is a recurrence
after operation. In the literature, which as yet is not at all well defined
concerning the active effects of this agent, there appears a diversity
of opinions; some claiming that the curative action arises from a
THEKAPEUTIC VALUE IX DISEASE. 473
stimulation of the nutrition of the part rather than from an actual attack
upon the cancer-cells, whereas, others believe that the rays act destruc-
tively upon the cells by diminishing their growth, thus permitting
the underlying connective tissue to reassert its functional activity
and reconstruct the deficiencies produced by the invasion of the new
growth.''
Codman, in commenting upon an extensive number of cases treated
in the Massachusetts General Hospital, claims that the beneficial effects
of this form of treatment arise from the stimulation of the nutrition of
the surrounding parts, rather than from a direct specific effect upon the
growth.
In the microscopic study of the tissues after the Rontgen-ray treat-
ment, a number of observers agree in general as to the structural changes.
They have found a necrosis of the cancer-cells and trabeculae, at times
fatty degeneration, an increase of elastic tissue, and a tendency to the
occlusion of vessels by a thickening of their inner walls. To the latter
effect is probably attributable the diminution of hemorrhage frequently
noted in these cases after the treatment is well under way.
C. SARCOMA.
What has been said relative to the results obtained in epithelioma
and carcinoma applies with equal force to sarcoma. I cannot believe that
many X-ray operators have achieved brilliant results with the rays in
this disease. I have found that irradiations in sarcomatous affections are
too often futile. Below are given some of the more interesting reports
upon the subject.
Ricketts l reports a case of melanotic sarcoma of the chest wall. The
tumor had much decreased in size and the pain had almost totally disap-
peared. The patient died in the mean time.
Carl Beck2 reports a case of melanotic sarcoma of the groin and
the thigh, recurring after operation. Vigorous X-ray treatments checked
the course of the disease.
S. \VT. Allen 3 reports a case of sarcomatous growth of the tonsil. The
operator exposed the swelling to the influence of the rays, with a result-
ing decrease in the size of the tumor, and at the same time the patient
could articulate words with much greater ease. Entire cure had not
been attained when this report was made.
F. "Williams4 speaks of a patient who had received fourteen treat-
ments for sarcoma of the arm, each exposure lasting from twelve to
twenty minutes, the tumor being exposed twice in one week. The
1 Journal of the American Medical Association, 1900, vol. xxxiv. p. 76.
2 New York Medical Journal, 1901.
3 Boston Medical and Surgical Journal, 1902, p. 431.
4 The Rontgen Rays in Medicine and Surgery.
474 ELECTRO-THERAPEUTICS.
induration had disappeared almost entirely, the swelling had dimin-
ished considerably, and the venous discoloration over the tumor had
given way to the normal hue of the skin.
Scholtz1 reports the results obtained in the treatment of two cases
of multiple sarcomata of the skin. He states that under active applica-
tions small nodules of the integument disappeared entirely. Jamieson's
case of mycosis fungoides which was treated with the X-rays showed
very marked improvement in every respect.
Dr. George Erety Shoemaker * reports the case of a woman who had
sarcoma of the abdominal wall, and probably also of the pelvic viscera,
which disappeared under treatment. On operation it was found that the
rectum, the uterus, and the left tube and ovary were massed together by
an apparent infiltration, but had a certain range of motion. The tumor
in the lower abdominal wall was united to this mass by a process of
thickened tissue a little to the left of the median line. ,The whole
appearance suggested a new growth, which it was thought unwise to
remove. The incision was closed, and a cut made directly into the
suprapubic growth. Examination of the piece removed for that purpose
showed that the mass was sarcomatous. Treatment by the Rontgen rays
was begun after the healing of the upper wound. This treatment con-
tinued for about nine months in all. The total number of exposures was
forty-nine. The improvement was remarkable. A year after coming
under observation the infiltration of the abdominal wall, the pain, and
the soreness were entirely gone.
In a case reported by Richmond,3 the patient had a swelling which
crowded the liver and other organs forward and inward. A diagnosis of
sarcoma was made. After treatment with the X-rays for nineteen
consecutive days the temperature had decreased to normal, night-sweats
were lessened, the tumor had apparently ceased to grow and seemed
softer, and the patient was generally improved. She was then sent to the
hospital, where the treatment was continued, and at the end of nine
weeks the growth had entirely disappeared, as far as could be determined
by bimanual examination.
McMaster* reports five cases of sarcoma in which treatment with
the X-rays proved entirely successful.
Dr. L. Webster Fox,5 of Philadelphia, had his attention called to
X-ray treatment in epithelioma of the lids. A year and a half ago he
had a case of sarcoma of the orbit ; the diagnosis was confirmed by
several colleagues and by the microscope. The case received forty-eight
1 Archiv f. Derm. u. Syph., 1902, lix. p. 42.
* American Medicine, December 26, 1903.
"Journal of the American Medical Association, June 10, 1903.
4 Canada Lancet, February, 1903.
6 Journal of the American Medical Association, December 17, 1904.
THERAPEUTIC VALUE IX DISEASE. 475
applications of the X-rays before the disappearance of the growth. There
was no recurrence.
J. G. Chrysopathos ' operated on a woman who had a large, rapidly
growing tumor of the right ovarian region ; finding it to be a sarcoma (a
diagnosis which was confirmed by microscopic examination), he began to
treat it with Eontgen rays. She was treated two or three times weekly,
and after about eight months was discharged as cured. Xeither abdom-
inal nor vaginal examinations offered the slightest abnormality. She is
now treated about once every two or three weeks, and has been well for
some months.
The tumor in the case cited by Skinner2 was situated in the lower
part of the abdominal wall, in the region of the cicatrix resulting from a
laparotomy, performed three years before, for what was regarded as a
fibroid uterine tumor. The fibro-sarcoma was of the size of a cocoanut,
filling up the entire iliac fossa, extending nearly to the umbilicus and
two inches beyond the median line to the left. The tumor was very
firmly fixed and seemed to involve the abdominal wall. Erysipelas toxins
were used for ten months. During the first two months the growth
decreased more than half in size, and for a long time thereafter, while
there was no decrease, there was no distinct growth. Later on the
influence of the toxins seemed to have become lost, and there was a slow
but gradual increase in size. X-ray treatment was then begun. The
patient received one hundred and thirty-six exposures within seven
hundred and thirty-nine days ; two applications were given in the course
of every five days at the beginning of the treatment, and later on, one in
five days, fifteen days, and thirty-seven days. Twenty-eight months
after beginning the treatment, the patient had increased considerably
in weight and the tumor had entirely disappeared.
Beclere 3 reports the case of a patient affected with sarcoma of the
floor of the orbit who was cured by X-rays. The disease had lasted four
years. Two operations had been performed, the last one including
removal of the eye. All other methods of treatment had failed, but
improvement set in as soon as radiotherapy was employed. Histologi-
cally, the tumor was found to be a malignant sarcoma. Beclere reports
an additional case of orbital sarcoma cured by X-rays.
Kienbock * reports a sarcoma cured by X-rays. This case is of very
unusual interest. A growth, having appeared in the nose seven years
before, in spite of operations oft repeated, had invaded the adjoining
structures and produced exophthalmos on both sides, with subsequent
optic atrophy. Pain ceased after the first treatment, and after thirteen
1 Munch, med. "Wochens., 1, 50.
'Archives of Electrology and Radiology, October, 1904.
s Gaz. dea Hop., June 14, 1904.
4 Quoted by Dr. G. Oram Ring, " The Value of X-Rays in Ocular Therapeutics,"
Journal American Medical Association, September 29, 1906.
476 ELECTRO-THERAPEUTICS.
applications the growth (an endothelial sarcoma) entirely disappeared.
The eyes resumed their normal appearance and vision partly returned.
Grossman ' reports a similar case which had almost entirely disappeared
under the X-rays. Theobald 2 has had one case of marked exophthalmos
(unpublished) with the diagnosis of inoperable sarcoma of the orbit — a
diagnosis in which two other surgeons concurred. Under the X-ray
treatment the case rapidly improved and after a lapse of seven months
seemed to be cured.
\V. B. Coley 8 treated 167 malignant growths, scattered over many
parts of the human body, and arrives at the conclusion that, while the
X-rays are of inestimable value in skin cancers, nevertheless the latter
often recur, and that undoubtedly surgery is in these cases far preferable.
He is opposed to the use of the rays in deep-seated carcinomas and
sarcomas, believing their value very slight and temporary. Where the
neoplasm had apparently disappeared, metastases quickly occurred. He
believes that irradiation is palliative in those cancers that are for any
reason inoperable. He asserts that post-operative irradiation rests
purely on theoretical grounds and needs further study as to its value or
usefulness in these cases.
1 believe that in many instances, where brilliant results were
achieved in irradiation of sarcomas, in all probability there was
a mistake in the diagnosis and a less malignant affection was present,
or else the operators were a little too enthusiastic when making their
reports.
George C. Johnston * reports three cases of inoperable and recurrent
sarcoma successfully treated by the X-rays. The diagnoses were made
clinically and pathologically. Xo auto-intoxication occurred.
Djemil Pasha, of Constantinople,5 reports that a case of sarcoma of
the breast seemed rather aggravated by treatment.
Dr. W. B. Coley 6 treated 68 cases of sarcoma. He obtained complete
disappearance of the tumor in five of them.
Dr. Russell H. Boggs T treated five cases of sarcoma. In two of them
the growth was reduced in size, but improvement was temporary. Later,
both patients died.
G. G. Burdick8 treated 34 patients; 18 are considered cured. The
tumors disappeared completely and are giving no trouble whatsoever.
'Quoted by Dr. G. Gram Ring, "The Value of X-Rays in Ocular Therapeutics,"
Journal American Medical Association, September 29, 1906.
2 Ibid.
*New York Medical Journal, April 7, 1906.
4 Journal of Advanced Therapeutics, 1904, p. 648.
* Revue de Chirurgie, Paris, xxv., No. 1.
•Annals of Surgery, August, 1905.
T Transactions of the American Rontgen Ray Society, 1905, p. 115.
•Ibid., p. 112.
FIG. 232.— SARCOMA OF THE LEO.— 1 and 2 show areas of recurrence ; 3 indicates the part that I irradiated.
FIG. 233.— Skiagraph of the same.
THERAPEUTIC VALUE IX DISEASE. 477
The patients are following their usual vocations. I think Dr. Burdick
has overstated these facts.
Dr. Charles E. Dickson,1 of Toronto, exposed within one year a case
of recurrent sarcoma 48 times to the rays. The symptoms disappeared
completely and, though the case was discharged about one year ago, the
sarcoma has not shown any signs of returning.
All of my cases ended fatally, although I have seen the same tem-
porary improvements. In one of my cases a sarcoma of the leg showed
the slow progress of the disease, and repeated recurrences even under
vigorous X-ray treatment were noted.
I treated a patient, aged 30, who in the spring of 1900 noticed a
small tumor of the right leg about two inches above the ankle. The
neoplasm was removed one month later and diagnosed microscopically as
a sarcoma. Three years later there was a recurrence. I then proceeded
to irradiate the part. I treated him for six weeks, thrice weekly, each
treatment of ten minutes' duration. The patient completely recovered.
In June, 1905, the vicinity of the scar became sarcomatous and was
operated upon by Dr. Babcock. In September, 1905, he returned to me,
as the sarcoma was again recurring around the former seat, and, because
he complained of pains in the chest, I skiagraphed the latter and found
in the lung sarconiatous rnetastases. The patient became very despondent
and ended his life. (Figs. 232 and 233.)
III. Constitutional Diseases.
A. TUBERCULOSIS.
The value of the X-rays in tuberculous affections is at present unde-
termined. The varying stages of the disease, the inexactness of the
reports recorded, and the particular behavior of the malady in the differ-
ent structures invaded, make it advisable to append the following reports
from experienced investigators.
Bergoni6 and Teissier2 give some of the results obtained in experi-
menting with the X-rays upon tubercle bacilli. They conclude that
animals infected with tuberculosis and subjected for varying periods of
time to the action of the rays die, for the most part, without any appre-
ciable change in the lesions and without any retardation in the course of
the disease.
Dr. Kennon Dunham3 said that he had found that the X-rays do
not affect the tubercle bacillus to any appreciable extent. He believes
that the favorable results obtained by treating tuberculous patients are
not due to a destruction of the bacillus, but to the stimulation of
1 Journal of Advanced Therapeutics, 1904, p. 654.
1 Arch, d' Electric! te Medicale, 15, xi., and 15, xii., 1898.
s Proceedings of the American Runtgen Ray Society, 1903.
4 7 s ELECTRO-TH ER APEUTICS.
the tissues. He had obtained good results by simply wrapping the
patient in a coil of copper wire connected with one pole of a high-
frequency current.
Chisholm Williams,1 in an article read before the members of the
Electro-Therapeutic Sub-section of the British Medical Association in
1901, stated that, of the forty-three cases of pulmonary tuberculosis
treated by the X-rays, only three had died, the immediate cause of death
being pneumonia, tuberculosis of kidney, and lardaceous disease. During
the treatment the temperature of the patient uniformly rose, the rise
depending upon the duration and strength of the treatment. Xight-
sweats increased at first, but gradually disappeared. The number of
bacilli in the sputum increased early in the treatment, but later on
formed clumps, became short and stumpy, took a stain more read-
ily, and later in the treatment began to decrease. The disease has
been arrested when the patient can take daily treatments of half
an hour or more without showing a rise of temperature during the
treatments.
Dr. Russell H. Boggs2 cited six cases of tuberculosis treated by him
with the X-rays. One of the cases has remained cured for over a year.
One case died from an intercurrent affection, and the other four are
decidedly improved in every way.
Dr. J. D. Gibson 3 cited a case of tuberculosis complicated by a very
large cirrhotic liver. After a treatment of six weeks the symptoms were
markedly improved. The treatment was discontinued ; the patient went
home and died. While the rays do not cure, yet they improve every
case, even the most desperate and hopeless.
Rudis-Jicinsky 4 states that he has employed the X-rays together
with other forms of treatment in 19 selected cases of pulmonary tubercu-
losis. Of these he states, in one year, one died.
Drs. Boido and Boido 5 report fourteen cases of tuberculosis treated
by means of the X-rays. The treatment had been conducted in Tucson,
Arizona, which has an altitude of 2300 feet, and a climate that is warm
and dry. The fourteen cases reported were all Mexicans, afflicted with
pulmonary tuberculosis in varying stages of disease. It is their opinion
that in treating such cases it is beneficial to the patient to employ a tube
which produces rays that induce a dermatitis, claiming that such rays are
of real therapeutic value. In making the exposures the vacuum tube was
placed 3 to 4 inches (8 to 10 cm.) distant from the skin. Exposures were
made both anteriorly and posteriorly, allowing five minutes for each side
of the chest. After these exposures ten of the fourteen cases had been
1 Archives of the Rontgen Ray, August, 1903, p. 48.
* Ibid. » Ibid.
4 The New York Medical Journal, March 2, 1901, pp. 364, 365.
5 American Electro-Therapeutics and X-Ray Era, February, 1903.
THERAPEUTIC VALUE IN DISEASE. 479
relieved of the pulmonary pain. The number of exposures varied in
each case. Their reports show that three deaths occurred in three years,
and the remaining eleven are still living.
J. B. Ransom1 reports treatment of forty cases of tuberculosis in
the lungs and other parts of the body. He specifies that the Rontgen
rays, and also the ultra-violet rays, are especially indicated for treating
tuberculous lesions located more or less superficially. As regards deep-
seated pulmonary lesions the number of such cases treated is entirely too
small and the time that has elapsed is too brief to arrive at any definite
conclusions. He believes that the Rontgen rays may soon prove to
be a valuable therapeutic agent in this class of diseases. He also asserts
that pain is relieved and sleep is permitted ; the local circulation is
stimulated and expectoration is considerably lessened.
Hahn 2 states that Rieder had applied the X-rays to the thorax of a
patient suffering with a chronic form of pulmonary tuberculosis, and the
results obtained were not encouraging in any way as was primarily
expected.
G. E. Pfahler * says that early in the history of the X-rays physi-
cians noted relief from pain, and to a degree from other symptoms, in
cases of tuberculosis of the joints which had been examined repeatedly
by means of the rays. He says that J. B. Murphy treated two cases
of tuberculosis of the knee-joint in which the synovial membrane was
involved. Both of the joints had been treated by injections without
improvement. One patient in whom the effusion had persisted nine
months was discharged as recovered after 21 days in the hospital, the
effusion having disappeared. Murphy also reports three cases of spinal
tuberculosis treated with the X-rays. The first case was one in which
the patient developed paraplegia. Pus and tuberculous debris, which
established the diagnosis, were removed with a hypodermic needle.
After the third application of the rays the pain disappeared, and after
twenty-five applications the paraplegia was cured. A second case was
one in which laminectomy had been performed a year before. The
patient was worse after the operation, and a sinus was left, but this healed
completely after twenty applications of the rays. The paraplegia in this
case was not improved. The third case was that of a paraplegic, whose
pain was controlled by large doses of morphia. Two exposures relieved
pain, and after the twenty-third irradiation he got about on crutches.
Henry K. Pancoast * mentions the results obtained in the treatment
of deep-seated lesions of the larynx, lungs, peritoneum, joints, and spine
with the X-rays. He found that tuberculous laryngitis maybe aided and
even cured by X-ray treatment, provided there can be brought about an
1 Medical Record, February, 27, 1904.
2 Fortschritte a. d. Geb. d. Rontgenstr., B. iii., H. 3, p. 119.
3 Philadelphia Medical Journal, February 14, 1903.
4 Therapeutic Gazette, August, 1905.
480 ELECTRO-THERAPEUTICS.
improvement iu the primary pulmonary condition. Too vigorous treat-
ments will cause a reaction which may be carried to an unfavorable
degree ; therefore, great care is necessary in determining the proper
dosage in each case. Pulmonary lesions in selected cases may be bene-
fited probably, but even greater precautions should be observed. He
does not consider Finsen-light applications of any value in treating
laryngeal lesions. Only the most powerful lamps need be tried, and such
exposures are of value only in lessening or retarding a skin reaction from
the X-rays.
Ausset and Bedart l treated a case of tuberculous peritonitis in a girl,
nine years of age, by tapping and abdominal section, but with negative
results. During this treatment her condition grew steadily worse, and
the tuberculous masses in the abdomen steadily enlarged. On March 7,
she was first subjected to the X-rays, the Crookes tube being placed 20
cm. from the surface of the abdomen for ten minutes, two days later at 13
cm. Throughout the month the treatment was continued every two or
three days. During most of the following month the treatment was
unavoidably discontinued. During the latter part of May there was
absolutely no abdominal effusion. From this time on, she steadilj- im-
proved, gaining in weight and strength, until she became apparently well.
Southgate Leigh * cites a case of tuberculosis of the elbow-joint. The
joint had been exposed to the rays for a period of two hours, and as often
as two or three times in a week. After twelve hours' exposure the
inflammatory process entirely disappeared ; no recurrence appeared in
the eighteen months that had since elapsed.
Dollinger3 reports for Kirmisson a case of tuberculosis of the wrist-
joint. The part had been exposed for ten minutes daily for a period of
two and a half months. The result was an improvement, and by the
subsequent application of electricity the part was absolutely cured.
Tousey 4 is of the opinion that judicious application of the X-rays, or
of the ultra-violet rays and high-frequency currents, is indicated in every
case of tuberculosis, especially tuberculosis of the larynx. One case, in
point, is reported in which the treatment was remarkably successful. The
expectoration ceased in three weeks ; there was great improvement in
the voice, marked gain in strength, normal temperature, and a gain in
body weight of about three pounds. The local condition also has im-
proved, an area of infiltration has diminished, and the abrasions have
healed with a whitish appearance, which may be due to cicatricial tissue.
The treatment consisted first in exposure to the X-rays once every
1 L'Echo MeU du Nord, No. 46, 1898.
1 Reported by Werner in the Fortsch. a. d. Geb. d. Rontgenstrahlen, B. Hi., H. 3,
pp. 122, 123.
'Fortech. a. d. Geb. d. Rontgenstr., B. ii., p. 72.
* Medical Record, September 3, 1904.
THERAPEUTIC VALUE IX DISEASE. 481
four or five days ; exposure to the Cooper- Hewitt light and application
of high-frequency currents once in each interval between the X-ray
applications.
Dr. M. C. Rice 1 reported the case of a woman, whose mother and
sister had both had enlarged glands, suppuration having occurred in the
case of the mother. The patient had a chain of enlarged glands extend-
ing from the ear to the clavicle ; the largest one, situated below the ear,
was the size of a hen's egg. These glands had been somewhat enlarged
for five years, but had been growing rapidly for four months. The patient
had been taking iodides for some time. After three months of treatment
with the high-frequency current, by means of the Tesla coil and static
machine, with only slight improvement, Rontgen rays were substituted,
after which the patient improved. After five months' treatment the
glands could scarcely be felt.
Dr. E. H. Grubbe2 has had under treatment more than thirty cases
of tuberculosis of the cervical lymph-glands, most of them in children,
and superficial. From the results he obtained, he feels that he can make
great claims for the Rontgen-ray treatment of this condition. Of course,
he prefers to treat them when they are primary cases, because one cannot
get such good results after the disease has extended to the deep glands
nor after surgical interference.
Dr. Russell H. Boggs 3 asserts that the results obtained by the Ront-
gen rays in the treatment of tuberculous adenitis compare favorably with
those obtained by any other method. A large proportion of the cases can
be apparently if not permanently cured. Several cases have remained
cured for over four years. Improvement is not attained, as a rule, until at
least twelve treatments have been given. There are exceptions, however,
one patient being improved after four treatments, and others not improv-
ing until after twenty-five or more exposures. A permanent cure should
not be expected until after at least three mouths' treatment. He advised
that in treating these cases the apices of the lungs should also be rayed.
To be beneficial, treatment must be energetic.
In tuberculous adenitis that has advanced to suppuration, my prefer-
ence is to have the patient submit to surgical interference and to the
subsequent employment of irradiations. Early in tuberculous adenitis,
the rays are useful in aborting the affection by the formation of fibrous
tissue within and around the gland.
Dr. James B. Bullitt,4 in a "comparison of Rdntgen-rays and sur-
gical treatment of tuberculosis," says: "I have collected 518 cases of
surgical forms of tuberculosis, reported by forty-eight observers ; most
of these have come through personal communication ; a few have been
1 Transactions of the Rontgen Ray Society, 1905. 2Ibid.
8 Journal of the American Medical Association, September 15, 1906.
* Transactions of the American Rontgen Ray Society, September, 1904.
31
482
ELECTRO-THEK A PEl'TICS.
collected from the literature. The following is the tabulated list showing
the number of cases of each kind and the number and percentage of cases
in each of the three divisions of the classification :
No. Patients
treated.
Cured.
Improved.
Unim-
proved.
Tuberculosis of long and flat bones
Tuberculosis of joints
71
141
26(36$)
54(38$)
25(35$)
53 (87
21 (29',i
34 (25', )
Tuberculosis of tendon sheaths
27
19(70$)
6 (22$ )
2(,~
Tuberculosis of peritoneum
32
13 (40$)
8 (25$ )
19 (35$)
Tuberculosis of testicle
21
7 (335? )
10 (48$)
4(19$)
Tuberculosis of lymphatic glands
00,5
79(35$)
92(40$)
55(25;,)
Tuberculosis of ekin (lupus)
518
616
420(68$)
148 (24'^ )
48 (8$)"
Drs. P. Eidard and Barret 1 report successful results iu treating osteo-
arthritis and tuberculous osteitis; also they noticed improvement iu
several cases of arthritis accompanied by fibrous aukylosis. Irradiations,
lasting seven minutes, were given with intervals of twelve to fifteen da vs :
by using a thin leaf of aluminium filter no dermatitis was produced.
I treated a number of cases of large areas of tuberculosis of the skin.
In Figs. 234 and 235 are shown the ravages of cutaneous tuberculosis in
a youth of 21. In the left-hand photograph is the view of the face and
neck when the patient first presented himself at the Philadelphia Hos-
pital for treatment. In the right-hand picture are shown the results of
X-ray treatment in the disappearance of all the elevations, white areas
replacing the former sites of tuberculous deposits.
B. LEUKJEMIA.
The value of the X-ray treatment of leukaemia is a matter of dis-
cussion. Many authorities assert that cases of this disease have been
permanently cured by the repeated application of the rays ; other inves-
tigators, equally distinguished, maintain that Rontgeu treatment is a
valuable adjunct only to the usual remedial agents employed. At the
conclusion of this article, some views on the subject, which are worthy
of perusal, are appended.
Fried1 stated, that iu a case of inoperable carcinoma of the mammary
gland and in a second case of iiitra-abdoininal sarcoma, treatment by the
X-rays showed a great decrease in the number of white corpuscles and
an increase in the reds.
Inseen s reports two cases of pseudo- leukaemia treated by the X-rays,
•Arch, d' Electricity Medicale, February, 1906.
1 American Medicine, June, 1902.
•New York Medical Journal, April 8, 1903.
THEKAPErXIC VALUE IX DISEASE. 483
in which marked improvement was noted. On account of the toxtemia
set up in each case, the treatments had to be suspended for a short period.
He believes that the rays will prove to be a means of curing a heretofore
incurable disease.
Xicliolas Seun l reports the treatment with X-rays of two patients,
far advanced in pseudo-leukaemia. In the first patient, after 34 applica-
tions of the X-rays, all the enlarged glands had almost entirely dis-
appeared and the general condition was much improved. When dis-
charged, no glands were palpable ; the blood, however, did not show any
characteristic changes. The second patient showed universal enlargement
of the lymphatic glands. The blood examination revealed a well marked
ameiuia and a leucocytosis of 208,000, the increase being most marked in
the lymphocytes (78.75 per cent.). This patient was also treated with
the X-rays, and after fifteen exposures he developed a slight toxaemia ;
treatment was then discontinued. However, the general condition of the
patient was much improved ; all palpable glands were diminished in size
and the number of leucocytes was reduced to 76,000. The treatment was
again renewed, and progressive improvement continued, the patient being
discharged practically cured.
Meyer and Eisenreich2 reported two cases of myeloid leukaemia
treated with the Rontgen rays. They differ in several points from others
that have been published. The first patient, aged 31, was a machinist
by occupation. Blood findings altered completely under the influence
of the rays, and a marked leucocytosis followed, with mast-cells predomi-
nating. By the end of four months the leucocytes had fallen from
10."). 000 to 6100, but then rose again to about 22,000, and later to 35,000.
The blood findings altered so materially under the influence of the rays
that no one would have suspected leukaemia from the blood picture. The
spleen returned to normal size in the first case, but remained enlarged in
the second case, in which the leukaemia was of longer standing and
the symptoms more serious. Since suspension of the treatment, the blood
findings have displayed a tendency to return to the leukaemic picture, so
that the hope of actually curing leukaemia by this means is not very
promising.
Wcndel, of Marburg, has collected from the literature 38 cases of
leukaemia treated with the X-rays and adds another to the list. He
tabulates the details of the various cases and states that more than
90 per cent, were favorably influenced. In two instances no appre-
ciable benefit was observed, and in two, the disease rapidly progressed
notwithstanding the treatment.
Dr. Steinwand,3 of Selma, Cal., reports a case of pseudo- leukaemia
1 New York Medical Journal, April 18, 1903.
2 Miinchener medicinische Wochenschrift, January 24, 1904.
3 Journal of the American Medical Association, March 26, 1904.
4S4 ELECTRO-THERAPEUTICS.
successfully treated by the X-rays: "The patient, a school-girl, aged
15. Family history : Mother died from heart disease two years ago ;
father well ; three brothers, two of them are well, one has chronic
stomach trouble ; three sisters, all well. Xo tuberculous or syphilitic
history.
"About five or six years ago the glands on the left side of her neck
became enlarged, but were not painful. During the succeeding years
they increased slowly but gradually, and there were occasional sharp
pains in the splenic region. Two years later the glands along both
borders of the sterno-mastoid muscle began to coalesce and rapidly
increase in size. The supraclavicular glands also became prominent, and
later the axillary glands were involved.
"The patient came for treatment April 1, 1903. She presented all
the symptoms above enumerated, with rapidly increasing nervous
phenomena and steady loss of weight. All the treatment she had
received was ineffective in checking the course of the disease. There
had not been any definite diagnosis.
"There were large glandular masses on the left side of the neck,
anterior and posterior to the sterno-cleido-inastoid muscles, the larger
ones about the size of a hen's egg. They were movable under the skin, but
bound down more or less to the deeper structures. The spleen was some-
what enlarged and tender to pressure. Temperature was 100° to 101°.
The haemoglobin index was 70 per cent. The differential leucocyte count
was negative. The pulse was 115 to 120. I failed to make a blood count.
At no time did I detect the temperature lower than 100° or the pulse- rat «•
less than 102.
"On April 20, I advised the use of the X-rays and gave the first
exposure. The neck measured 13 i inches over the most prominent por-
tion. I made one exposure each day, of a duration of fifteen to twenty
minutes. After the exposure on the second day the patient complained
of feeling much worse. After the third exposure splenic tenderness was
greatly increased, so that gentle percussion caused considerable pain.
"April 24th her neck measured 12V inches and had visibly decreased
in size. Two days later it measured 12 inches. The temperature was
103°, the pulse 115.
"On April 30 the neck measured 11 J inches. The supraclavicular
glands were much shrunken and becoming hard, nodular, and more freely
movable under the skin. Temperature was 100°, pulse 100.
"May 1 I stopped X-ray treatment, as there was some evidence of
dermatitis. On May 5, temperature was 98.4° ; pulse 100, this being the
first time I found temperature normal in three months' observation.
"May 12. The dermatitis was fully developed and the skin was
sloughing in some places."
Until the latter part of July, treatment could not be directed to the
local seat of disease, because of the derinatitic area.
THERAPEUTIC VALUE IX DISEASE. 485
"July 24 the glands were still receding, and the neck measured
11 inches. The contour fairly matched that of the opposite side. She
stated that she felt in the best of health, and her appearance fully bore
out her assertion.
" As treatment progressed, the spleen increased in size. This phenom-
enon was also noted by Senn, but I have not seen any mention of the
distinct rise in temperature after each treatment, encountered in this
case. The only explanation that I can offer is that there must have beeu
certain toxic products, liberated through the influence of the X-rays,
which were at once taken up by the circulation, causing also the acute
exacerbations of ill feeling following each exposure. This condition of
elevated temperature and ill feeling lasted from ten to fourteen hours,
and was so severe at times I thought of abandoning treatment had it
not been for the steady reduction of the size of the glands."
In my own cases, however, I have never encountered this so-called
auto-intoxication resulting from irradiations. It would seem that the
subject needs much further investigation.
At a meeting of the Chicago Medical Society held January 25, 1905,1
Drs. Joseph A. Capps and Joseph F. Smith reviewed the advancements
made in the treatment of lymphatic leukaemia with the X-rays.
The first case was treated by Dr. Pusey for one month, but without
improvement. In 1903 Dr. Nicholas Senn reported a case of leukaemia
symptomatic-ally cured. The patient presented the typical symptoms of
spleno-niyelogenous leukaemia and had been ill for fourteen mouths.
Treatment was begun daily, and was given every other day through the
latter part of January and during February, March, April, and May ; at
the time of Senn's last observation the white count came down to 10,000
and the spleen was almost of normal size. The patient felt perfectly
well, but died later with symptoms of toxaemia. Cases of lymphatic leu-
kaemia treated by Senu, Churchill, and Pusey died within seventeen
mouths.
The authors reported three cases of lymphatic leukaemia treated by
the X-rays, two of which were of the acute form. One patient died in
six days, and the other in ten days. Of the subacute cases there were
two. While the X-ray exerted a beneficial effect, it did not control the
disease. Better results were obtained in treating chronic cases, of which
the authors reported three. They stated that patients with spleno-
niyelogenous leukaemia should receive X-ray treatment, because they are
greatly benefited thereby. They respond more slowly than do patients
with chronic lymphatic leukaemia. These patients feel that they are
cured, but in the light of cases reported as symptomatically cured, some
of which have since died, physicians must not be too sanguine in regard
to pronouncing cures.
1 Journal of the American Medical Association, February 10, 1905.
486 ELECTRO-THERAPEUTICS.
Arneth ' made a careful study of the blood findings after exposure
to the Rontgen rays, aud analyzes all the testimony thus far offered. His
final verdict is that the Routgeu rays have an undoubtedly favorable
action in leukaemia, but that it is indirect. They do not cure the lesions,
but they destroy the parasites which are causing the lesions. The action
of the Rontgen rays in leukaemia is like that of quinine in malaria. Both
cure the patient by killing off the micro-organisms causing the trouble.
This assumption entails the necessity for more thorough and more gen-
eral exposure to the rays. They should be as extensive and as protracted
as possible, to seek out and destroy the causal germ in its remotest
lurking-places, not restricting the exposures, as in the past, to the blood-
forming organs alone. This conception supplies, for the first time, an
etiological treatment for leukaemia and one that is proving more successful
than any in the past.
The clinical and histologic findings in leukaemia after Rontgen
treatment were observed by Lessen and Morawitz.2 The patient was a
man of 36, previously healthy, with inyeloid leukaemia for two or three
years before it terminated fatally. Forty Routgeu exposures were made,
but did not seem to arrest the progress of the disease after the first
transient improvement. The composition of the blood and the blood
findings changed under the exposures, finally presenting the picture
accompanying aplasia of the blood-forming organs, and the anatomical
findings were those of hypoplasia. It was most pronounced in the bone-
marrow, but was also unmistakable in the spleen and lymph-glands. It
was accompanied by pronounced proliferation of the interstitial tissue.
Lessen and Morawitz are inclined to regard the hypoplasia as favored and
possibly originated by the three weeks of rather intense Routgeu treat-
ment given in this case. Of 7 leukaeinic patients treated by Rontgen expos-
ures, 3 were materially improved, and the others are still under treatment,
with the exception of the fatal case mentioned above. In one case of
myeloid leukaemia the leucocyte formula became normal, and the elimina-
tion of uric acid also returned to normal proportions. This suggests an
increased new formation of leucocytes as probable. In the first case
with extreme leucopenia the amount of uric acid eliminated remained
abnormally high throughout.
While Drs. David L. Edsall and ,T. K. Pancoast, of Philadelphia.
believe that X-ray treatment of leukaemia is unsatisfactory because of
secondary results, Musser* is of the opinion that the reason for this is
that the treatment was undertaken in old cases in which secondary
changes had occurred before the use of the X-rays, which only served to
stimulate the progress of such changes. In one case of his own, treated
'Munch, med. Woch., August 22, 1905.
*Deutsches Archiv f. klinische Medizin, Leipaic.
1 New York Medical Journal, April 7, 1906.
THERAPEUTIC VALUE IX DISEASE. 487
by the X-rays, there had been an entire disappearance of the leukaemia
and the patient had been restored to a normal condition generally. The
leucocytes had been reduced from 6000 to 4000, and he believed
that a cure had been effected. At the same time, he thought it would be
necessary to resort to the X-rays from time to time in order to pre-
vent a recurrence such as had taken place in another case which he had
treated.
IV. Miscellaneous Affections.
A. TRACHOMA.
My technic in treating cases of trachoma consists in covering the
Crookes tube with a dark cloth, excluding all light from the room,
because of the excessive photophobia. With adhesive plaster I attach
the everted eyelids to the skin, and expose the surface of the eye ; thus
preventing burning the fingers of nurse or assistant. I cover the face
with a leaden sheet, and treat one eye at a time, through an aperture in
the lead. Rapidity of action is obtained by getting the patient to
keep the eye open while under treatment. There is less danger of
burn to the cornea than there is to the skin of the eyelid, but, should
a slight corneal haziness result, it quickly disappears, and the corneal
scar will be absorbed. I had two acute and two chronic cases of
trachoma at the Philadelphia Hospital. The acute cases had severe
photophobia and lacryuiatiou, which disappeared after four or five
exposures.
Sydney Stephenson and David Walsh l report the results of treat-
ment of trachoma or granular lids by the X-rays and by brush discharges
obtained from a D' Arson val high-frequency apparatus. The writers
treated a single eye in four cases of severe bilateral trachoma in children.
Two eyes were cured, that is, the granulations and conjunctival hyper-
trophy disappeared, and have not returned after a period of several
mouths. The remaining two eyes were greatly benefited and are recov-
ering. The cures were effected by 17 exposures in one case and but 6 in
the other. The average time was ten minutes. The good effects were
found to be equally marked with closed as with everted eyelids. Twenty-
two applications of a mild high-frequency brush, using a vulcanite elec-
trode connected with a D'Arsonval apparatus, cured a severe case of
trachoma in another patient.
Radiotherapy in trachoma presents advantages over the ordinary
treatment by escharotics. It is more rapid and is painless. The fact
that equally good results were obtained with an active focus tube, and also
by a high-frequency brush discharge, suggests that the curative agency
may be identical in both instances.
1 Lancet, January 24 1903.
4ss ELECTRO-THERAPEUTICS.
At a meeting of the Philadelphia County Medical Society, Xovem-
ber 23, 1904, l Drs. "W. S. Xewconiet and J. P. Krall presented a girl of
18, who had been subjected to all the operations for the cure of trachoma,
without success. She was treated with the X-rays from July, 1903, until
January 1, 1904. The inflammatory reaction was so intense that it was
thought better to abandon the treatment. Later, however, it was found
that she could count fingers at close range. The cornea was entirely
clear, and only with special illumination could there be seen fine blood-
vessels. The eye not treated with the X-rays showed all the symptoms
that the treated eye formerly exhibited. The condition of the patient
had been present since infancy, and she had been unable to see across the
room. Treatment was given every other day for five minutes for about
six weeks, when a burn developed and treatment was withheld. Dr.
Newcomet believed the result to be due to the accidental burn produced
in the course of treatment.
Ruggero Pardo J describes two cases of trachoma of long standing,
rebellious to treatment. Six exposures, with a total of 44 minutes in one
case and of 47 in the other, caused so marked an improvement that a
permanent cure is anticipated. The tube had a spark length of 2.5 to 2.7
inches (6.5 to 7 cm.), the distance varied from 12 to 15 inches (30 to
45 cm.), the applications were from 4 to 10 minutes at a time, and only
one eye was treated ; the eyeball was protected by a sheet of lead at some
of the stances.
Geyser8 maintains that a few exposures, six to eight, will suffice to
bring about a perfect cure. An important consideration is to cause
absorption and stimulate normal nutritional processes ; nothing seems to
answer the purpose any better than the direct contact of the tissues with
a high-frequency vacuum tube, generated by a static machine or X-ray
coil. Complete details of technic are given in the article.
H. X. Bishop 4 gives the results of electrical treatment of trachoma
at the Middlesex Hospital. Cases had been treated with well-equipped
apparatus, with rays, high-frequency currents, and radium. With regard
to the X-rays he explains that there were two sets of rays emanating
from the tube, (1) the X-rays proper, (2) the overflow rays that cause
the severe burning of the skin which sometimes occurred. The former
of these rays were used. Four cases of trachoma were treated in this
manner. Two were young women. In one, fifty applications were made
in five months. The right eye showed changes that might reasonably
have been produced in this time without treatment, while the left, which
was at first unaffected, steadily got bad. The disease subsequently
1 Journal of the American Medical Association, January 14, 1905.
'Gazzetta degli Ospedali, Milan, last indexed xiii., p. 1193, April 10, 1904.
3 Journal of Advanced Therapeutics, May, 1904.
4 British Medical Journal, August 26, 1905.
Fro. 234.— Tuberculosis of the skin.
FIG. 235.— The same after irradiation.
FIG. 236.
FIG. 237.
•Vi
- ''^; 1
/Wfl
Group8 of patients that I Irradiated for epilepsy at the Philadelphia Hospital. Upper two rows
(Figs. 236 and 237) show alopecia iinxluciMl by X-rays during three months of treatment for epilepsy.
No. 8 on the second row was not thns affected. Fig. 238, taken six months later, shows the regrowth
of the hair. No. 7 wns previously bald, but upon application of th<- rays the growth of hair appeared.
THERAPEUTIC VALUE IX DISEASE. 489
cleared up in the usual manner with bluestone. None of the three other
cases did any better. The seven cases treated with high-frequency
currents did not improve at all.
Yassiatiiisky1 asserts that the rays diminished the infiltration in
trachoma, caused the disappearance of the granulations and of the
pannus, and produced a pronounced improvement in the subjective signs
of the malady. As a rule, however, trachomatous granulations dis-
appeared but slowly under the influence of the Eontgen therapy. The
rays proved to be harmless in treating the eyes, and no evil effects were
noted in any case, nor was pain experienced by the patients. The author
thinks that the rays are of service in cases in which ordinary methods of
treatment fail.
I treated a case of chronic conjunctivitis of both eyes referred to me
by Dr. T. B. Schneideman. The patient had been a sufferer for fifteen
years. I exposed the eyes, once weekly, to the action of the rays. The
treatment was not continuous, as I feared a constant and frequent appli-
cation of the rays. I began treatment with a one-minute exposure twice
weekly, tube fifteen inches from the part. Within two years sixty appli-
cations were made. The first fifteen treatments were of one minute
duration. I then increased treatments gradually up to five minutes. The
conjunctivitis is practically cured, and the blood-vessels of the part have
become small and shrunken.
B. KELOID.
Dr. William H. Harsha5 reports the case of a young man, eighteen
years of age, who had a small growth behind the right ear for ten years
that microscopically proved to be a keloid. It was excised, but in three
or four months the tumor was as large as ever. X-ray treatments
were then begun and were given at intervals of two or three days,
but were not kept up regularly. He had not frequent treatments by
the X-rays in the last six mouths. The growth now showed not more
than one-sixth of its size when the treatment was begun and it was still
getting smaller.
Dr. A. J. Ochsner asserts that the treatment of keloid by means of
the X-rays is worthy of attention. In several cases the improvement was
very marked after operation by the subsequent X-ray treatment. He
believes that before removing any keloid one should treat it thoroughly
with the X-rays.
Dr. H. K. Varney3 reports a case of keloid of the foot, caused by pas-
sage of a rifle-ball. Eight treatments were given ; complete disappear-
ance of the keloid with development of normally appearing scar tissue
1 Roussky Vratch, January 8, 1905.
z Chicago Surgical Society, December 7, 1903.
s The International Journal of Surgery, October, 1903.
490 ELECTRO-THERAPEUTICS.
resulted. The patient had also a keloid the diameter of a silver dollar at
the site of vaccination.
Dr. G. P. Edwards1 reports three cases of keloid cured with the
X-rays.
Morris and Dore * report that they have treated a few cases of keloid
with the X-rays, in some of which there had been a decided increase in
the growth. Pain was in all cases completely relieved.
Dr. Henry K. Pancoast3 reported two cases of keloid treated by the
rays. In one case there were multiple keloids following a burn. The
other patient had a large keloid involving the ear, neck, and angle of the
jaw. Both patients were colored. In the first case six treatments were
given, and in the second forty-three treatments. The results were nega-
tive, probably because the treatments were not pushed.
Drs. Fordyce,4 Fox,5 and H. R. Barney6 report favorable results.
Dr. O. S. Barnum7 uses an abundance of rays emanating from a tube
of high resistance and excited by a large coil. He believes that it is
better to have the tube too high than too low. The tube's distance should
be fifteen to twenty inches, depending on the thickness of the tumor.
The thicker the tumor, the higher the tube, the greater the distance and
the longer the exposure. He usually exposes the growth for from fifteen
to twenty-five minutes on alternate days for ten days, and then stops
treatment for ten days, repeating the procedure until the tumor has dis-
appeared. He has had excellent results in the treatment of keloids by
this method.
Drs. Boggs, Pancoast, and others favor preliminary excision of
the tumor, whenever this is possible, following this with Rontgeu treat-
ment. The tumors disappear more rapidly and are not so liable to recur.
C. EXOPHTHALMIC GOITRE.
Dr. Charles H. Mayo,8 in a paper entitled " Thyroidectomy for
Exophthalmic Goitre," says: "It has been our fortune, or misfortune
from its difficulties, to operate on several cases of cervical adenitis which
had been exposed for many times to the X-rays. It was noted that the
lymph system was greatly sclerosed. As this was in line with the
reported action of the X-rays upon glandular activity, we applied this
treatment to ten cases of very marked exophthalmic goitre during the
1 The International Journal of Surgery, October, 1903.
1 British Medical Journal, June 16, 1903.
s Proceedings of the Philadelphia County Medical Society, November 30, 1903.
4 Journal of Cutaneous Diseases, April, 1904, p. 187.
5 Ibid., July, 1903, p. 323.
6 Journal of the American Med. Association, June 6, 1903.
'Transactions of the American Rnntgen Ray Society, 1906.
8 Medical Record, November 5, 1904.
THKRAPK! TI< VAIJ'K IX DISEASK. 49L
past year, to first reduce glandular activity, and second, reduce absorp-
tion by its possible effect upon the lymphatics. While I would not
as yet say that any of these cases are cured, they have certainly been
markedly benefited ; first, in the general nervousness ; second, in tremor
of the muscles ; third, in tachycardia ; and last, in the exophthalnios.
The benefit is sufficient to give this method a place in the treatment of
Graves' disease, or at least make it a preparatory treatment to a prospec-
tive surgical method at a later period. .
"Our rules, concerning the cases of Graves' disease which come to us
for operation, are to operate, if their condition is fair, but if the pulse is
from 130 to 160, or if it suddenly fluctuates in tension and rapidity, if
there is anaemia, with swelling of the feet, the patients are placed upon
the belladonna treatment for some days. The more severe types are also
given X ray exposures in addition, which are continued from two to six
weeks."
Gorl ' has tried radiotherapy in goitre with what he considers very
encouraging results. Seven cases were treated, and in all there was
marked diminution in the size of the growth, as well as improvement in
the other symptoms. The author believes that it is primarily the paren-
chyma cells that are affected by the rays, and not the blood-vessels, as the
diminution in size of the gland begins so promptly and takes place so
uniformly. Medium soft or soft tubes were employed, and at a compara-
tively short distance from the skin. Care is necessary to prevent burns ;
in one case the author found the patient's skin was unusually sensitive to
the rays, and he suggests that this condition may be one of the symptoms
of the disease.
G. E. Pfahler2 speaks of 31 cases that he collected, with an im-
provement in 28 of them. Stegmau3 speaks most favorably of X-ray
treatment in 35 of his goitrous patients.
Widerrnan4 has noted improvement in some of the symptoms in his
five cases.
Dock5 treated 32 patients with exophthalmic goitre, and be believes
that X-ray treatment is only an adjunct to other therapeutic measures.
Pfeiffer6 describes his experiences with Rontgen treatment of goitre
at von Bruns' clinic at Tubingen. The particulars of 51 cases are given
and the histological findings in 8, with the results of experimental re-
search. The general conclusion is to the effect, that Rontgeii treatment
of goitre is ineffectual as a rule and should not supplant the better-tried
methods.
•
1 Munch, rned. Wochenschr. , vol. Hi., Xo. 20.
* Therapeutic Gazette, March 15, 1906.
3 La Tribune Medicale, January 27, 1906.
4 Ibid.
5 American Medicine, February 24, 1906.
'Beitriige R. klin. Chirurg. von Bruns, Tubingen, p. 1149.
492 BLBCTBO-THBBAPEUTICa
Dr. Charles Lester Leonard ' noticed marked improvement in four
cases of goitre. One of the patients has had no recurrence for a period
of three years.
Dr. T. V. Crandall had a patient, aged 22. suffering with a unilat-
eral goitre. I irradiated the tumor twenty times within sixty days, and
the goitre became markedly decreased in size. The previous nervous dis-
turbances at once abated. I believe the action of the rays in these cases
is quite analogous to its action in tuberculous adenitis and other
glandular affections.
D. HYPERTROPHIED PROSTATE.
Carabelli and Luraschi 2 report two cases of hypertrophied prostate
treated by X-rays after one year's observation. They were the first cases
properly treated by this method. The patients were respectively sixty
and sixty-five years of age. They were placed on a sloping table, the sur-
rounding parts carefully protected, and the Rontgen rays applied to the
perineum, with the tube from 20 to 25 cm. from the skin. Carabelli did
not think it necessary to introduce a tube into the rectum, as the atro-
phying action of the Rontgen rays on deep-lying glands, like the ovary,
spleen, and lymphatics, had been amply established. It is evident, also,
that the action of the rays on the prostate is more pronounced when the
hypertrophy is in the first stage. The relief of the pain was marked
from the very first. The rays were applied fifteen times, at first two or
three times per week and then once a fortnight. The sensory symptoms
vanished and urination became very much easier.
In the second case the prostate was much enlarged and hard, and
there were about 200 gnu of residual urine and evidences of chronic
catarrh of the bladder. After six applications of the X-rays, the urine
became clearer, the pain subsided, urination was much easier, and the
residual urine was only 40 gm. After the tenth application, there wore
only 10 c.c. of residual urine, and the patient was dismissed as practi-
cally cured. The treatments were from three to seven minutes in the
first case and ten minutes in the second ; the current 14 amperes and 100
volts. After one year the results are permanent.
In view of the fact that hypertrophied prostate in most instances is
due to a glandular proliferation, and therefore contains epithelial ele-
ments very susceptible to the Rontgen rays, Dr. Moskowicz, of the
Rudolph Hospital,3 has treated a number of cases of this kind by radia-
tion through the rectum. After a few treatments the patients were able
to urinate spontaneously, and the improvement has persisted. Large
1 New York Mc.liral Journal, April 21, 1906.
< ia/.zctta dt-jfli Osjiedali Milano and abstracted from The Jour, of the Am. Med.
Asso., Sept. 2, 1905.
'Semaine Mi-dicale, April 5, 1905.
THERAPEUTIC VALUE IN DISEASE. 493
indurated prostates became smaller and softer. It is the intention of
Dr. Moskowicz to try radium in other cases, as being more suitable and
probably more efficient.
i;. ANALGESIC ACTION OF THE RAYS.
. — It would seem almost a certainty that the X-rays pos-
sess an analgesic action. In carcinoma the pain is frequently alleviated
after the first few exposures. The analgesic action is less potent in deep-
seated cancers than in superficial ones. Freund, in 1899, reported that
Grunmach had most excellent results from the use of the rays in neural-
gia and articular rheumatism. Gocht found marked temporary relief in
a case of obstinate trigeininal neuralgia. Dr. William M. Sweet,1 of Phil-
adelphia, believes that X-rays exert a peculiar action on the nerve tissue,
as the skin after intense irradiation becomes quite anaesthetic. In con-
nection with this interesting subject are appended the views of Dr.
Charles Lester Leonard, of Philadelphia,2 who reports eight cases, six
of neuralgia, one of neuritis, and one of scar tissue of the brain follow-
ing the removal of a cyst from the motor area five years previously, in
which the Rdntgeu rays formed the principal treatment.
All of the six cases of neuralgia were due to impaired metabolism
of the nerve tissue. The first was infra- and supraorbital neuralgia fol-
lowing an attack of influenza ; the pain was relieved by the first treat-
ment of three minutes and cured permanently by four more such treat-
ments. The second was a severe neuralgia of both inferior and superior
dental nerves, which had lasted seven months and was accompanied by
loosening of the teeth; three five-minute applications upon each side
of the face every other day relieved the pain entirely ; the teeth
resumed their proper place, and at the end of eight treatments the patient
was entirely well. He has remained so for the past two years.
The third was a case of migraine which had existed for ten years,
resisting various kinds of treatment. The first application lessened the
intensity of pain, and at the end of the course of treatment (number of
applications not stated) she was entirely cured.
The fourth case was trigemiual neuralgia and was much relieved,
but the patient discontinued treatment after four weeks and has not since
l>een heard from.
The fifth was a case of brachial neuralgia ; this patient also discon-
tinued treatment prematurely.
The sixth was a case of severe tic douloureux with crises almost
every five minutes. The first application relieved the pain, but the
patient left town after four treatments, promising to report if he had
any further attacks ; he has not since reported.
1 American Medicine, Dec. 13. 1902.
'Ibid., July 8, 1905.
494 ELECTRO-THERAPEUTICS.
The case of neuritis occurred in the facial nerve, and evidence of de-
generation was shown by areas of local anaesthesia over its entire distribu-
tion, the point of most intense pain being over the inastoid region and the
posterior surface of the ear in the distribution of the posterior auricular
nerve. This patient was greatly relieved, but not eatirely cured, possibly
because the treatments were not applied with sufficient regularity.
The patient in whom it was attempted to produce absorption of scar
tissue had complete paresis of the right arm, with glossy skin on the
fingers and absence of wrinkles ; the arm could not be raised voluntarily.
Right leg was also somewhat lame. Slight epileptiforni attacks which
had occurred recently were attributed to a recent blow upon the occiput.
As a result of the X-ray applications the epileptiform attacks became
less severe and less frequent, and the patient gradually gained control of
the arm and hand, so that he could raise the hand to his head and mouth
and could grasp objects of moderate size. There was also decided improve-
ment in his gait and speech. He received 12 applications in 6 weeks, the
rays being applied through the trephine-opening in the skull. As the
bromides were continued in increasing doses with the Routgen applica-
tions, it is considered possible that the results cannot be attributed
exclusively to the rays.
Leonard appears to believe that successful treatment of such cases is
very largely dependent upon a proper technic.
Haret1 treated successfully with X-rays an obstinate case of trigeni-
inal neuralgia after all other methods had proved unavailing. The pain-
ful region was irradiated through the mouth, the neighboring parts be-
ing protected by a tube of lead glass. The X-rays were directed on the
alveolar border in the region of the first and second molar teeth. A dose
of four Holzknecht units was given daily, using rays corresponding to
number seven or eight on Benoist's scale. After the first and second
stances there was no noticeable change. After the third irradiation the
patient asserted that there was some diminution of the pain. There \\ as
slight reaction of the skin on the border of the upper lip, which had been
imperfectly shielded from the rays. After the fourth stance there was a
complete cessation of all pain. Since then the patient has remained free
from any recurrence of the affection.
For four years Faber's* patient had suffered from trigeminal neu-
ralgia, with two intervals of a few month's freedom from pain after oper-
ation. As the neuralgia recurred with increased intensity and frequency,
ten Rontgen exposures of ten minutes each were applied to the upper
half of the face within sixteen days. Improvement was evident at once
and the patient was soon entirely free from pain. There has been no
recurrence during the few months since.
1 Archive's of the Rontgen Ray, May, 1906.
1 Hospitalstidende-Copenhagen, last indexed page 813.
THERAPEUTIC VALUE IX DISKASK. 495
Dr. E. B. Bondurant1 reports that one application of the X-rays
apparently cured facial and intercostal neuralgia. Dr. S. W. Allen re-
ports several cases which show that neuralgic pains ceased even when the
X-rays were used for making the diagnosis. I have noticed that many
cases of neuralgia were temporarily cured when the X-rays were used for
diagnosing dental conditions.
F. EPILEPSY.
Four years ago I examined a boy's skull for depressed bone, the lad
being a sufferer from epilepsy. His physician informed me that since his
X-ray examination there was a complete absence of epileptic seizures ;
this suggested the treatment of epileptic cases by the X-rays.
Two years ago, through the courtesy of Dr. W. W. Hawke, Superin-
tendent of the Insane Department of the Philadelphia Hospital, twelve
patients were selected, the youngest being six and the oldest sixty, the
attacks varying from a very mild type to a severe epileptic seizure. (Figs.
236, 237.)
X-ray treatments began in February, March, and April, 1904 ; treat-
ment three times a week, exposures five minutes, distance of the. anode
8-10 inches (20 to 25 cm.). Various parts of the skull were exposed.
After two months' treatment alopecia was produced.
The results and improvements from the X-ray treatment were quite
satisfactory, as will be noticed from the lower group of photographs.
(Fig. 238.)
The following table exhibits the number of attacks in 1903 and 1904,
showing the improvement due to the rays :
CASES. RESULTS.
I. Number of attacks in 1903 were 68.
Number of attacks in 1904 were 41. Decrease of 27.
II. Number of attacks in 1903 were 845.
Number of attacks in 1904 were 412. Decrease of 433.
Nti attacks during October, November, December.
III. Number of attacks in 1903 were 59.
Number of attacks in 1904 Avere 14. Decrease of 45.
Attacks ceased two months after treatment, but patient died on May 7, 1904.
IV. Number of attacks in 1903 were 85.
Number of attacks in 1904 were 80. Decrease of 5.
Patient died five months after the beginning of the treatment.
V. Number of attacks in 1903 were 144.
Number of attacks in 1904 were 120. Decrease of 24.
No attacks during October, November, December.
1 New York Med. Jour., August, 1902, vol. Ixxvi. pp. 194-196.
496 ELK( TH( )-THERAPEUTICS.
VI. Number of attacks in 1903 were 209.
Number of attacks in 1904 were 191. Decrease of 18.
No attacks during October, November, December.
VII. Number of attacks in 1903 were 69.
Number of attacks in 1904 were 4 during the same months.
VIII. Number of attacks in 1900 were 6.
Since then no attacks.
IX Number of attacks in 1903 were 148.
Number of attacks in 1904 were 164. An increase of 16.
Number of attacks increased during the treatments, but during October,
November, December, there were no attacks.
X. Number of attacks in 1903 were 61.
Number of attacks in 1904 were 77. Increase of 16.
Increased during the treatment.
These results of X-ray treatment of epileptics, I believe, are encour-
aging when we notice the decrease in the number, duration, and severity
of the attacks. I cannot think that any harm can be done, except the
alopecia that may be produced.
The sudden death of two young patients during and immediately
after the treatment was not the direct result of the X-ray treatment,
although the autopsy showed congestion of the brain, which might have
been due to some other cause.
Horace Manders l states that it is only two or three years since Branth
conceived the idea of using the X-rays for the relief of epilepsy, on the
theory that these rays stimulate protoplasm into greater vital activity.
He gave three treatments a week, beginning with five minutes' exposure
at 15 inches distance, and increased to ten minutes' exposure at 10 inches
distance. A different part of the skull was exposed at each sitting. A
hard or high-vacuum tube, backing up a spark-gap of 5 to 8 inches, was
used. One objection to this treatment is the alopecia which follows it,
but the hair will return in a stronger growth than before. It may also
be desirable to continue the use of the bromide with the X-rays. This
treatment is usually followed by a gain in weight, by improvement in
enunciation (if that were faulty), and by lighter seizures of shorter dura-
tion and at longer intervals. This treatment is not available if
degenerative processes of the brain have begun.
Dr. J. H. Branth1 gives three treatments a week, beginning with
5-minute exposures at 15 inches distance, and by degrees increases to 10
minutes at 10 inches. A different part of the skull was exposed at each
sitting, and a tube of high penetration used. The hair drops off usually
near the parts exposed, but returns later in stronger growth. In some
1 Archives of the Rontgen Ray, April, 1905.
*New York Medical Journal, June 11, 1904.
THERAPEUTIC VALUE IN DISEASE. 497
cases the bromides can be dispensed with ; in others, small doses prove
beneficial. In young subjects a gain of weight soon results, and a marked
improvement in the mental faculties takes place. The impediment in
speech, which occurs in severe cases of long standing, has been removed
by raying, and the attacks, which numbered from 6 to 10 a day, were
reduced to one every 2 or 3 weeks.
It is to be hoped that these results will be confirmed by others. 1
recall a case where I took two radiographs of the head, with a view of
locating the cause of the seizures. The patient had no attacks for over
two months following the exposures.
CHAPTER VI
RADIUM AND OTHEE EADIO-ACTIVE SUBSTANCES.
THE remarkable chemical body radium, discovered some years ago
by Prof, and Madame Curie, belongs to the alkaline group of elements.
Madame Curie makes the atomic weight 225. We know that barium has
an atomic weight of 136.4 and thorium 230.8 ; thus, according to the
periodic law of atomic weights, first outlined by Mendeleeff, radium would
stand between the two just mentioned. Demarcay first demonstrated
that radium was an element, being characterized by a spark spectrum of
14 or 15 lines.
OCCURRENCE.
Radium is a very rare element and has for its source ordinary pitch-
blende, occasionally spoken of as uranium. An abundance of this
mineral is found in various parts of the world, chiefly in(Cormvall.
Colorado, Nevada, Saxony, Bohemia, and Thibet.
Pitch-blende is a mineral of a "pitchy" appearance ; chemically, it
consists of the double oxides of uranium, the oxides of lead and zinc, in
combination with more or less rare and peculiar metallic bodies in smaller
quantities. Uranium, a commonly used body, the salts of which are of
beautiful tints on the border of yellow, has been for years extracted from
pitch-blende. What was formerly cast off as the useless substance of
pitch-blende is to-day saved for the purpose of extracting therefrom
radium, helium, etc.
CHEMICAL AND PHOTOGRAPHIC EFFECTS.
Professor Henri Becquerel, a noted French physicist and chemist,
learned that the compound potassio- sulphate of uranium was endowed
with properties similar to those manifested by zinc sulphide and other
bodies. He discovered that when uranium or any of its salts was
exposed to helious radiations, they became endowed with the faculty
of absorbing the rays, which in turn could be induced to act upon the
film of a sensitive photographic plate. That this phenomenon was dis-
played by metallic uranium caused him to believe that the same result
might take place if he used the ore from which it was derived primarily.
Following this line of reasoning, he employed ordinary ore (pitch-blende),
desiring to influence a sensitive plate by exposing the complex ore to the
rays of the sun. The sun was obscured by clouds ; so he removed the
ore, also a key (that he desired to image), and the sensitive plate to a
KM
RADIUM AND OTHER SUBSTANCES. 499
closet, intending to conduct the experiment at some future day. Fortu-
nately for science, he forgot the experiment for several days, and, upon
examining the plate after developing, he observed that the image of the
key had already been imprinted into the sensitive coating of the pitch-
blende. Thus, accidentally, he discovered that uranium ore, the pure
metal and also its salts, would cast an image on a plate, and that a previ-
ous exposure to sunlight was not essential to the evolution of these dark,
invisible rays. Even though a uranium salt be crystallized out of its
solution in the dark, and allowed to remain there, it still possesses the
property of emitting rays which affect ordinary photographic plates.
Photographic paper becomes brittle after prolonged exposure. Ozone
is formed in the air about radium. The rays are not affected by the
t-xtiviiH'S of temperature.
Like Elster and Geitel, who observed that certain substances which
had been exposed to light emitted radiations capable of discharging
nt -Datively electrified bodies, Becquerel observed the same quality in the
radiations that bear his name.
Sir William Crookes, soon after the discovery was made public,
subjected the salts of uranium to a close examination, and he theo-
rized that these radiations were not due to the uranium itself, but to
contained impurities in the salt. He crystallized repeatedly the sub-
stances, exercising care to separate the crystals into two portions, — on
one side he placed those crystals which formed with greater ease, and on
the other those which formed slowly. He observed that one set of crys-
tals possessed the power of readily emitting raj s, — i.e., they were said
to be radio-active, — while the other lot of crystals were devoid of such
phenomenal activity.
At the outset Professor and Madame Curie reasoned, and correctly
so, that the largest percentage of the radio-active substance, as yet
unknown, was found in the ore (pitch-blende) and not in uranium. They
undertook the task of extracting the unknown body from the ore, and
they discovered that they had now to deal with two distinctly different
bodies, the one substance was that which gave off the Becquerel rays,
and the other, since those days, has been termed radium, actinium, and
polonium. Radium is present in pitch-blende in larger quantities than
any of the other radio-active substances.
After the oxides of uranium have been separated from the ore, the
residue remaining behind constitutes little more than three- quarters of
its weight. This residue contains all the other metals entering into its
complex construction, and from these the newer radio-active substances
have to be separated, requiring severest attention. Thorium, one of the
radio-active elements, extracted from the refuse ore, is not new ; having
been known by chemists for years. Polonium is contained in the ore in
only the minutest quantities. Prof. Markwald was able to extract only
15/100 of a grain of this element from two tons of refuse ore, from which
500 ELECTRO-THERAPEUTICS.
uranium oxides had been extracted. It seems to be somewhat related to
bismuth. Radium usually accompanies the barium obtained from pitch-
blende ; it resembles it in its reactions, and is separated from barium by
the differences of the solubility of the chlorides iu water or alcohol con-
taining hydrochloric acid. Radium, in the metallic or pure state, has
not up to the present time been isolated. It could, however, be isolated
with practically no difficulty whatever, according to the opinion of Prof.
Curie, by carefully treating the chloride part of the salt with sodium
or potassium, forming a chloride salt of either one or both of the latter
substances.
PHYSICAL PROPERTIES OF RADIUM.
Radium appears like ordinary table salt, with a slightly yellowish
tinge. It is weighty and non- deliquescent. It continuously emits a
feeble light, which is only recognizable in a darkened room. All the
bodies coming in combination (or otherwise) with radium have imparted
to them radiations, which are in turn given off. Zinc-blende is especially
able to take up these radiations. Radium also constantly gives off heat
rays, so that the temperature is always 1.5° C. above that of surrounding
objects. The view that the ray and heat emanations from a radium salt
do not cause a decrease or loss on the part of the salt, is incorrect, the
opposite being the case ; although we must bear in mind that this loss is
very minute.
Penetration. — These rays, like the Rontgen emanations, traverse
wood and the lighter metals. By placing an aluminium disk on a
black paper envelope, covering this with a card, over which are
sprinkled crystals of the double sulphate of potassium and uranium
that had never been exposed to light, Becquerel was able to obtain a
radiograph.
Fluorescence and Luminosity. — This is well illustrated by the spin-
thariscope of Crookes. This consists of a brass tube, having at one end
a fluorescent screen and in front of this a little movable arrow. On the
under surface of the tip of the arrow, that is just opposite the screen, is
a minute particle of radium. At the opposite end of the tube is an
adjustable lens. Upon going into a dark room and adjusting the lens to
suit the eye, one can see minute particles of light flying off from the
screen in every direction, and dancing around at a rapid rate, suggesting
a shower of shooting stars. Slight phosphorescence is also produced by
radium.
Greef discusses the fact that the rays of radium are visible to the
naked eye in the dark. It is not a phosphorescence, as radium maintains
this property indefinitely when kept exclusively in the dark without
exposure to any light It induces fluorescence in other objects, and also
emits the radium rays proper.
KADI I'M AXD OTHER SUBSTANCES. 501
THEORETICAL CONSIDERATIONS : CLASSIFICATION OF THE BAYS.
What are the emanations (radiations) from radio-active bodies ? Like
the problem with the Routgen rays, the very same state of affairs exists,
and is yet to be solved in so far as radium and associated radio-active
bodies are concerned. A number of authorities are of the opinion that
the radiations are minute particles given off, and not the undulations in
the surrounding medium (ether).
Crookes speaks of three kinds of radiations : Similar or identical
with the cathodic emanations, free electrodes, or matter in the ultra-
gaseous existence. Distinct atoms, electrified positively, the air being
rendered a conducting medium, and affecting photographic plates. Rays
of a very high degree of penetration accompanying the others ; Crookes
believing them to be identified with the X-rays.
Taking the first group, we may state that the rays are strongly devi-
ated in a magnetic field, the second rather slightly, and the third not at all.
They all produce effects on photographic plates, and excite phosphores-
cent bodies, though all with variable differences. The former and the lat-
ter affect strongly platino-barium cyanide ; the second have no such effect.
Some speak of three kinds of radio-activity : alpha, beta, and gamma.
The alpha rays are easily absorbed and carry a positive electrification ;
the beta rays easily penetrate solids, and carry a negative charge ; and
the gamma rays have a very intense penetrative power, but carry no
charge. Some state that the gamma and the Rontgen rays are identical,
though Strutt, of Cambridge, is of the opinion that there is a vast differ-
ence. Crookes maintains that they are actual emanations, — the projec-
tion of minute particles from the radio-active body into adjacent space.
Rutherford asserts that if the radiant particles were ejected with
slightly less velocity, they would neither ionize the air, affect a photo-
graphic plate, nor cause fluorescence ; in truth, there would be absolutely
no effect capable of detection by our apparatus.
BIOLOGICAL EFFECTS.
Bactericidal Action. — Crookes exhibited a number of plate cultures
and photographs illustrative of the bactericidal properties of the ema-
nations from radium. Various cultures of bacteria were exposed to the
action of ten milligrammes of bromide of radium, through a mica screen,
at a distance of one inch from the surface of the plate. After having been
subjected to the action of the radium emanations, the plates were incu-
bated for 24, 48, or more hours. In every case it was found that the mi-
crobes were killed where they had been exposed to radium, so that on
incubation, a bare space, free from bacterial growths, was left on the
plate opposite the point where the radium had been placed. Among
the bacteria experimented upon were the bacillus coli communis, the
bacillus prodigiosus, etc.
502 ELECTRO-THERAPEUTICS.
The Ji(thicitr,< of Uadium on At/'/lnfimition. — P. P. Jagn l tested the
effect of radium ou the specific properties of blood serum in typhoid fever.
It was found that after an exposure of the typhoid blood serum to
radium bromide, lasting 2 or 3 days, the serum completely lost its agglu-
tinating properties. An exposure of shorter duration does not destroy
the agglutinating power, though the latter undergoes a considerable
reduction. These phenomena the author is inclined to attribute to the
so-called "beta rays."
Frederick Soddy l states that five minutes' application of radium is
equivalent to ten years' application of thorium, although both instanta-
neously produce radio-active emanations of gases in infinitesimal quanti-
ties. He believes it possible to inhale the emanations of both tlnise
substances in the treatment of pulmonary tuberculosis. The maximum
dose of radium solution should be the gaseous contents of a bubble ; a
few bubbles every 24 hours.
Physiological Action. — Heineke3 believes that the action of radium
rays is approximately the same as that of the* Rontgeu rays. Lymphoid
tissue is affected in the same way, but not to the same extent as with the
Rontgeu rays, unless the radium is brought into close contact, when a
brief exposure will astonishingly induce extensive changes in the
lymphoid tissue, apparent in a few hours.
Effects on the Nervous System. — The effects on the nervous system are
interesting and have been chiefly studied in young mice. London found
that mice exposed to a strong preparation of radium were killed. There
was first redness of the ears, then blinking of the eyelids, then drowsi-
ness, slowness of movement and feeble response to stimuli. This was
followed by paralysis, then coma, and finally death. The symptoms
developed about the third day of exposure, and the animals died on the
fourth or fifth day. Along with these nervous symptoms were well
marked effects on the skin. The hair and epidermis were loosened and
the subcutaneous tissue was greatly congested.
Effects on the Eye. — Radium produces luminous effects on the retina
even when the eyes are closed. This is due either to fluorescence of the
tissues of the eye, or to direct effect on the optic nerves, probably the
former. This effect has been taken advantage of by Javal,4 London, and
others, in experimenting on the blind with radium. In his experiments
.Javal found, in two cases of blindness in which there still remained a
slight perception of light, that the patients perceived a light sensation
when radium was held before the eyes. In two other cases of blindness,
one due to optic atrophy, and the other to glaucoma, both patients being
absolutely blind, there was no perception of light from exposure to
1 Roussky Vratch, December 6, 1903.
* Nature, vol. 78, July 25, 1904, p. 266.
3 Miinchener med. Wochensrhrift, vol. li., No. 31, 1904.
4 Physikal. Zeitechr.. 1900, i. p. 476.
EADIUM AND OTHER SUBSTANCES. 503
radium. London's results are to the same effect. Blind patients who
still retained a slight perception of light were cognizant of a visual sensa-
tion when radium was applied to their eyes. In those totally blind the
results were negative.
RADIUM AND THORIUM AS THERAPEUTIC AGENTS.
The attention of the medical world is at present directed to the
therapeutic experiments with radium, and so far the results lead us to
hope that it will prove of value in the treatment of certain skin
diseases and malignant conditions. It is still too soon to pronounce
authoritatively upon the permanency of the cure in malignant cases.
Already many instances are recorded in which the use of radium has
effected complete disappearance of carcinomatous growths, especially
the epitheliomata.
Radium does not give so good a differentiation of the tissues as can
be obtained by the X-rays, it is of little value in taking radiographs or
in making examinations with the fluorescent screen ; but on the other
hand, radium is far more convenient ; it can be easily transported, and
can be applied in positions difficult of access with the X-rays, and its
action can be readily controlled. It is not so convenient as the X-rays
when large surfaces require treatment, but this objection may be over-
come by the fact that the emanations from radium salts which will pass
through the air, but not through glass, are taken up by rubber and
other articles. The absorbed rays are given off slowly from the articles,
and apparently have the same effect as those directly derived from the
radium salts. Williams1 remarks that his clinical results with the beta
rays have been very good, and he is now trying the effect of the gamma
rays upon deep-seated growths.
The gamma rays are the fewest in number, but are deeply pene-
trating ; the beta rays are more numerous, but act very superficially,
and are probably instrumental in causing the burns that have been re-
corded. The action of the gamma rays alone can be obtained by inter-
posing an aluminium screen, which intercepts the beta rays, but allows
the gamma rays to pass through, if the screen be not too thick.
Diseases of the Skin. — Scholtz2 has been testing 25 nig. of radium bro-
mide in the treatment of various skin affections and in tumors, and in
conducting experiments on animals. The treatment proved particularly
effective in lupus and superficial cancer. The results indicate that
radium rays produce effects closely similar to those of the X-rays. The
radium can easily be introduced into the mouth, nose, throat, and vagina.
F. Williams3 bases his conclusions on the study of fifty cases of
1 Medical News, February 6, 1904.
1 Deutsche med. Wochenschr., vol. xxx., No. 24.
s Boston Medical and Surgical Journal, Feb. 25, 1904.
504 ELECTRO-THERAPEUTICS.
various diseases, treated with radium bromide, in quantity about 50
milligrammes, aud of a radio-activity of about 1,500,000. The author
presents the following summary of his observations :
"1. The rays from radium salts, unlike the X-rays, are not service-
able in diagnosis, either by means of radiographs or of fluoroscopic
examinations. 2. The beta rays are useful as a therapeutic agent in
certain skin diseases and new growths, if the diseased tissues are super-
ficial or are not more than about 1.25 cm. (1-2 an inch) below the surface
of the skin or accessible mucous membranes. 3. The beta rays from
radium salts will heal some cases of new growths that are not healed by
the X-rays, and they act more promptly, but not over so large a surface
at one time as do the X-rays. 4. Radium salts of an activity of 8000,
or considerably more, are not sufficiently strong to be efficient. Pure
radium salts, which have a radio-activity of about 1,500,000, are not too
strong for the work to be done. 5. The radiation from radium salts,
unlike that from the X-ray tube, is uniform. 6. Great care should be
exercised to avoid burns."
Dr. Meyer and William J. Hammer treated favorably a large axil-
lary cancer with radium of 300,000 activity. The exposure was one
minute daily. While this case was incurable, the cancer grew smaller
and less painful under the rays.
Lovell Drage ' believes that, in cancer, radium first produces a leuco-
cytosis, and then a fibrosis. In the case of pulmonary tuberculosis there
is no difficulty in producing these conditions ; in that of cancer much
greater difficulty is experienced in advanced cases than is the case with
tuberculosis.
Professor Havas observed a necrosis after the application of radium
to a mevus piginentosus, and considered its action similar to that of the
Rontgen rays.
Mode of Retrogression of Cancer Metastases under Radium Rays. — Exner
was able to trace histologically the retrogression of carcinomatous nod-
ules in the mamma in one out of the two cases described. The findings
were controlled by histological examination of excised, non-exposed nod-
ules. He found that exposure for a single half hour was able to induce
complete retrogression of a nodule. The retrogression was complete in
five weeks. The most remarkable feature of the phenomenon is that while
the cancer cells retrogress, none of the other cutaneous elements was de-
stroyed. Within a week of the exposure there was a new formation of
connective tissue, while at this time the cancer cells showed no change.
There are numerous new formed capillaries in the new connective tissue.
No change appears in the cancer cells until two weeks have elapsed. The
rapid proliferation of connective tissue seems to diverge the cancer cells
and overwhelm them by its growth, actually squeezing them to death.
1 British Medical Journal, December 12, 1904.
RADIUM AXD OTHER SUBSTANCES. 505
Holzknecht treated several cases of cutaneous affections with the
radium rays, of one application each. One was a case of psoriasis gyrata
of the entire body, which had been nearly cured with the X-rays and
the cure was completed by the application of the radium. Very slight
and brief applications of the X-rays are enough to cure psoriasis. The
patches heal, while the sound skin is not affected by the applications.
The same is true of the radium.
Francis H. Williams1 has employed radium in forty-two cases, and
states that of the patients treated, 9 were suffering from acne, 2 each
from eczema and psoriasis, and 4 from lupus vulgaris. Of the 33 re-
maining, 1 was keloid, 5 were cases of rodent ulcer, 23 of epidermoid car-
cinoma, and 4 were cancer of the breast. The keloid case has improved,
2 of the 5 cases of rodent ulcer have healed, and three show improve-
ment. Of the cases of epidermoid cancer, 11 have healed and 12 are
improving. The author made experiments to test which were the more
beneficial, the beta or the gamma rays from radium ; these showed that
the lift a rays do not penetrate, and are therefore suited for superficial treat-
ment, while the gamma rays have a marked power of penetration. His
conclusions are as follows: That there is much similarity between the
action of the radiations from radium and the Rontgen rays ; that if the
results obtained by radium prove permanent, this new therapeutic agent
may be largely used instead of the Rontgen rays ; also that certain diseases
promise to yield more readily to treatment by radium and others to the
Rontgen rays. He argues that a disease that has attacked different parts
of the body of a given patient may be better treated in certain regions
by radium, and in others by the Rontgen rays. And, lastly, that it is
quite possible that, in some cases, the two remedies used together on the
same area and at the same sitting may accomplish better results than either
employed alone.
Lassar 2 gives illustrations of a number of patients with melanoma or
cancroid cured by application of 1 mg. of radium bromide, in a small cap-
sule of lead foil, upon a sheet of mica. He thinks that his experience
justifies him in proclaiming that neoplasms can be cured with radium
in the hands of any physician.
M. Danlos3 reports a case of lupus of the face exposed to the action
of a salt of radium, at two points, which had a radio-activity of 19,000
from 24 to 36 hours. The result was disappearance of the disease, with
the formation of a smooth, white cicatrix, blending into the surrounding
normal tissue.
MM. Hallopeau and Gadaud 4 report that too prolonged exposure
to the emanations from radium led to ulcerations which lasted from five
to six months. Dr. Blandamour has also used radium in lupus. His
1 Medical News, Feb. 6, 190i. 'Derinat. Zeit, Berlin, p. 1599.
3 Revue d' Electrotherapie et Radioth^rapie, Nov. and Dec., 1902. 4Ibid.
506 ELECTRO-THERAPEUTICS.
best results followed the use of salts with a radio-activity of 5200 and
19,000 respectively.
The exposures were made for from twenty- four to forty hours, and
were followed by marked erythema with maceration of the tissues ex-
posed, and even ulceration. The recovery was perfect and the cosmetic
effect good, the resulting scar being white, smooth, and soft. By modify-
ing the power of the radium and shortening the exposure, he expressed
the hope that the desired effect might be obtained without ulceration.
Two cases reported to the Viennese Society of the Imperial Academy
of Science ' had been submitted to the action of radium. One, a man aged
62, had been repeatedly operated on for cancer of the palate and lip, but
with no benefit. Further operative measures had been declared useless.
In the published report, the radio-activity and technic were not given,
but a bromide of radium was used. The tumors gradually and com-
pletely disappeared. The patient was treated in the clinic of the late
Prof. Gusenbauer. The second case was one of melano-sarcoma which
was also reported cured.
Win. Allen Pusey * believes that the effects and the therapeutic uses
of radium are in some respects inferior but quite analogous to the action
of the X-rays, and that radium finds a promising field in the treatment
of lupus and cutaneous cancers.
Einhorn 3 makes some observations on the method of radium treat-
ment, its physiology and diagnostic value, and on the therapeutic results
he has obtained in the treatment of carcinoma of the oasophagus. Kine
cases of oesophageal cancer were treated, of which six showed some
improvement. Three cases were not improved. None of these latter
received adequate treatment. Pain was diminished in some of them.
Dr. John B. Shober has devised the radiode, for radium applications to
the less accessible cavities. (Fig. 240.)
Dr. Mackenzie Davidson, * of Charing Cross Hospital, London, re-
ports a case of cancer of the nose cured by the same means. Four ex-
posures, aggregating an hour altogether, were given at intervals of a few
days. In three weeks healing was progressing satisfactorily, and in six
weeks the growth was all gone.
Foveau de Courmelles5 describes numerous experiences to show the
great sedative power possessed by radium. It soothes pain, whether or-
ganic or cancerous, nervous or neuralgic. Some cases of facial neuralgia
and one of sciatica, long rebellious to other measures, yielded to the
action of the radium rays. The girdle pains in two cases of ataxia were
1 New York Medical Journal, August 15, 1903.
1 Journal of the American Medical Association, July 16, 1904.
'New York Medical Record, July 30, 1904.
4 Journal of tin- Anu-rirun Medical Association, June 25, 1904.
6 Progres Medical, May 28, 1904.
RADIUM AXD OTHER SUBSTANCES. 507
cured, one by the radium and the other by the Rontgen rays. The subjects
were not informed in regard to the nature of the treatment, so he thinks
that suggestion may be excluded.
Eobert Abbe ' employs only large quantities of stronger radium.
15 centigrammes Curie radium, strength 300,000
l'l milligrammes ( u-rman bromide, strength .... 1,000,000
100 milligrammes German bromide, strength 1,800,000
The working unit of the most powerful and pure radium manufact-
ured is 10 milligrammes radium bromide 1,800,000, and is best used in a
small cell covered by a thin layer of mica.
He puts 35 of his cases in the lupus type, including the epithelio-
niata, and asserts that not one failed to show a marked improvement.
Twenty have been cured, at least for the time, and with the proba-
bility that many are permanent, but with a slight point or two of recur-
rence in some, which always have yielded to a short secondary treatment.
Many of these were distinctly malignant epitheliomas.
His results have been so uniformly excellent in the treatment of the
sarcomata, that he unhesitatingly advocates radium therapy in these
cases with the utmost confidence.
Exophthalmic Goitre. — Robert Abbe 2 reports a case of goitre undesir-
able for operation. An opening was made in the tumor, into wrhich a tube
containing radium was inserted and retained there for twenty-four hours.
At the end of four months there was still a certain degree of tachycardia,
but the tumor had contracted to one-sixth of its former size. Two possible
explanations of the favorable action are given ; there may be retrograde
changes in all overgrown tissue, or there may be irradiation of the
ganglia of the sympathetic, even of the thoracic and cardiac ganglia.
Rabies. — Tizzoni3 describes two series of experiments which have at-
tracted much attention. In the first, the virus was exposed in vitro to
the action of the radium rays ; in the second, animals were inoculated in
the eye, or sciatic nerve, or under the dura mater with virus, and the
part was then exposed to the rays, an hour a day for eight days. The
results indicate that the radium rays destroy the virus of rabies both in
vitro and in the living animal.
Xa'nis. — Hartigan4 reports a case of nsevus successfully treated by
radium bromide. The first was a large port-wine nsevus affecting the
whole of one cheek in a woman of twenty-six years. The treatment
lasted nine months, during which time thirty-nine exposures were given,
varying from half an hour to an hour. The nsevus entirely disappeared,
1 Journal of the American Medical Association, July 21, 1906.
* Archives of the Rontgen Ray, March, 1905.
3 Riforma Medica, Palermo and Naples, last indexed vol. xliv. p. 1818.
4 British Journal of Dermatol., December, 1904 ; Treatment, April, 1905.
'•US
ELECTRO-THERAPEUTICS.
witli rhe exception of a few untreated areas. The amount of radium used
was 10 milligrammes. Usually within twenty-four hours an erythema oc-
curred, followed by vesicles, which fell off as scabs in a few days, leaving
behind a thin white skin.
Radio- Active Treatment with Thorium. — Tracy1 illustrates the radio-
activity of thorium and calls attention to its anti-fermentative property.
He suggests two methods of using radio-activity in tuberculosis. One is
by using a saturated solution of nitrate of thorium in a large shallow re-
ceptacle. A slight current of air can be caused to pass over the solution
from a compressed air tank, while the patient is inhaling. With the
nitrate of thorium there may be more or less free nitric acid ; this must
be neutralized by passing the emana-
tions, before inhalation, through a wash-
bottle containing a saturated solution of
sodium bicarbonate. The more satisfac-
tory way, he thinks, is by heating the
oxide of thorium by the Lieber appa-
ratus. The procedure leaves in the
lungs a fine film of radio-active matter,
which in turn produces the phenomenon
of induced radio-activity in the same
parts, which may last for one or two days.
This is shown by the patient, after inhal-
ing thorium emanations, exhaling on a
photographic plate which produces the
ordinary effects on the silver salts. An
inhalation given every day or every
other day, he says, will keep the lung
cells constantly in a radio-active and
antiseptic condition. The heat emanat-
ing from a Lieber apparatus can be
cooled by passing through a glass and
rubber tubing, and the inhalation may be given for a period of fifteen
minutes at the outset, gradually increasing to half an hour. This
method of treating tuberculosis will not interfere with medical, dietetic,
or other treatment.
Sharp * reports two cases of pulmonary tuberculosis treated by inha-
lations from thorium nitrate solution. In both cases there was marked
improvement, the patients being enabled to return to work. The appa-
ratus employed consisted of an ordinary gas washing bottle, holding 500
c.c. of water, in which were dissolved 100 grains (6 grammes) of thorium
nitrate. When dissolved, any excess of nitric acid was neutralized with
FIG. 239.— UARTIGAS'S RADIVM AP-
PLICATOR.—The applicator figured here-
with has been made at the suggestion of
Mr. Hartigan, F.R.C.S.. Assist. Surgeon,
Blackfriars' Hospital, and permits of the
application of radium to hitherto inacces-
sible situations, e.g., O3sophagus, larynx,
bladder, etc. It is practically the size of a
No. 12 catheter for the bladder, suitable
carriers being provided for internal and
extemal application. The applicator has
a Rpnerical front of a material allowing of
the utilization of the maximum efficiency
of the radium.
1 Medical Record, January 23, 1904.
'New York Medical Record, June 4, 1903.
RADIUM AND OTHER SUBSTANCES. 509
ammonia. Two patients may inhale the emanations continuously for an
hour a day each at an interval of eleven hours, it taking about half that
long for the gas to collect.
Rheumatism. — Glanders,1 in choosing a radio-active substance for the
relief of rheumatic pain, favors thorium, because ; (1) Its radiations are
spontaneous and are not destroyed by a physical state or by chemical
transformation ; furthermore, they are practically inexhaustible and do
not need stimulus from any outside source of energy ; (2) though infi-
nitely less radio-active than radium, thorium is much more active than
uranium ; it is rich in the penetrating beta rays, which are required for
deep therapeusis, and poor in the X-rays, which provoke a destructive
molecular change in the elements of the superficial tissues.
Hartigan,2 who employs his radium applicator (Fig. 239), treated a
woman of 66, with a scirrhus of the breast of 16 years' duration. She
received forty applications of radium bromide, lasting twenty minutes
each. Twenty milligrammes of radium were used. The pain disap-
peared, hemorrhage ceased, and the ulcer began to heal. Later the
growth disappeared and the ulcer vanished.
I have made a comparative study of the values of radium and the
Rontgen rays on a series of epitheliomatous cases. Half of the lesion
was covered with lead when exposing to the X-rays, and, conversely, when
the other half was exposed to the radium emanations, the remaining half
of the face was shielded. From clinical and microscopic observation no
FIG. 240.— SHOBER'S RADIODE.— This radiode is especially designed to facilitate the application of
radium for medical purposes, especially in cases where applications are made in the smaller cavities of
the body. The radium Is contained in an aluminium capsule shown on the tip of the radiode at " F".
This capsule is attached to a slender rod. To prevent the capsule and radiode becoming fouled in use,
a glass protecting tube or shield, with one end closed, is made to fit snugly over the radiode, as
shown in Fig. " G". The radiode can then be inserted in a cavity without danger of contamination in
any way. Instead of the glass protecting tube as shown in cut "G", we can supply a similiar protecting
tube of aluminium. It is known that glass has the effect of cutting off some of the radium rays, and for
this reason some operators prefer to encase the radiode in an aluminium protecting tube. A lead-lined
box is supplied, as shown at " H" in cut, for containing the capsule of radiode when not in use, thus
protecting the operator. (Courtesy of Williams, Brown, & Earle.)
improvement or changes were evidenced from the radium therapy. The
results from the use of the X-rays were in every way superior and gave
good practical results. Further experiments are needed, and the possi-
bilities of the radium are promising. In this country Pififard, William J.
Morton, Dieffenbach, RollinH. Stevens, and many others report favorable
results from radium therapy.
1 Archives of the Rontgen Ray, September, 1905.
2 British Journal of Dermatology, December, 1904 ; Treatment, April, 1905.
CHAPTER VII
PHOTOTHERAPY.
IN order to grasp the principles involved in the study of photo-
therapy, it is necessary to understand the more simple elementary facts
concerning the physics of light and the spectrum.
Regarding the nature of light, two theories have been advanced.
Xewton asserted that luminous bodies emitted infinitely small particles
in parallel lines, which produced in the eye the sensation of light.
Huyghens, whose view now generally obtains, formulated the theory that
light is produced by waves or undulations, that are transmitted with
inconceivable velocity through the atmospheric ether.
All light, whether natural, as that from the sun and other celestial
bodies, or artificial, — i.e., the electric spark or ordinary flames, — is of a
INVISIBLE
VISIBLE RAYS
INVISIBLE
FIG. 241.— SOLAR SPECTRUM.— Scheme of the wave lengths of different radiations. A B C is the
curve of thermal action ; D E F G is the curve of chemical action ; H I K is the curve of light action,
with a maximum at yellow.
compound nature. If a ray of sunlight be suffered to fall upon a glass
prism, it is diverted from its original direction, and, as its constituent
colors are bent unequally, they are separated. When the transmitted light
falls upon a white surface, the colors become visible, the tints blending
where one color merges into another. This zone of blended tints is called
the spectrum. The colors seen are violet, indigo, blue, green, yellow,
orange, and red.
According to the undulatory theory of light, each of these constitu-
ent colors has its own rate of vibration. Red has the lowest and vio-
let the highest rate of vibration ; the former is least refracted or retarded ;
the latter undergoes most refraction or retardation. Different colors have
510
PHOTOTHERAPY. 511
different wave lengths, diminishing from red to violet, so that those color
rays in relation to the violet end of the spectrum are designated ''rays
of lesser wave length," and vice iv/ *</.
At the extremes of the solar spectrum are additional rays. Beyond
the red rays lie the infra- or ultra- red rays ; beyond the violet are found
the ultra-violet rays.
The luminous rays of the sun are accompanied by others, possessing
heating powers, the temperature increasing from violet to red. In the
spectrum obtained by passing sunlight through prisms of rock salt, the
highest temperature is manifested at a position far beyond the extremest
visible red rays. From these facts, it is inferred that the great thermal
rays of the solar system are at the same time the least refrangible.
Directly opposed to the heat-rays are the so-called chemical or
actinic rays. The latter rays are capable of effecting both chemical
combinations and chemical decompositions, as is evidenced in the black-
ening and decomposition of the silver salts in photography. As before
intimated, these chemical rays lie beyond the violet end of the spec-
trum, and are the rays that are instrumental in effecting dermatitic
changes. (Fig. 241.)
THE ACTION OF LIGHT ox PLANTS.
Plants cannot exist without light. Through its agency they extract
CO2 and by means of chlorophyll assimilate it. Light is not necessary
for the germination of plants and seems to exert a retarding effect upon
growth. This would seem to account for the varying rate of growth at
different hours of the day. Indeed it has been shown that all light rays
except the red and ultra-red retard the growth of plants, and that the
effect is most pronounced in the rays that suffer most refraction in the
spectrum.
" Heliotropism " is the faculty, possessed by many parts of plants,
of turning toward and away from the direction of greatest light. Stems
and leaf-stalks are positively heliotropic (growing toward the source of
light, in the direction of the light rays), while roots and rhizomes are, as
a rule, negatively heliotropic.
ACTION OF LIGHT ON BACTERIA.
That diffused and also direct light can destroy the bacteria of putre-
faction was first enunciated by Downes and Blunt in 1877. * They like-
wise showed that the effect is the same whether the bacteria are moistened
or dried, that the presence of oxygen is requisite, and that the manner
in which light a,cts in these experiments is not to be sought in a modifica-
tion of the nutritive basis. These data are now accepted by all scientists.
Proceedings of the Royal Society of London, December 6, 1877, vol. xxvi. p. 488,
and December 19, 1878, vol. xxviii. p. 199.
512 ELECTRO-THERAPEUTICS.
Dieudonne observed, in a series of most elaborate experiments, that
bacteria were killed in thirty minutes by direct sunlight, in six hours
by diffused daylight, in eight hours by the Brush light of 900 candle-
power, and in eleven hours by the electric incandescent lamp. It is
worthy of remark that very many observers have conclusively demon-
strated that not only is the nutritive basis of bacteria unfavorably
affected by light, but the protoplasm itself suffers a direct injury ; it is
in this way that street dust is in a great degree disinfected by its
exposure to the direct rays of the sun.
THE EFFECT OF LIGHT ON ANIMALS AND MAN.
It is a recognized fact that many animals can develop only in the
presence of light, and that its absence causes either a delay or a complete
suspension of development. But not only is the general growth affected
by varying the supply of light, but also the development of individual
organs and parts of organs. At Finsen's clinics patients and nurses
acquired a thicker growth of hair on those parts constantly exposed to
the powerful electric rays.
The stimulus given to change of form and the transformation of
energy through the agency of light is indeed remarkable. It is weD
known that the change of light causes change of form in the cutaneous
contracting pigment-cells of many amphibians, reptiles, and fishes.
That ciliary movement is regulated or modified by varying the color
of the light employed, is asserted by Uskoflf, who observed that the epi-
thelium of the cesophagus is equally swift in red and violet light, but is
suspended if red light is substituted for previously acting violet. De
Parville claims to have proved that the red end of the spectrum is nerve
irritating, and the opposite end nerve soothing. On the higher animals,
light produces marked effects on the cuticle. Those parts constantly
exposed to the light become coarser and harder, the protoplasm becoming
reduced to keratiue. Indeed Moeller l demonstrated that light produces
a hyperplasia and a horning process of the skin. Finsen and Moeller
proved by experiment that skin which has been exposed to powerful
chemical rays (blue, ultra-violet) retains for a long time (months and
years) a peculiar tendency to react quickly (by reddening) to mechanical,
thermal, and chemical stimuli.
We know that pigment is a protective to the skin against the action
of the light rays. Freund2 mentions the case of a dark-complexioned
man whose body and face showed the presence of many vitiligo patches,
who, after a long walk over the Grossglockner glacier, developed a vio-
lent erythema in the neighborhood of the white patches on the face,
but in these regions alone. The remainder of the skin was unaffected.
'Der Einfluss des Lichtes auf die Haut. Biblioth. med., Stuttgart, 1900, p. 18.
'"Elements of General Radiotherapy," p. 420.
PHOTOTHERAPY. 513
Finsen proved that acquired pigmentation may also have protective power
against the injurious action of light rays. He painted with black pig-
ment a ring around his arm. He next exposed the part to strong sun-
light for three hours. After a time the skin appeared normal save at
the edge of the painted belt, where some slight erythema was noted. A
few hours subsequently a violent erythematous eruption developed in the
exposed part, but the painted zone appeared unaltered. Again Finsen
exposed the unpainted part to the sunlight ; the result was the reverse,
— /. e.j the white zone was destined to suffer an erythematous change,
the remaining parts undergoing no alteration. Many observers have
since shown that mild erythema and light pigmentations are due to the
ultra-violet rays.
Blood absorbs light in a high degree, this being especially true of
haemoglobin. Oxyhsemoglobin gives a different absorption spectrum from
methiemoglobin. Quiucke 1 showed that haemoglobin gives off its oxygen
more quickly in the light than in the dark ; hence light augments the
oxidizing power of the blood and, correspondingly, the processes of
oxidation in the human economy.
Godnew2 found that persons and animals to whom daylight was
accessible excreted more urine, urea, and chlorides than those remaining
in the dark.
THERAPEUTIC ACTION OF LIGHT ; ITS USE AMONG THE ANCIENTS.
The therapeutic value of light and the appreciation of its virtues are
almost as old as civilization itself. Historical records show that light
was valued as a remedial agent centuries ago in China, Mexico, Japan,
the West India Islands, etc., the patients being subjected to sun-baths for
therapeutic purposes, and others placed in total darkness as a means of
punishment
The ancient Greeks, who lived in flat-roofed houses, were accustomed
to expose their entire bodies, after anointing them, to the sun, believing
that its powerful rays acted very beneficently in bringing about and main-
taining both health and beauty of the body. In the essays of Cicero and
Yestricius we learn that the Romans were accustomed to sun-baths, these
being frequently followed by cold sponges. Solaria, or out-buildings de-
voted to these baths, were quite common before the fall of the Roman
Empire. Herodotus recommended sun-baths for those who were feeble
and in debilitated health, and Antyllus also gave elaborate descriptions
of the effects of the sun's rays upon the human body. Not only was the
skin treated by " heliosis," but also such diseases as jaundice, nephritis,
sciatica, rheumatism, nervous and mental diseases. During the Middle
Ages this form of treatment was consigned to the limbo of oblivion. It
1 Pfliiger's Archiv, 1894, vol. Ivii. p. 134.
2 Zur. Lehre v. d. Einfluss d. Sonnenlichtes auf die Thiere. Kasanche Dissert., 1882.
514 ELECTRO-THERAPEUTICS.
was during the 19th century that the parasiticidal action of light engrossed
the attention of bacteriologists, and it is due to their labors that the
hidden secrets of light have been seized by eager experimentalists in the
hope of discovering a reliable therapeutic agent.
TREATMENT WITH SUNLIGHT.
Sunlight is the most natural source of light, but its use depends on
the weather, and upon other circumstances which affect the chemical
intensity as well as the optical brightness. Long ago it was indisputably
shown that the chemical intensity of light does not coincide with optical
brightness. The chemical light-intensity of the sun's rays varies with
the sun's height in the heavens. In the summer the chemical action of
the sun and the blue light of the sky is far greater than during the winter
season. The extent to which the air absorbs light varies with the amount
of vapor, carbonic acid, and suspended dust in the atmosphere.
The chemical intensity of sunshine increases proportionately with a
decrease in the atmospheric pressure. Thus, Timony found that the
ultra-violet end of the solar spectrum extended much further toward the
more strongly refrangible end at a height of 3500 meters than on the level
of a table-land.
Ordinary sunlight is used as a remedial agent in the form of baths.
The following is the modus operandi : Place the patient on a rug, ele-
vate the head, and protect him from the wind, in a veranda entirely open
to the south. Shield the eyes with dark glasses. The bath is best taken
during the warm season. The first bath occupies a duration of fifteen
minutes, which may be subsequently lengthened. During the bath the
position is changed at intervals so that different parts of the body may
be exposed to the light. Maintain these positions until violent perspira-
tion occurs on these parts. This is to be followed by the usual water
bath (70° to 80° F.). Have the patient massaged, and advise him to
exercise thereafter.
/
TREATMENT WITH THE INCANDESCENT LIGHT.
The incandescent electric light is poor in violet and blue rays, and
rich in yellow, red. and green. Its chemical action is, therefore, slight,
but this, as well as its brightness, may be materially increased by
strengthening the current. By this augmentation we not only affect the
optical brightness, but also its blue and violet rays. Of normal power,
380 incandescent lamps have the same chemical effect as natural light at
a distance of one metre. This form of treatment is of paramount value
where the longer- wave rays are to be applied.
The modern incandescent baths are made for connection with the
street electric wires. They consist of octagonal boxes supplied with panes
of mirrors, with a movable lid above, for the patient's neck. (Fig. 242.)
FIG. 2-12.— Cabinet for the treatment of diseases by the employment of incandescent lights.
(Kny-Scheerer Co. )
FIG. 24:i.— The Flnsen method of treatment.
PHOTOTHERAPY. 515
Forty to sixty lamps, of 16 candle-power each, line the inner walls, and
are so arranged that they can be put in, or withdrawn from within or
without, by means of several switches in series, along vertical, horizontal,
or spiral lines. The lamps are protected by a lattice work. A thermom-
eter for measuring the inside temperature is fixed on the wall. A win-
dow is sometimes made in the wall of the chamber, through which the
pulse and the course of the perspiration may be observed.
The patient is divested of his clothing and placed on a stool in the
cabinet. All external light is excluded by a towel placed around the
neck opening. An ice-cap is applied to the head. Begin the bath at a
temperature of 110° F., and, if the patient reacts, gradually raise it to
155° or 165° F. The bath should be of a half-hour's duration. Increase
the temperature by increasing the number of lamps, and also the
strength of the current. Observe the pulse carefully, and after the light-
bath employ the ordinary water bath or douche. The incandescent bath
acts beneficially by radiating heat. In this way heat can be made to
affect the deeper structures, and is more advantageous than the Turkish
or Russian baths, which at best only exert an influence on the surface of
the body. The most striking effect of this treatment is its action on the
secretion of sweat, probably due to stimulation of the peripheral nerve
endings, or by an elevation of the patient's temperature, or by a com-
bination of both these factors. The incandescent electric light is of
great value in muscular rheumatism, in the various forms of anaemia,
in arterio-sclerosis, in valvular heart disease, in neurasthenia, migraine,
tuberculosis, etc.
TREATMENT WITH THE CONCENTRATED ARC LIGHT.
Actinotherapy, or the treatment of disease by the application of
light, was inaugurated by Finsen. Triumphant over the intense resist-
ance that greeted his earlier efforts, the world to-day rings with his
praises.
Sunlight is undoubtedly the best source of light, but, as it is not
always available, it is necessary to have recourse to artificial illumina-
tion, especially to electric light. It is better to use the voltaic arc, for
the light given by incandescent lamps contains too few chemical rays.
Finsen' s method (Fig. 243) consists in concentrating actinic light,
through rock-crystal lenses, on any desired part, rendered as exsanguine
as possible by means of pressure, because the presence of blood acts as a
barrier to the passage of the chemical rays to the tissues.
When the voltaic arc is used, 60 to 80 amperes of current are
employed. The apparatus consists of the light, the cooling apparatus,
and the light-concentrating apparatus. From the source of light there
radiate four telescopes, for the four patients. The active rays are ob-
structed to a very slight degree by the lenses of rock crystal. The space
ELECTRO-THERAPEUTICS.
between the lenses is filled with water to moderate the temperature, and
a surrounding water-jacket still further accomplishes this purpose. As
the rays from this artificial light are divergent, the lenses are so arranged
as to make them converge. The rays are brought to a focus by a water-
cooled lens, held by the assistant, who presses the latter firmly on the part
to be treated.
The applications are of about one hour's duration, and repeated
daily. A few hours after treatment, erythema with some tenderness is
often manifested, but there is no actual pain.
The reaction varies in different cases, but it is always seen in lupus
vulgaris, perhaps never in lupus erythematosus. Following a few
applications, most remarkable iinproveTiicnt
frequently results. Twenty or twenty-five
applications should always be given ; after
which the skin will usually present a soft,
pliable, scarless condition, save where destruc-
tion of tissue is marked by the earlier ravages
of the disease.
THE DERMO OR IRON ELECTRODE LAMP.—
(Fig. 244.)
As the chemical composition of the mate-
rial composing the electrode defines the quan-
tity of the ultra-violet rays, experimenters
have been on the alert to turn this principle
to advantage. Although many electricians
battled with the problem only to find disap-
pointment the price of endeavor, it remained
for Bang, of the Finsen Institute of Copen-
hagen, to successfully construct a lamp with
metallic electrodes suitable for phototherapy.
By using iron electrodes,, and tempering their
heat by water-circulation, a lamp is produced
that yields a maximum of chemical rays with
a minimum production of heat. This lamp
is only adapted for the treatment of superficial skin diseases, as the rays
are not penetrative but diffusible in character.
THE COOPER-HEWITT MERCURY- VAPOR LAMP.
Worthy of mention is the Cooper-Hewitt lamp,1 described by
Maurice Leblanc, and which briefly is as follows :
The lamp in its simplest form consists of a glass tube about 70 cm.
*Le Radium, Paris, June, 1905.
FIG. 244.— The dermo or iron
electrode lump.
PHOTOTHERAPY. 517
long and about 3 cm. in diameter. One end, the upper, is enlarged into
a bulb, and contains a cup-shaped iron electrode which becomes the anode
of the device. A small amount of mercury at the lower end is the
cathode. In series with the lamp and connected at the anode end are a
resistance and an adjustable self-reductor.
The well-known greenish color of the light given by mercury vapor
when glowing under an electric discharge is spoken of by Leblauc. He
also mentions some experiments of de Eecklinghausen in mixing some
other gases, such as argon and helium, with the contents of the tube.
These were conducted with a view to correcting this serious defect, but as
yet have not been successful.
This lack of red is not entirely without advantage in some situa-
tions, however. The Hewitt light has been found admirable for its non-
excitable character, and it is also excellent for photographic purposes.
As glass absorbs ultra-violet rays, lamps have been made of quartz
for special use in phototherapy in the treatment of lupus.
Most normal lamps take from 3 to 5 amperes of current, and have an
efficiency of about 0.45 watt per candle-power. Several special forms of
bulbs have been devised.
THE FINSEN OR BED LIGHT TREATMENT OF SMALLPOX.
To Kiels Finsen (Fig. 245), more than any one else, the civilized
world owes a debt of gratitude for his untiring industry and indefatigable
research in bringing the subject of the therapeutic action of light to the
notice of the medical profession, and for having established his teachings
upon a rational basis. So profound an impression did he make upon the
minds of scientists that, in 1896, the government of Denmark founded a
public institution for the purpose of carrying out the principles of photo-
therapy, and especially for the treatment of lupus and other cutaneous
affections through the agency of concentrated chemical light.
From 1893 until almost the very day of his death, Fiusen had been
busily engrossed in the study and action of light treatment, but it is his
labor to prevent the pitting from variola by excluding all but the red
light that has won him deserved renown.
From his experiments at Copenhagen, he was able to prove that the
blue, indigo, violet, and ultra-violet rays of the solar spectrum are the
ones, and the only ones, that produce chemical effects upon animal
tissues.
As far back as the sixteenth century, it was empirically recognized
that the pitting from smallpox could be obviated by shading the doors
and windows of the room with curtains of red material. Indeed, the use
of this color fabric was first suggested by John of Gadesden in the four-
teenth century, of whom Gregory remarked, ""What think ye of a man,
a prince, of royal blood of England (John, the sou of Edward the
518 ELECTRO-THERAPEUTICS.
Second), being treated for smallpox by being put into a bed surrounded
with red hangings, covered with red blankets and a red counterpane,
gargling his throat with the wine of the mulberry, and sucking the red
juice of the pomegranates? Yet this be the boasted prescription of John
of Gadesden, who took credit of no meanness to himself for bringing his
royal patient safely through the disease."
Jn 1867 Black had published in the London "Lancet" an essay on
the peculiar influence of light in smallpox, asserting that the complete
exclusion of light, in spite of the fact that the patient had not been pre-
viously vaccinated, effectually prevented pitting of the face. In 1871
Waters published in the same journal a declaration that the severity
of a case of variola was markedly modified by the exclusion of ordinary
daylight.
In the same year, Barlow stated that he was able to distinguish a pro-
nounced contrast in the two sides of a patient's face, one half of which
had been covered with colored gelatin to exclude all actinic rays, while
the opposite half of the face was allowed to remain exposed to the
influence of these rays.
Finsen, a poor and obscure medical instructor in a little Danish
town, devoted his spare moments to experiments and observations upon
light, with a hope of preventing the ugly disfigurement of smallpox.
What he aimed to ascertain was the physiological effect of light on
animal and vegetable tissues. As the result of the experiments he soon
arrived at very important conclusions so far as the influence of light was
concerned in the eruptive diseases, and notably so in smallpox. By
simple reasoning he reached his first great discovery. He observed,
when earthworms were placed in an oblong box covered half with red
glass and half with blue glass, that they would invariably crawl away
from the blue light, seeking shelter under the red light. In the light cast
by the blue glass they were intensely active, restless, and ill at ease ; in
the red light they lay quiet, apparently perfectly contented.
With a chameleon he conducted a peculiar experiment. He placed
the little reptile in such a position that one half of its body was under
the light cast by blue glass and the other half in that cast by red. He
noted that the parts of the animal's body covered by blue light turned
almost black, while the half covered by the red light presented an
almost white color. From this he concluded that the creature had in its
integument movable pigment-cells which acted as a barrier against the
blue light.
Whilst in the midst of his experiments and researches Finsen wan-
dered one day into a medical library in Copenhagen, where an article of
Dr. Piteoe, published in 1832, attracted his attention. In this pamphlet
it was mentioned that during an epidemic of smallpox among soldiers,
those confined in dungeons suffered from the disease less severely, and
recoveries occurred without any attempt at suppuration and consequent
FIG. 245.— THE LATE PROFESSOR NIELS R. FINSEN.— (Born in Faroe Island, Iceland, December 15,
1860. Studied medicine at Copenhagen University and received his doctor's degree in 1890. Awarded
the Nobel Prize and the Cameron Prize for studies in practical therapeutics from the University oi
Edinburgh. Died September 24, 1905.)
PHOTOTHEKAPY. 519
scarring. Finsen grasped its meaning. "Red light contains no actinic
rays,7' lie reasoned ; " why not use red glass in the windows?" this being
physiologically the same as darkness. Thus, he suggested, the windows
of the wards or rooms in the hospitals inhabited by sufferers from
smallpox should have the white panes removed and replaced by dark-
ruby glass panes. Personally he had never seen a case of smallpox, but
he based his reasoning on theoretical grounds.
In 1893, the first trial of this therapeutic agent was made at Bergen,
in Norway, b}' Dr. Liudholm, chief physician of the military service,
and by Dr. Svendsen. Eight cases, four of them being of a severe type
in children who had never been vaccinated, were treated, the results being
a triumph for Dr. Finsen. Dr. Svendsen remarked, "The period of sup-
puration, the most dangerous and most painful stage of the disease, did
not appear ; there was no elevation of temperature and no osdema. The
patients entered the stage of convalescence immediately after the stage of
vaccination, which seemed a little prolonged. The hideous scars were
avoided."
Control tests showed that smallpox cases exposed to daylight after
beginning the red-light treatment invariably suffered suppuration and
scarring, only a trifle of daylight sufficing to do harm, the irritated
integument being almost as sensitive to the actinic rays as a photo-
graphic plate. A clear red light of such intensity as to permit the
patient to read in the room is sufficient in ordinary cases. If the case be
a very severe one, it is necessary to employ a red light of deeper or
darker appearance.
The treatment of smallpox by the exclusion of the chemical rays of
the sun has now been tried by a number of physicians, chiefly in Den-
mark, Sweden, and Norway. Practically all of these men have been
favorably impressed with the results.
Mygind (Denmark) treated 22 cases (variola 12, varioloid 10) ; one
died, the remainder upon leaving the hospital had hypenemic spots only.
Abel (Bergen, Xorway) had 23 cases, 8 of them very severe. One
case, admitted very late, terminated in recovery, but with suppuration.
In the others there was no suppuration and no scarring.
Back man (Fever Hospital at Koliikomaki) treated 62 serious cases,
with 7 deaths ; the remaining 55 recovered without scars.
Feilberg (Copenhagen) used the method in 11 cases. There was no
secondary fever and no pitting. Pigmented or hypersemic spots were
present.
Strangard (Denmark) had 4 cases ; all recovered with no pitting.
Benckert (Gothenberg, Sweden) treated 16 cases (5 were varioloid
and 11 were variola) ; 3 died ; one of the deaths was due to suppura-
tion. Benckert remarks, "Suppuration is usually abolished, scars are
extremely rare, and the duration of the disease is shorter."
Finsen, in summing up these cases, says that out of a total of 140 to
520 BLECTEO-THERAPBUTICB.
150 cases of smallpox, in one case only (that of Dr. Benckert) was the
method inefficacious.
The Conditions for Success by Finxcn'* M'tltod. — Two conditions are
absolutely indispensable to obtain good results :
1. The patient should be placed under treatment sufficiently early.
"When the patient comes under treatment early enough," Finsen
asserted, "before the fourth or fifth day of the disease, suppuration of
the vesicles, even in un vaccinated persons and in cases of coulluent
smallpox, will be avoided. Should the patient come under treatment
after the fifth day of the disease, it is uncertain whether suppuration can
be avoided. Sometimes this is the case, sometimes not."
2. "The chemical rays of daylight should be absolutely shut out.
The efficiency of the method is so certain that, in case suppuration should
occur in a patient who has been placed under the treatment in proper
time, the first thing to be thought of is that, from want of care either on
the part of the patient or of the nurse, daylight may have penetrated.
Therefore, before the method can justly be declared a failure, the
thoroughness with which it is carried out should be tested by exposing
photographic plates or sensitized paper as a means of control in different
places in the sick-room. If these photographic plates show the influence
of the white light, the technic of the treatment has been imperfect. A
few of those who have applied the method have at the same time treated
the patient by other remedies as well. Such a course is objectionable for
scientific purposes, as it is then impossible to decide which agency is
responsible for the results. In order to give the experiments decisive
scientific value, they should be carried out under strict control, and the
patient placed under the treatment in proper time."
BLUE LIGHT.
Before closing, I wish to allude to the therapeutic use of blue and
ultra-violet light. The subject is evidently still in its infancy, and much
may be expected from the successes that are said to have followed its
employment. Already there are many authorities who extol the efficacy
of the concentrated actinic rays in the treatment of chronic ulcers,
lupus, and other destructive cutaneous lesions.
Blue Light as an Anaesthetic. — Within recent years it has been found
feasible to employ the visible chemical frequencies of the spectrum, by
the use of screens of blue glass. This glass acts as a barrier to the pas-
sage of the frequencies of the ultra-violet portion of the spectrum, and
shields from the frequencies beyond the blue or the yellow, the green and
red frequencies.
Minin, of St. Petersburg,1 believes that the visible chemical frequen-
cies of the spectrum from the blue to the ultra-violet, by acting on the
1 Journal of Physical Therapeutics, January 15, 1902.
PHOTOTHERAPY. 521
vaso- motor nerves, are sedative and analgesic in nature. He asserts that
the most beneficial results are to be found when the source of light
is at a considerable distance from the area to be treated, thus refut-
ing the hypothesis that the action produced is dependent upon residual
thermal energy. Minhvs view now generally obtains, that by the agency
of isolated visible frequencies, constriction of the vessels and pronounced
anaesthesia result ; while white light effects directly opposite results.
Mr. II. Hilliard, anaesthetist at the London Hospital, has used blue
light as an anaesthetic ' after M. Redard's method.2 He says : "Following
M. Redard's plan, I have out of a total of thirty-two cases had twenty
absolutely successful results, eight failures, and four cases in which the
patients stated that they felt pain, and yet showed no sign of doing so
beyond 'screwing up' their eyes during the operation. Most of the
failures can, I think, be explained on the grounds that the patients were
highly nervous, that they had while waiting their turn been told by others
that some new experiment was being tried, and that they did not carry
out my directions and keep their eyes fixed upon the light. The
remainder may be explained, perhaps, by the fact that a different reflector
\v;is used, whereby the rays were not concentrated upon the patient's
eyes, but were more widely diffused.
"In addition to the evidence advanced by M. Redard against the
view that the influence of the light is hypnotic, I do not believe that so
large a percentage of ordinary persons are so easily hypnotized, and I
find that the results vary with the technic. I do not agree with M.
Redard in the opinion that a general anaesthetic effect is produced, for I
have found that, although sensation in the extremities is temporarily im-
paired, yet there is no real analgesia, this apparently only existing over
the area of distribution of the cranial nerves.
"In all the successful cases dilatation of the pupils was observed,
and in two or three, the eyes became fixed and the lids drooped, the pa-
tient developing a somnolent condition ; but in those instances in which
the patient moves his eyes constantly and blinks, the pupils will not
dilate, and no analgesic effect should be expected. "
1 British Medical Journal, July, 1905.
2 Lancet, May 12, 1905.
APPENDIX
TECHNIC OF RONTGEN BAY THERAPY
DURING the preparation of the present volume, I conceived the idea of address-
ing letters to some of the better known Rontgen therapists, asking that they supply
the data of their technic on the blank enclosed for that purpose.
I was gratified by the cordial responses that my communications elicited, and
interested in the widely divergent opinions, that have their adherents in this
country and abroad.
The statements offered, in several instances, were so comprehensive that space
was lacking to record the data. In those cases, an asterisk (*) has been placed,
referring the reader to a detailed explanation in the addendum.
The following abbreviations have been employed, which, like the tabulation
itself and the addendum, are arranged in alphabetical order.
COILS.
A-N . = Apps-Newton .
C.=Caldwell.
Fes.=Fessenden.
K. & K.=Kelley and Koett.
K.=Kinraide.
L.= Leeds.
L. & N.=Leeds and Northrup.
Q.=Queen.
R., G. & S.=Reiniger, Gebbert and Schall.
Ruhm.=Ruhmkorff.
R. \ __ Rontgen.
R. M'f'g. Co.] "Rontgen Manufacturing Co.
Sch.=Scheidel.
Sn.=Snook.
W. & B.=Waite and Bartlett.
Will.=Willyoung.
INTERRUPTERS.
D.=Davidson.
G:ii. Gaiffp.
K. Kinniidp.
R.=R6ntgen.
W.=Wehnelt.
STATIC MACHINES.
V. & T.=
Columb.=Columbia.
fVan Houten and
\ Ten Broeck.
Wag.=Wagner.
W. & B.=Waite and Bartlett.
VACUUM TUBES.
F.=Friedlander.
G. & B.=Green and Bauer.
G.=Gundelach.
M. & W.=Macalaster and Wiggin.
Mach.=Machlett.
Mon.=Monell.
M.=MUller.
Q.=Queen.
W. & B.=Waite and Bartlett.
APPENDIX. 523
ADDEXDOI TO THE SYNOPSES OX TECHXIC DsT ROXTGEX
KAY THERAPY
BAETJER, F. H. He uses 20 volts, ten amperes on two small coils ; 110 volts
direct current. He employs different makes of coils : Heinze 20-inch, Queen 9-inch,
and Biddle 9- and 18-inch, respectively. He uses a hammerless interrupter on each
9-inch coil ; the Wehnelt on the 18-inch. Vacuum tubes include : Queen, Heinze,
Swett and Lewis, Miiller, etc. He employs large (110 v.) and small (20 v.) coils ; and
believes that an erythema is necessary in all cases, except those of very superficial skin
lesions.
BARNUM, O. SHEPARD. Barnum uses his own penetrameter, and remarks that
his average length of treatment is entirely too variable to state. He protects the
healthy part by placing a shield around the tube and lead-foil on the patient.
BRENEMAN, PARK P. Breneman varies the frequencies of his irradiations, giving
treatments twice or thrice weekly and then again only three times every two weeks.
CALDWELL, E. W. Ten-inch coil of his own design, rotary mechanical break, 20
breaks per second ; " break " lasts ^ second and the " make " fa. Uses the alumin-
ium screen for deep parts. For lupus, low penetration and no screen. He writes :
" I use any old tube that is not good enough for radiographic work or that needs
seasoning for that purpose." He declares that the static machine, for X-ray work, is
useless.
DUNHAM, KENXON. He believes that a French tube is best ; he also employs the
Friedlander and the Gundelach. He has not found self-regulating tubes valuable,
unless personally regulated. He says that the distance of the anode from the patient's
skin varies, because he brings the glass to within one inch of the cutaneous surface.
His voltage (primary) is 40 to 90, with load ; 115, without load ; and he has the anode
red hot (usually), before treatment is finished. He regards the spintermeter and
penetrameter as inaccurate, so that he prefers a new method. He protects the parts
very carefully, but not close to the lesion. An erythema, he asserts, is necessary in
lupus, mycosis fungoides, epithelioma, etc. He often gives daily treatment ; at other
times only once in two weeks.
FRANKLIN, MILTON W. He estimates the degree of vacuum of the tube by both
the spintermeter and the penetrameter ; preferring Holzknecht's method of standard-
ization of the electroscope and the Franklin electroscope for general use. It is his
practice to cover everything with lead except the lesion. The best indication to
cease the treatment is the presence of any inflammatory sign on the healthy skin ; his
only other rule is, when excessive sloughing occurs on an open lesion.
FREUND, LEOPOLD. For superficial lesions, a soft tube (Wehnelt-ekiameter),
5-12 cm. ; for subcutaneous and deep-seated lesions, a hard tube (Wehnelt-skiameter),
10-15 cm. In treating the more deeply seated affections, Freund is guided by the
green-blue light of the tube ; in superficial affections, by a deep yellow fluorescence.
He emphasizes the question of individuality, idiosyncrasy, etc., and advocates repeated
small doses until slight reaction — i.e.., swelling, redness, pigmentation, etc. — ensues.
He protects the patient with lead-foil or mercurial plaster and urges the operator to
seek his own protection in a lead apron, spectacles, etc. He believes that treatment
should temporarily cease when inflammatory signs, with pigmentation, epilation, and
subjective symptoms are evidenced. He formerly condemned the employment of
Liquor Burowii as being an irritant in acute cases,1 but recently he advocates the
treatment, which I have appended, in his technic.
GIBSON, J. D. Gibson brings the anode close to the affected area in cutaneous
lesions, and as distant as 18 inches for deep-seated influence. Amperage for deep
penetration, 5 to 10, superficial, 1 to 2. For pulmonary cases, he employs a quantity
of rays equivalent to that required to take a skiagraph in from 30 to 60 seconds. He
1 Elements of General Radiotherapy, by Leopold Freund, translated by G. H. Lancashire, 1904,
p. 348.
524 APPENDIX.
measures dosage by the fluoroscope and spark-gap. He ceases treatment at the
appearance of an erythema or an elevation of temperature. He approves of the
production of an erythema in malignant and superficial affections.
GIRDWOOD, G. P. Current of 220 volts from the street ; in the hospital 110 v.
For hospital use a 12-inch Biddle coil and a 10-inch Leslie Miller. In the office a 6-
inch (Chadwick) mercury dip and a 12-inch Apps coil. He varies his interrupter
according to his coil and tube, from 300 mechanical to 3000 electrolytic. He em-
ploys a voltage of 220 cut down by the rheostat to 200. He is guided in his dosage
by a greenish-yellow fluorescence of the tube.
GRUBBE, EMIL H. A subdued fluorescence of the luminous hemisphere of the
tube is his guide ; the vacuum is estimated by the resistance of the tube, as compared
with air resistance between the prime conductors of the generator. He protects the
healthy parts by means of Grubbe's X-ray foil. He believes that an erythema is
necessary in the treatment of all superficial lesions.
HALL-EDWARDS, J. He uses German and French makes of vacuum tubes, and
finds the non-regulating best for radiography, the self-regulating for treatment. He
uses all tubes, no matter what the vacuum, at from 4 to 12 inches. He employs
the radiochromometer, radiometer, etc., for experimentation only. He protects the
healthy parts by plaster of Paris masks and a bandage covered with lead-foil.
He writes me that in all his varied experience — Officer in Charge of the X-ray
Department of the Birmingham General Hospital and late of the Imperial Yeomanry
Hospitals in South Africa — he has found nothing to relieve the painful, chronic
dermatitis, from which he is a sufferer.
HETHERINGTON, J. P. He uses his own water-cooled interrupter or the Kin-
raide, the number of interruptions in either being about equal to the Wehnelt. He
uses a variety of vacuum tubes, among which may be mentioned : The Queen, Volt-
Ohm, Friedlander, Wagner, Swett and Lewis, Miiller, etc. He tells me that he pre-
fers the non-regulating and the self-regulating, to the osmo-regulating, variety. For
cutaneous lesions, he brings the anode as close as possible to the part, unless the
affected area is very large ; in deep-seated conditions, as low a vacuum as will pene-
trate to the desired depth. He only uses lead to protect special parts, such as the
hair ; and discontinues treatment at a commencing erythema, or disappearance of the
lesion. He believes an erythema is necessary to obtain rapid results, or to remove
hair. It is his aim to produce erythema in nearly every case.
HOLDING, A. The indication to discontinue treatment is a "slight erythema."
He says that " a slight erythema may at times be necessary in superficial skin lesions,
but even then it is to be avoided if possible." He believes that prevention is better
than all the cures for X-ray dermatitis.
KIENBOCK, ROBERT. He approves of the Benoist-Walter radiochromometer,
average penetration 4 to 6, mostly 5. He uses his quantimeter in conjunction with
Sabouraud-Noir6 radiometer for dosage, and for comparison by artificial illumination
he takes advantage of Scheiner's benzine lamp. He believes that a complete treat-
ment by massive doses, once or twice monthly, is the most effective method. He is
much opposed to frequently repeated irradiations.
LAQUERRIERE, ALBERT. The milliamperage in the secondary is measured by
Gaiffe's milliamperemeter, the length of the spark by the spintermeter. The pene-
tration is determined by the radiochromometer of Benoist, and the dosage by the
radiometer of Sabouraud and Noire". The occurrence of erythema causes him no
fear, indeed he often looks for a certain determinate degree of it ; he believes that
its likelihood can never be rigorously excluded, as idiosyncrasy plays so largely the
role. He asserts that an erythema is beneficial in certain rebellious cases of lupus
and in some of the epithehomata. The various kinds of apparatus devised by Gaiffe
are much in vogue in France.
LEONARD, CHAS. L. Leonard uses, as protective measures, a lead-covered box,
a lead-glass shield, and an aluminium screen. He believes an erythema necessary when
the disease will not yield without.
MORTON, REGINALD. He advises the employment of the Apps-Newton coil.
He finds that the best results in his work are accomplished by two ten-inch coils and
one eighteen- inch. He estimates his dosage by the apple-rgreen color of the tube,
APPENDIX. 525
with the anode dull-red. At the appearance of slight dermatitis he discontinues treat-
ment. Nevertheless, he believes that the more severe the lesion, the more necessary
it i.s to bring about definite but not severe reaction. Dr. Morton informs me that
the London Hospital, to which he is the radiologist, treats the superficial cutaneous
lesions, including rodent ulcer, in the department of dermatology ; cases of malignant
and constitutional disease are cared for in the electrical department under his super-
vision.
MORTON*, WM. J. His guide in dosage is the fluorescence of the tube only. He
doubts if an erythema is ever really necessary ; asserting that in three weeks' time
a mild erythema usually develops, followed by tanning. He employs only high-
vacuum tubes, preferably old and " hardened "; these giving "a 'therapeutic' X-
ray, in contradistinction to the quality of the X-ray best adapted to making a good
skiagraph." He believes that his method is much safer as regards X-ray burns.
NEWCOMET, WM. S. He estimates the degree of vacuum by the appearance of
the tube and spark-gap. He believes the time to discontinue treatment is when
the treatment is no longer needed, and that an erythema is not necessary. He
remarks that the occurrence of erythema is not necessary — it is accidental.
PANCOAST, HENRY K. Pancoast uses the mechanical spring interrupter for
therapeusis ; the Wehnelt interrupter for radiographic work ; the Queen and Gunde-
lach tubes for superficial treatment ; the Queen, Macalaster and Wiggin tubes for deeper
work. With the mechanical spring interrupter and a 24-inch coil, his amperage is 2
to 3 ; on 18-inch coils it is usually more. He estimates the vacuum of tne tube by
equivalent spark length when the tube is known to be reliable and constant ; other-
wise he resorts to the Benoist scale in addition. He tells me that his average length
of treatment is a very variable quantity: for the average case of epithelioma, 10 to
15 minutes three to five times per week. He protects the healthy parts by the
diaphragm of the tube shield, lead-foil or wet leather. He remarks that treatment
should be discontinued when it is certain that the condition has been cured, and that the
production of an erythema is a poor and misleading guide. As a prophylactic measure
against X-ray dermatitis alcohol with talcum powder or stearate of zinc is recom-
mended. The above will also answer for burns of the first degree, or an evaporating
lotion of lead water and laudanum may be used for a slight dermatitis. For burns of
the second degree : dry powder ; lead water and laudanum ; zinc oxide ointment ;
or picric acid solution 1-1000. For burns of the third degree : zinc ointment, or
picric acid solution. For pain: lead water and laudanum or orthoform. For burns
of the fourth degree : the same ; to be treated more as a surgical condition. Chronic
ulceration of the patient, Pancoast regards as a surgical condition. In some cases
picric acid has been satisfactory. If healing is obstinate, excise, allow the ulcer to
heal, or skin graft, or suture the edges together.
PFAHLER, G. E. He employs a 7-inch Leeds coil and a number of coils of the
Rontgen Manufacturing Co. — 9-, 15-. 18-, and 20-inch. The vacuum tubes that he pre-
fers include': Heinze and Bauer, Green and Bauer, Miiller, Friedlander, Machlett,
Macalaster and Wiggin. He is of the opinion that a dermatitis or toxaemia is a danger
signal for the operator, and that it is seldom necessary to produce an erythema
except when irradiating superficial lesions.
PRICE, WESTON A. He uses a large number of coils, interrupters, and tubes,
but fails to give their make or names. The distance of the anode from the patient's
skin varies ; usually it is from 6 to 10 inches. He states that his vacuum tubes also
vary very much in superficial, subcutaneous, and deep-seated conditions. " For my
dental work," he writes, " I use very high amperage and very high penetration,
modifying these with different conditions."
RuDis-JicmsKY, J. With the static machine, 200 to 300 revolutions per
minute for therapy, 500 for skiagraphy. Length of spark-gap, 18 inches (maximum).
In therapy he also employs a 12-inch coil with two layers of primary connection in
series ; interruptions, 10 per second ; primary current, 2£ amperes ; direct current,
110 volte. For superficial lesions he is guided by a yellow-green fluorescence of
the tube ; for deep affections, by what he terms "a perfect green." He varies his
len<tth of treatment " according to each individual case, the condition of the patient,
and the condition of the tube." He informs me that in his belief all " deep cases
should undergo a " tanning, " and that the production of an erythema is only justifi-
able in a few obstinate diseases.
526 APPENDIX.
SCHAMBERG, J. F. He uses Queen, Muller and Gundelach (regulating) tubes.
One-fifth to two-fifths milliampere with medium high tubes ; three-fifths to one and
three-fifths milliamperes for low tubes. For accurate dosage Schamberg depends upon
Benoist's radiochromometer ; regarding No. 3 as fairly exact for superficial lesions,
and from 6 to 8 for the deeper varieties. The average length of treatment in cuta-
neous affections is 5 to 6 minutes twice or thrice weekly. He asserts that erythema,
especially if it occur early following vigorous treatment, is an indication that the
irradiations should be discontinued. It is his belief that in ordinary cutaneous
affections, such as acne, an erythema is not a sine qua non, but that its production
acts as a remedial measure.
SCOTT, J. N. Scott says : "I try to use the same tube on the same patient.
Upon beginning treatment, I record the length of treatment, amperage, number of
interruptions, spark-length that the tube will 'back up,' etc. I gradually lengthen
the treatment until an erythema is evidenced, basing future treatments on the
above data." He irradiates epithelioma every day, and deeper growths every second
or third day. He protects the patient by a metallic box which has adjustable
openings for the passage of the rays. He believes that an erythema is necessary in
every case, except when the eye is involved.
SHOBER, JOHN B. He judges of the dosage by a whitish-yellow to a light green
fluorescence of the tube ; the anode normal to cherry-red. He estimates the degree
of vacuum by the spark-gap on the coil and tube, the amperage in the primary
current, the degree of the fluorescence in the fluoroscope, etc. He discontinues treat-
ment if the case is getting worse, instead of better (" toxaemia "). He says : " Of late
I prefer to use Curie 300,000 radium bromide, 20 milligrammes in two aluminium
capsules, 2 to 3 times weekly, from 1 to 3 or 4 hours ; valuable in furunculosis, boils,
carbuncles, moles, warts, nsevi, epithelioma, sarcoma, etc."
SMITH, J. F. Dosage is determined by a light to dark green fluorescence of the
tube ; " the heavy anodes," he asserts, "do not get red hot." He believes that the
best time to discontinue treatment is at the appearance of any erythema, taking into
consideration the duration and number of the exposures.
STEWART, THOS. J. For superficial conditions he uses a Queen tube or one that
can be kept low. In his work he employs the Gundelach, Queen, and Muller tubes ;
using the first and last for therapy. He believes that the maximum quantity of
rays is emanating from the tube when the anode is of a dull red color. He thinks
it necessary to produce an erythema to determine the maximum individual dose.
STOVER, G. H. Stover uses a great variety of coils, interrupters, and tubes.
Among the coils may be mentioned : Heinze 12-inch, Scheidel 12-inch, Meyer 6-inch,
etc. The vacuum tubes include Green and Bauer, Macalaster and Wiggin, Swett ami
Lewis, Muller, etc. In estimating the vacuum of the tube he takes into consideration
the primary current, the appearance of the tube, and the spintermeter-gap. He gives
ten minutes' treatment to cutaneous diseases and from 10 to 15 minutes' for sub-
cutaneous and deeper affections. He believes that the best time to discontinue treat-
ment is at the approach of cure or transient or definite erythema. He asserts that in
lupus vulgaris and cutaneous epithelioma, the production of an erythema is necessary.
WALSH, DAVID. Walsh writes me that of late he has not followed up the thera-
peutic aspect of the X-rays, beyond treating a few cases of ringworm, recurrent
carcinoma, and rodent ulcer. He remarks that his publications contain much of his
technic.
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30
81
92
90
75
Girdwood G P
\^ .......
300
50 to 100
18
U
i
•
Grubbe K H
Chicago 111
16
Hall-Edwards John
Hetherington, J. P
Logansport, Ind...
Albany N Y. .. .
Wag
4
1200
30
75
U
3,
Holding A
Kienbock Robert
Vienna
Ebonite
10
800-1200
22
55
Paris
Leonard ('has. L
Philadelphia, Pa..
Troy, X. Y
Marsh, Jas P
Morton, R
Morton Win J
New York, N. Y...
Philadelphia, Pa..
Philadelphia, Pa..
Philadelphia, Pa..
Cleveland, O
V. A:T
15
6
300-600
H
IB
80
65
u
12
a
3
Pancoast, H. K
Pfahler, G. E
Price, Weston A
Rudis-Jiclnsky, J
Cedar Rapids, la. .
Philadelphia, Pa..
V.&T
10
•.(•0-31M*
32
M
18
Schamberg, J. F
.1. X
Kansas City, Mo. .
Philadelphia, Pa..
Chicago, 111
shuU-r, John B
Smith, J. F
Stewart, Thos. J
Philadelphia, Pa..
.•r. Col
(!. H
David
London
TGEN THERPAY.
RATUS.
B. SOURCE OF CURRENT
1. Accumulator, Capacity
2. Hirect Current
3. Alternating Current
4. Transformer
C. COIL
D. INTERRUPTER
E. CROOKES VACUUM-TUBE
Variety
or Make
Length
• .f Spark-Gap
(Parallel)
1. Mechanical \i. Mercury 1. Non-regulating
:i. Wehnelt 4. Caldwell 2. Self-regulating
5. Simon 3. Osmo-regulating
IncheH
Cm.
'
(2) 110 volts H. Q. B
Western
12, 16, 18
15
10
IS, 12
8,12
10
10
12
30, 40, 45
38
25
45,30
20,30
25
25
31
1,*3,*(6) variable
2,3, (6) 120 to 1200
2,*3, G., Q., H. M
2, (4) M., F
(2) 110 volts Q
1.2
1, 2, (4) Q., M., G
G., M.*
(2 ) 110 volts C
1* (6) 1200
(3) 115 volts Sch., K. «fc K. .
My own, (6) variable
3,4
3
1, 2, (4) F., G.*
Will., W. & B.
' 2, (4) G.,G. &B
2,3, (4)G.,M
2 (4) M . .
(2) 110 volts
(2) 220 volts K., W. & B. . . .
1, K.,3,4
1, 2, 3, 4, (6) 300-3000*
123 (6) l^O to 3000
'1234*
(Q 1 * Vary*...
(1) 14 v 30a-h (2) 110
40,20
12, 15*
18,12,12
8,12
12
16
10
4, "
ta
10, 18 *
18-20
18,20,12
18, 24
9,18
16
20, 12, 8
20,12
20,18
9
12,14,22
12, 18
90,50
30,4^
45,30,30
20, 30
30
40
25
10, 17%
30
25,45
45-53
45,51,30
45,61
23,45
40
50,30,20
50,30
50,45
23
30,35,55
30,45
9 a
(3) £».
(9) 2°0 volts Coxe home-
1, 2, 3, (6) D., Gai 1 94*
made.
(1) 10 cells 21 volts. Q.,Sch., K....
(3) 100 volts.
(2) 110, (4) valve, k.k. . W. & B., K. &
K..
(2) 100 volts
K. and my own
(1) some, (2) prefer, 3, 4.*
2, (4) W.&B
3
3,4, W
123
(2) 110 volts R., G. & S
(2) 110 v • (4 ) Gaiffe . Gaiflfe
2 3 14 t&\ M
(2) Gaiffe
2 3
(1) lO-'JO volts L. <fc N
(2) 110 volts . . Q
1
(21 O M (31 G
(1) Queen
2 (4) Q M F
(°) 70 volts A-N
1, (6) 600-2000
23
(2) 80 volts Will
1, 2, 3, my own, (6) 3000-
40,000.
1,3
1, 3*
3 (4) M G
< L.,Sn., Q
R.Mfg.Co....
(1)16 volts; (2) 110 v. L.,R.Mfg.Co.*
(2 ) 110 volts
|l, 2,Q., M..F..G
(4) Q G M & W .
1 3
1 4* ...
1, 2, 3, 4 1 2
Sch., Ruhm. . .
1 3 9 lt\ d M Mmi .
(2) 110 volts Q
1 3
4*
(2) 110 volts Sch., Fes
(1) 'JO volts R
1, 3, (6) 800
123/4\ many . .
1
2, (4) Q
(2) 110 v • (4) Rotary' Sch
23...
2, (4)F., G.,M. <feW
2 (41 Q G M *
Mercury.
(2) 110 volts ." Q., L
1 3 (6) 600 ....
234
9 a t*\ *...
(2) 200 volts A-N
12
30
2,D Bi-anodal
TECHNIC OF RONT
:
~-
}
1
1
4
1
6
7
-
1
10
u
:-•
U
1!
U
H
i:
U
U
IB
B
B
•
M
•
•
-•:
-'•
1
.:!
I. V.M 11 M Tri:i: KMI-I
II. DISTANCE or ANODE FROM PATIKNT s Skis
III. Et|VIVAI.EN
Superficial
Sub-
cutaneous
De«p-
-...!• •!
Soft or Low
Vacuum
Medium
Hani or High
Vacuum
Superficial
Sub
Inches
Cm.
Inches
Cm.
Inches
Cm.
Inches
Cm.
Inch
Soft
Low ....
Low ....
Low ....
Very Nil
Very soft
Medium
Medium
Medium
Medium
Medium
Soft
Hard ...
High....
High....
High....
Hard ...
Medium
or hard.
8
5-9
6-12
5
*
•—
2-5
*
20
13-23
15-30
12%
6
8-12
9-15
12
6-8
6-8
15
20-30
23-38
30
15-20
15-20
5
12-30
1-2-20
20
15-20
12-15
4-6
*
12%
30-75
30-50
50
B8-4M
30-38
10-15
IK
2-3
3-6
1
4
5-7^
7H-15
2K
._>_01
:v-4i
6-S
13-20
5-12
4-8
1X-2
2-3
10-20
3-5
5-7%
•J-:;-
Medium
*
Low ....
Medium
soft.
*
Low —
Medium
High....
Hard
2-5
*
5-12%
4-7
*
10-17%
M
*
15-20
1-3
3-5
iM*a
i
2%-7%
754-13
3K-6
2%
4-C
2-1
*
Medium
*
High....
*
S-6
*
7%-15
6-10
15-25
6-20
15-50
8
11-21
M
3
4
7-12
1
*-l
Of
K-i
M
20
3-6
H
7%
10
17%-30
2%
l*-2%
3%
H-2X
7%-10
6
2-8
3
4
*
15
5-20
7%
10
10-12
8-20
10
8
*
25-30
20-50
25
B
IK
6
7-1
1-1'
•t
IV
i--"
8
5
6
*
20
13
15
Low ....
Medium
Medium
High....
Hard ...
Soft
G..Q...
Soft....
*
Low ...
Medium
low.
Soft....
Low ....
Low —
Q-*
Soft to
Bottom
High....
Same ...
Medium
*
Medium
Medium
high.
Medium
Medium
M.-.limn
Medium
•oft.
Medium
High....
Q.M.&W.
Hard. . . .
*
High.old
4-10
7-9
6
10-25
18-23
15
4-10
8-12
10
10-25
20-30
-'.-.
10-20
12-18
ia-15
25-50
30-46
8048
5-7
10
10-12
8-10
8-10
10-15
13-17%
25
j:,-::n
20-25
15-25
• n
12-15
u
12-18
10-14
10-15
15-30
30-38
45
30-45
j.v:;:,
s04e
38-75
Hard ...
High....
Medium
high.
Medium
Medium
to high.
8
6-10
M
M
3-8
20
15-25
15-20
15-20
7%-»
1
>*-l
2%
1^-2%
*•»
lM-2«
1-.
THERAPY— Continued.
NIC. — Dosage.
M.K LENGTH OF I V. < TRUEST
PI.HYF1I
.i.'|.>iu.i.i|iililS
V. PENETRATION
VI. CHEMICO-
I'HYSIi'AL
VII. PHOTOMETRIC COMPARI-
feme
Cm.
Deep-scat. •<!
Primary
Coil
Secondary
Coil
1. liailinrliriiiiiniiirti-r
1 Iti'llnist)
2. Pcwtnimctcr
(Walt.. .
r °JJ
f "3
5 -i -^ i .^ = :5
>- — •= -/. — - —
C« 3"
1. Kiuli.i-Activitv
-'. Artificial Ucbl
::. S'lcniuni crll
(Uiihincr Levy)
1. I'liii/alioii
1 i.u.klin)
luorescenco nf
T.ll.r
'i'-e of
A node
lermomrtcr
(Kohl.-r)
Inches
Cm.
Volt
AIIIJP.
Millianip.
&"< •< H
— ' Tl CO
',-11
fc-20
4-6
8-12
5
10-15
11-14
20-30
5
1 . YPS
110
110
110
*
115
110
220
220*
1^-24
2
•2
1
1,2 (red)
3-6
2-12
5-8
3-6
1-2*
5-10
1
2
(1) 3 to 8
10-20
6-8 +
i-s
3-6
15-20+
10-20
7^-15
15-60
4-10
1 2
1 2
4
*
3* ....
1*
*
2*
1*
10-15
5-10
5 +
8-14
3-5
4-6
12^4-
20-35
7^-13
10-15
3-15
1-5
*
60
21
80-120
5-15
2^-5
4-8
(1) About 7
9
(1) partly,
(2) red hot.
1, (2) on some
tubes.
0.5-2.0
(2) 4-6
1
2
12
2-J
2^-5
8
6-8
7-12
4
2-4
3
1-10
5-6
30
5-10
20
15-20
10
5-10
2^-25
13-18
70
3
0.2-0.6
Gaiffe*
1-6
1*
2* 4*
2*
19
4-7
15
.13
5
5
94-10
b-13
Yes
Yes
1
2
20
4-10
70
2-8
1
Yes
1. 2* ...
.. 1 ..
110
110
2-3*
2-5
*
1
(1) 3 superficial
6 deep.
110
110
110
20
no
110
5
8-8
2-4
2
5
3-6
19 . : . . .
*
i *
1*...
-V-
2-4
5-10
.. 1. 2* ...
1* ..
**
2-1
5-10
Yes
*•
1. 2*
di l-i orCB..
.1,2, partly...
TECHNIC OF RONTGE1
3. PRACTICAL
T
:
3
I
I
s
\
1
••••
;
B
6
-
g
u
u
a
u
u
u
!•
B
U
IS
no
B
a
•
a
•
8
a
a
a
::l
DOSAGE AND CI.ISICAI, A-
1. Do you vary the
length of treat-
iiit-nt '.'
1!. What i" your aver-
age length of treat-
ment ? How often
j«er week ?
3. Do YOU protect
healthy part,
and h»w?
4. What is the I't-st in-
dication tiMlisron-
tillllr trratlllrllt ?
Is it a iiiilil i-r\-
tlii-ma?
.">. AVhrii iln V.MI IK
lieve an rrytlu
ma i- •
Yes
5 minutes; thrice
Varies; daily to 3
weeklv.
«
Lead-foil
Yes *
Yes
Mild ervthema
*
Maliirnancv
VOB
Yes
Yes shield
Krytlu-ma generally . .
Yes
Tanning sometimes. . .
Superficial <
Lupus
Voa
10;1 to3
Tin-foil
*
When indicated
Yes *
Lead *
* Yes....
Vcrv rarelv
Yes *
*
*
V«B
1% minutes ; thrice . . .
5-10; daily to monthly
10 minutes; daily
5 minutes; thrice
3-5 minutes ; 1-3 days.
Yes, for eye and hair .
* VITV mild
*
Y> -
Lupus *
Yes*
Yes*
Lead
*
Yes
Slight dermatitis
\l\vftvs
Yes
* Prefer
Usually*
YP«
Lead
* Yes .
10 minutes ; twice
Varies
Lead-foil
Lead *
Yes
Usually
Yes
Yes
*
*
Yes
Lead
? Yes
*
Yes
10 minutes ; thrice —
15 minutes ; 2-3 times
20 minutes ; thrice —
10 minutes ; 1-7 times .
Varies * ...
Tin-foil
Hy perse mi a some-
times.
Yes *
Skin k-sions
Yes
No
No
Lead
Recovery *
g $
*
*
Yes
Yes
Yes*
* *
Yes
10-30 minutes; 1-6
times.
10-15 minutes ; thrice.
5 minutes; '2-3 times. .
9 minutes*
Lead
Yes * *
Yes*
Tin-foil
Y|.» *
Yes
Lead-foil
Yes*.. . .
Yea*
*
*
Yes
Yes
!.*> minutes ; 3-6 times.
Usually
Yes
Lead
Yes
Id mi link's; tliricc ...
10-15 minutes ; thriee.
Lead and glass shield
Ix-uci
*
Yes*
•
*
THERAPY— Continued.
PLICATION.
i N RAY DERMATITIS
What i< your treatment for the acute and chronic forms of the above?
In the acute form, a non-irritating unguent, as lanolin, prevents incrustation and is strongly recommended.
For deep, sloughing burns, clear up, and stimulate with the galvanic current. If rebellious to treatment,
excise- nnd skin graft.
This depends entirely on the severity of the dermatitis and the idiosyncrasy of the patient.
Discontinue treatment.
Dry heat. Simple ointments, sparingly. Salicylic collodion for scales; for ulcers, argyrol (20 to 30 per cent,
solution); cover latter with silver-leaf.
I have none, nor do I know of any.
Lime-water, lanolin, lard, equal proportions (Dr. C. \V. Allen's formula).
Avoidance of the X-ray atmosphere. For acute cases, Liquor Burowii and 15 per cent, boracic lanolin —
Buspenatom*
Never had any case of dermatitis to treat. Have nothing specially adapted to recommend.
Varies. If superficial and painful. I use liq. plumb, subacetat. dil.; much pain, lanolin with a trace of
cocaine and surrounded by an oleaginous material on lint, the whole protected by absorbent cotton.
Acute : Cease treatment ; allay itching with a saturated solution of sodium bicarbonate. Chronic: Cleanse
with a saturated solution of 'potassium permanganate and apply plain sterile vaseline on sterile gauze.
For the acute form, a lead lotion. Have found nothing satisfactory for the chronic form.*
Castor oil and Basham mixture.
Acute: Lanolin and picric acid. Chronic: Excision and skin grafting for ulceration. Lanolin in cases of
parched condition, lor circulation and cutaneous nutrition. High-frequency currents, for stimulation of
the circulation, locally.
For the acute form, protection from air and mechanical injury.
The usual methods in vogue.
The lesion should be unexposed and be kept away from the rays. The application of a thick ointment of the
i ixii It- of zinc. The effluve from a high-frequency machine.
Stearate of /inc. with ichthyol 10 per cent., to prevent and allay dermatitis and itching. For chronic cases,
sterile gauze and normal salt solution with orthoform for pain.
Paint the part with an aqueous solution of resorcin (25 per cent.), once daily. For itching, immerse in hot
water, the hotter the better. In the chronic form, removal of the patient irom X-ray influence for a year
or eighteen months.
Cessation of irradiation. Lead lotion.
Lanolin.
Meet the symptoms as they arise, the same as you would in any other condition.
The treatment recommended is a lengthy one, and is described fully in the addendum (vide).
Discontinue X-ray therapy. Treat as any other burn. Avoid all irritating applications.
Olive oil. listerine. and bismuth subnitrate. equal parts of each.
Pain has been relieved, in a few instances, by an ointment composed of ten grains each of orthoform, resorcin,
and calomel, in one ounce of cold cream.
No active treatment is recommended. Avoid the X-ray atmosphere. The operator is advised to remain in
a room thirty feet from the tube, and to place himself behind an iron screen one-fourth of an inch in
tblcknev.
Had no occasion to employ any.*
Simple dry, or absorbent, aseptic dressings. Zinc oxide ointment.
Avoid active treatment. Zinc oxide to allay the itching.
Acute : Removal from the exciting cause ; soothing and antiphlogistic drugs and preparations. Chronic :
Avoid the rays, developing fluids, and cold water: apply hot water, bland unguents, and mild high-
frequency currents. For deep Koiitgen ulcers apply caroid to slough and treat as local gangrene.
ROXTGEN RAY TREATMENT CHART No.
Name
Address, or
190
Dept. and Ward
Historj
Ag>-
Sex
Part affected, Extent,
Duration. rl<-.
Macroscopic.
1
Microscopic
Diagnosis
Previous Treatment
I
_
1!
.=
I
!'
-~ '-
i 3
\ ;
•s -s §•
: ja = CJ
! til
: -, « 5.
. w a:
8 3 S
3 i ^
•S < 5
3 -3 I
Months
1
Minutes
Methods Used in
Measuring Dose, i.e.
Quality and Quantity
of Ray
Remarks and Results
3 Inch
Cm. Inch
Cm.
Totals.
Reduced from the size of original clinical chart.
INDEX
In order to facilitate reference, the various diseases and their treat-
ments are grouped under four headings, — X-rays in the treatment
of, radium treatment of, high-frequency currents in, and electricity in
diseases of. Thus, in studying the action of the Rontgen rays on acne,
the reader will refer to X-rays in the treatment of acne. The very
arbitrary and artificial division of the headings electricity (faradism,
galvanism, static current, etc.) and high-frequency currents is simply
an index convenience.
Abbe, his statistics on renal skia-
graphy 353
on radium strength and radium
therapy 507
Abrams, on the causes of restriction
of the diaphragmatic wave 310
Accelerator, for photography 223
Accessories to the static machine. . . 52
Accumulators 41
Action of light on plants 511
of the X-rays on bacteria. . 389-394
Acute X-ray dermatitis 400
Adamson, on the X-ray treatment of
ringworm 450
Advantages of fluoroscopy 213
of print in skiagraphy 231
of stereo-skiagraphy 251
of X-rays in the differential di-
agnosis of complicated
fractures 257
in the treatment of tra-
choma 487
Albers-Schonberg, on the consump-
tion of tubes 198
on the four degrees in vac-
uum tubes 195
on the likelihood of X-ray
dermatitis 402
on sterility caused by the
X-rays 412
Alternating current 45
Ampere 37
Ampere-hour, definition of 42
Analgesic action of the X-rays 493
Anatomy, value of the X-rays in, 252-255
Aneurisms, aortic, their diagnosis and
differential diagnosis skiagraphic-
ally 333-335
Apostoli and Oudin, on the treatment
of X-ray dermatitis 411
Apparatus and method of X-ray
therapy 420-427
used in dental skiagraphy 370
Arm bath 79
Arneth, on the blood-changes induced
in leuksemia by the X-rays 486
Ascending current 67
Ausset and Bedart, on the X-rays in
tuberculous peritonitis 480
Author's cases of cerebral skiagraphy . 281
of incipient pulmonary tu-
berculosis diagnosed by
the X-rays 317,318
of mammary carcinoma
treated by the X-rays 465-467
examining box 236
head rest for cerebral skiagraphy 278
method of irradiating cases of
trachoma 487
cases of uterine cancer. 470
of skiagraphing rectal imper-
foration 345
of treatment of chronic X-
ray dermatitis 409
report on irradiation of cases of
epilepsy 495, 496
527
.VJS
INDKX.
Author's table for skiagraphy, stereo-
skiagraphy, and X-ray treat-
ment 200,248
tank 228
tube-holder 201
views in regard to the limitations
and value of the X-rays in car-
cinoma 464, 4(>o
Auto-conduction by the solenoid 147
B
Bacteria, action of the X-rays on 389-395
Bactericidal action of radium 501
Bar and Boulle\ on red light treatment
of X-ray dermatitis 411
Barnum, on the X-ray treatment of
keloid 490
Barrel's method for the localization of
foreign bodies 300
Barthelemy and Oudin, on the X-rays
in hypertrichosis 448
Batten, his method of treating ring-
worm by irradiation 450
Bauer's vacuum tube 194
Beck, on microscopy of adeno-carci-
noma after irradiation 418
on skiagraphy in hepatic condi-
tions 348
osteoscope of 196
Becquerel, studies of, with radio-ac-
tive substances 498, 499
Behavior of light on animals and man 512
Berton's experiments with the X-rays
on the Klebs-Loffler bacillus 389
Bishop, on exophthalmic goitre 121
on X-ray treatment of trachoma 488
Blackening of the tube 197
Blackmar, on the action of the X-rays
in malignant disease 417
Blondlot, R., on velocity of propaga-
tion of X-rays 167
Blue light as an anaesthetic 520
Boggs, on the X-rays in tuberculous
adenitis 481
Boido and Boido, their reports of irra-
diation in cases of pulmonary tuber-
culosis 478
Bordier, on dermatitic changes caused
by the X-rays 405
Box-cover for X-ray tubes 202
Brant h, his method of irradiation in
cases of epilepsy 496, 497
Brewster's refracting stereoscope for
stereo-skiagraphy 249
Brown and Osgood, on sterility due to
the X-rays 412, 413
Brush discharge 57
Bullitt, his comparison between the
X-rays and the surgical treatment
of tuberculosis 481
Bunsen cell 63
Burr, reports of cases by, on bony con-
genital deformities 27.5
Caldwell and Simon's interrupter. . . . 178
Cald well's cavity vacuum tube 424
Campbell, on the radiotherapy of acne 452
Cannon's studies on the stomach dur-
ing digestion as viewed fluoroscopi-
cally 342
Capp and Smith, on a review of the
advancements made by irradiation
in lymphatic leukaemia 4s">
Carabelli and Luraschi, on the X-rays
in prostatic hypertrophy 492
Care of battery 64
of photographic plates 222
of static machine 51
of vacuum tube 196, 197
Catalysis 98
Cataphoresis 75
its bearing on galvanism 75
Cataphoric electrodes, for high-fre-
quency currents 144, 145
Cathode rays, chemical and photo-
graphic effects of 159
deflection of 185
fluorescence and phosphores-
cence of 159
physiological effects of 159
production of 158, 185
radiability of 158
rectilinear propagation of ... 187
reflection, refraction, and
polarization of 159
theories to explain the exist-
ence of 159
Causes and prevention of faulty nega-
tivos 231
of X-ray dermatitis 398, 399
Cautery batteries 69
Cells, Bunsen 63
charging the 64
I X 1 )EX.
529
Cells, galvanic 62
"group" arrangement of 41
Grove 63
Leclanche 64
" parallel " arrangement of . ... 40,63
"series " arrangement of 40, 63
types of 63
wet and dry 63
Central galvanization 69
pneumonia, value of the X-rays
in 320
C. G. S. system 36
Chain-holder for the static machine ... 53
Changes induced in diseased tissues
by the X-rays 415^419
Chart of static modalities 60-61
Chemical and photographic effects of
radium 498, 499
Chromoradiometer of Bordier, for
measuring X-ray dosage 433
of Holzknecht, for measuring X-
ray dosage 432
Chronic X-ray dermatitis 400
Cinemato-radiographs of the heart . . . 329
Clark, on the therapeutic action of
the X-rays in cancer 471^i73
Classification of radio-activity 501
of radium rays 501
Closure of the bladder, shown skia-
graphically 360
Codman, on fluoroscopy and skiagra-
phy in a study of joint mechan-
ism 254,255
on latent stage of X-ray derma-
titis 401
on pathology of X-ray dermatitis 404
on relationship of static machines
and coils to X-ray dermatitis . 403
Coil. (See Induction coil.)
Coleman, on electricity in many oph-
thalmic affections 136, 137
Coley, conclusions of, on the value of
the X-rays in malignant disease . . . 476
Commutator 172
Compression diaphragm 202
disadvantages of 203
Condenser 171
Condenser electrode 145
Conditions necessary for success by
Finsen's method 520
Conductive currents 58
Conductivity 38
34
Connal, on high-frequency currents
in dulness of hearing 154, 155
Connections of a galvanic battery. . . 62
Construction of induction coil 171
Continuous current 45
Contremoulins' measurement of X-
ray dosage 439
on the skiagraph in pelvime-
try 363-365
Convective currents 57
Cossar's cavity vacuum tubes 424
Coulomb 38
Courtade, radiometer of 438
Covell, on a case of asthma with
fibroids, cured by galvanism 126
Crookes, experiments on radio-active
substances 499
his assertion that matter is radi-
ant 157
spinthariscope, for studying the
fluorescence of radium 500
tube 187
tube for therapeusis 422
(See Vacuum tube.)
Crypto-radiometer of Wehnelt, for
measuring X-ray dosage 431
Cryptoscope 199
examination with 211
Curie, Professor and Madame, on the
study of radio-activity 499, 500
Current going to the primary coil, in
the study of X-ray dosage 427
Dally, his classification of shadow
quality with percussion note .. 319
on pleurisy with effusion, studied
skiagraphically 322
Dark room in photography 221
D'Arsonval, on high-frequency cur-
rents 138,141
Data on the negative in skiagraphy. . 218
Davidson, contact rotary interrupter
of 174
his method of localization of for-
eign bodies in the eye 295-297
Davies, experiments with the X-rays
on bacteria 389
X-ray study of gravid uteri .... 366
Definitions of electro-therapeutic
terms 67
Degeneration of muscles 90
L\Di:x.
Dermatitis. (See X-ray dermatitis.)
Dermo or iron electrode lamp 516
Descending current 67
Destot's views on dermatitic changes
caused by the X-rays 405
Developers in photographic work 222, 223
Developing papers 232
Diagnosis and differential diagnosis
of aortic aneurisms by the X-
rays 333-335
Diaphragm (skiagraphic) 202
compression 202
its disadvantages 203
lead iris 221
Differentiation between ordinary pho-
tograph and skiagraph 214
Disadvantages of compression dia-
phragms 203
of fluoroscopy 214
Disan's method of fluoroscopic exam-
ination of the normal heart 324
Disk interrupter 174
Disruptive currents 58
Distance of the tube, for X-ray
treatment 424
from the plate 219
Dodging 232
Dorn, Professor E., on visibility of
X-rays 167
Dosage of the galvanic current 67
of the static current 56
of the X-rays 426, 427
(See X-ray dosage.)
Dry cells 63
Drying the negative 228
Du Bois-Reymond, his law for the
electrical stimulation of
muscles 94
on muscular contraction fol-
lowing electrical irrita-
tion of motor nerves 92
Ducretet's self-regulating tube 192
Dunham, selenium cell of, for X-ray
dosage 439
Duration and course of X-ray derma-
titis 406,407
of exposure in irradiation 425
Eder and Valenta, on the degree of
vacuum of tubes 195
Edsall, Pancoast, and Musser, on the
asserted secondary results occurring
after irradiating cases of leukaemia 486
Effects of light on bacteria 511, 512
of radium on the eye 502
on the nervous system . 502
Effluve 145
Einhorn, his observations on radium
therapy 506
on transillumination of the stom-
ach 341
Electrical currents, effects of, on sen-
sory cutaneous nerves 95
on the abdominal or-
gans 97-98
on the head 97
on the sensory nerves
of muscles 95
on the skin 97
on the special senses . 95 -96
on the spinal cord 97
on the sympathetic sys-
tem 96
pathological physiology of,
in disease 98
douche bath 79, 80
energy, sources of 39
mains 45
reactions of nerves of special
sense and of the sensory
nerves 91
souffle 58
stimulation of muscles 94
wind 58
Electricity as a part of the medical
curriculum 31, 32
for aneurism 127-128
historical sketch of the rise of . 29-31
in cutaneous affections 99-103
in acne 99
in alopecia 99
in cutaneous anaesthe-
sia 101
in eczema 99
in furuncles and car-
buncles 102
in herpes zoster 101
in hypertrichosis 100
in moles and warts. ... 102
in naevus 102
in port-wine mark 102
in prurigo 101
in pruritus 99
IXDEX.
531
Electricity in cutaneous affections :
in psoriasis and pity-
riasis 101
in ringworm and sclero-
derma 101
in diseases of the articular sys-
tem 105-107
in chronic articular
rheumatism 105
in fibrous ankylosis. . . . 106
in gout 106
in hydro-arthritis 105
in rheumatoid arthritis 105
in synovitis 105
in tuberculous arthri-
tis 106-107
in diseases of the digestive sys-
tem 107-111
in constipation : 108
in dilatation of the
stomach 107
in enteritis 109
in fissure of the anus. . 110
in hemorrhoids Ill
in nervous dyspepsia. . . 108
in prolapse of the rec-
tum 110-111
in stricture of the rec-
tum Ill
in vomiting 107
in diseases of the genito-urinary
system 111-116
in impotence 116
in incontinence of urine 115
in nephritis 116
in orchitis 116
in paralysis of the uri-
nary bladder 114
in prostatitis 113-114
in spermatorrhoea 115
in stricture of the male
urethra 111-112
in diseases of the nervous sys-
tem 116-122
in cephalalgia 117
in chronic spinal muscu-
lar atrophy 119
in epilepsy 119
in exophthalmic goitre. 120
in hemiplegia 118
in hypochondriasis and
melancholia. . .120
Electricity in diseases of the nervous
system : in hysteria .. 120
in insanity 120
in insomnia 119
in locomotor ataxia. . . 119
in neuralgia 116-117
in neurasthenia 120
in paralysis, from arse-
nic, etc 118
from rheumatism . . 118
from syphilis 118
in paraplegia 118
in peripheral neuralgia. 118
in poliomyelitis 119
in sciatica 118
in tic douloureux 117
in gynaecology 122-127
in amenorrhoea 124
in chronic metritis 125
in dysmenorrhcea 124
in fibroid tumors 124
in ovarian tumors 124
in periuterine haematocele. . 125
in post-part um hemorrhage . 125
in slow labor 126
in stenosis of the cervical
canal 125
in subinvolution and atro-
phy 125
in urethral caruncle 125
in vomiting of pregnancy. . 126
in muscular affections 103-105
in muscular contrac-
tures 104
in myalgia 103
in my asthenia gravis . . 105
in secondary hemiplegic
contractures 104
in torticollis 104
in writers' cramps . 103-104
in ophthalmology 134-137
in blepharospasm 134
in cataract 135
in diseases of the lacrymal
canal 135
in oculo-motor paralysis. . . 134
in retinal anaesthesia 135
in various ophthalmic affec-
tions (a summary). .. 136,137
in otology 131-134
in chronic suppuration of
the middle ear. . . . 131
INDEX.
Electricity in otology: in deafness of
auditory nerve origin 131
of hysterical origin. ... 134
in otalgia of neuralgic origin 134
in pruritus of the auricular
canal 134
in stricture of the eustachian
tube 134
in tinnitus aurium . . 132, 133, 134
in rhinology and laryngology 129-131
in anaesthesia of the
pharynx 130
in anosmia 130
in asthma 131
in atrophic pharyngi-
tis 130
in atrophic rhinitis 129
in laryngeal fatigue. ... 130
in <>/;i-ll:i 129
in pharyngitis 129
nature and properties 34
Electrodes, for cataphoresis, with
high-frequency currents. . 144,145
for galvanic battery 66
for laryngology and rhinology . . 129
for prostatic hypertrophy 113
for static applications 52
glass vacuum, for high-frequency
currents 143, 144
Electro-diagnosis, hints for practical
testing in 89
rules to be followed in 81
Electrolytic interrupters 175-178
Electro-magnetic or "absolute" C. G.
S. units 37
Electro-magnets 34
Electro-motive force 37
of the static machine ... 52
Electro-physiology 92
Electro-static units 36
Electro-therapeutic terms, definitions
of 67
Electrotonus 94
Ellis, on tissue changes due to the X-
rays 418
Envelo developer 227
Erb's method with electrical applica-
tions in epilepsy 119
Essential features of Crookes' vacuum
tube 188
Evolution of the X-rays 156, 157
Examinations with the cryptoscope . . 211
Exner, on the mode of retrogression
of cancer metastases under radium
therapy 504
Explosion of the tube 198
Extra-oral method in dental skiag-
raphy 371
F
Factors varying the time of X-ray
exposure 220
Farad 38
Faraday's laws 169
Faradic current, as a diagnostic agent 74
as a therapeutic agent 74
method of application 73
Ferguson, on the radiotherapy of
mammary carcinoma 469
Ferris, on the X-ray treatment of pso-
riasis 457
Filters, as prophylaxis against X-ray
dermatitis 407
for X-ray work 426
Finsen, his experiments with light on
acquired pigmenta-
tions 513
with red light 517, 518
method of, with concentrated arc
light 515, 516
treatment of smallpox 519
Fixing 227
bath, acid chrome 227
Fluorescence, its application in dis-
ease 442,443
its natural and artificial produc-
tion in the human body 441
of radium 500
of the screen, for measuring X-
ray dosage 440
of the tube and appearance of the
electrodes for measuring X-
ray dosage 440
Fluorometer of Williams, for measur-
ing X-ray dosage 438
Fluoroscope 199
method of examination with. . . . 210
Fluoroscopic examination of biliary
calculi 346-348
of costal angle 309
of diaphragm, in health and
disease 308, 310, 311
of heart. . 308, 311, 325, 329, 332
of liver. . . 346
INDEX.
533
Fluoroscopic examination of lungs 306, 308
of spleen 348,349
of stomach 338-341
(See Skiagraphy and the X-rays
in the treatment of various
diseases.)
Fluoroscopy 210
advantages of 213
disadvantages of 214
positions of the tube and patient
for 212, 213
preparation of the patient for. ... 211
size, shape, and intensity of the
image in 213
Foreign bodies and their localization. 285
in the eye 289
in the genito-urinary tract . . 288
in the intestines 288
in the larynx, trachea, and
bronchi 288
in the oesophagus 287
in the stomach 288
their localization by Barrel's
method 300
by Davidson's method
295-297
by Fox's method 298
by Grashey's method
303-305
by Grossman's method
297,298
by Harrison's method . . 302
by Leonard's method.. 302
by punctograph 299
by R6my's method 300
by screen method 299
by Shenton's method.. 301
by Sweet's method 290-295
by tr iangulat ion met hod 303
Fox, his method of localizing foreign
bodies in the eye 298
on the treatment of retinal anaes-
thesia by voltaic alternatives. . 135
Fractures and dislocations. (See X-
rays as a diagnostic agent.)
Franklin, his views on the ionization
of confined gases for use in X-ray
dosage 436
Frequency of X-ray exposure 426
Freund, on dangers of X-ray therapy 403
on fever production in X-ray
dermatitis. . . 405
Freund, on hypertrichosis 447
on lupus vulgaris 444
radiometer of 435
X-ray action on diseased tissue. . 416
Friedlander's interrupter 177
Galvanic battery 62
care of 64
charging the cells of 64
connections of 62
polarity of 64
(See Cells.)
current 39
dosage of 67
Galvanism 62
Galvano-faradic box 67
Galvano-faradization 69
Galvanometer 66
Gassiot, experiments of, with the
Ruhmkorff coil instead of cells . . . 156
Gassmann, on blood-vessel changes
due to the X-rays 397
Gassmann and Schenkel, on dermati-
tis due to the X-rays 396
Geissler, Heinrich, on glow discharges 156
General reduction of the negative. . . . 230
Geyser, on X-ray treatment of tra-
choma 488
Gilchrist, remarks of, on dermatitic
areas due to the X-rays 395
Gill, on cataphoresis 75-77
Glass, plates of, for static machines. . 52
vacuum electrodes, for high-fre-
quency' currents 143, 144
Gocht, the form of the ray-emitting
area of anti-cathode 219
Griffith, on electricity in the treat-
ment of aneurisms 127
Grisson's resonator 185
Grossman's method of localization of
foreign bodies in the eye 297-298
Ground glass substitute 232
"Group" arrangement of cells 41
Grouven, on X-ray action on diseased
tissue 416
Grove's cell 03
Grubbe, on the X-rays in tuberculous
adenitis 481
Guilleminot, his instrument for cine-
mato-radiographs 329
534
INDEX.
Guilleminot, on the measurement of
the costal angle 309
Guilleminot-Courtade method of mea-
suring X-ray dosage 438
Hahn, on the radiotherapy of eczema 451
Halberstaedter, on sterilty caused by
the X-rays 412
Hallopeau and Gadaud, on the sclero-
genic action of the X-rays 417
Hard tubes 195
Hardening the negative 229
Hare, on electricity in aneurisms. . . . 128
Haret, on the X-ray treatment of neu-
ralgia 494
Harris, Sir W. Snow, on spark length . 156
Harrison's method for the localization
of foreign bodies 302
Hartigan, on radium therapy of car-
cinoma 509
of naevus 507
Heliotropism 511
Hemmeter's method in skiagraphy of
the stomach 340
Henry, the, as an electrical unit 38
Herringham, on the brachial plexus
in the new-born 88, 89
Hertz, on high-vacua discharges. . . . 157
resonator of 146
Heiiman, on exophthalmic goitre. . . . 122
Hewitt, Cooper, mercury vapor lamp
of 516,517
High-frequency currents 138-155
apparatus for 139, 140
D'Arsonval's 141
Morton's 140
Tesla'a 142
electrodes for 143-145
history of 138
methods of application of
146-148
auto-condensation 148
direct application. . 146,147
indirect application. . . 147
local application 148
Oudin resonator for 143
physical properties of .. 145,146
dynamic effects 145
electro-static effects. . . 145
induction effects 145
resonance effects .. . 146
High-frequency currents, physiologi-
cal properties of .... 14\ 1 lit
treatment by, in colitis. . . . 152
in dulness of hear-
ing 154, 155
in epilepsy 153
in gonorrhoea 155
in gout 150
in hysteria 151
in lupus vulgaris 151
in obesity 150
in ozaena 152
in piles, rectal fissure,
and pruritus ani. ... 151
in rheumatism 150
in rodent ulcer and ma-
lignant disease 151
in skin diseases 154
in trachoma 154
in tuberculosis 149
Hillard, on blue light as an anaesthetic 521
Hint in using coil and interrupter in
X-ray therapy 420, 421
Hints for practical testing in electro-
diagnosis 89
Hirschmann's monopol tube 194
Hirst, on the limitations of galvanism
and faradism in gynaecology 122
Histological changes induced by the
action of the X-rays 395-398
Historical sketch of the rise of elec-
tricity 29-31
History taking in skiagraphy 216
Hoffa, on the probability of X-ray
dermatitis 402
Hoffman's measuring stand and ex-
amining frame 200
Holland, on skiagraphing a case of
biliary calculi 347
Holtz' influence machine 49
Holzknecht and Be"clere, on the ob-
lique method of examination of
aneurisms 334
Holzknecht and Brauner's technic in
gastric skiagraphy 340
How to view the X-ray negative. . . . 234
Hultz, on skiagraphy of the stomach . 340
Huntington, on the pathological phys-
iology of X-ray dermatitis 404
Hyde, Montgomery, and Ormsby, on
radiotherapy in acne rosacea 454
in psoriasis 456
INDEX.
535
Hydraulic analogy, illustrating poten-
tial 34
Hydro-electric bath 77, 78
Idiosyncrasy to static current 55
Immobilization of part in skiagraphy . 217
Improvement of the negative L'L'i)
Independent vibrating hammer inter-
rupter 172
Induction coil 169
construction of 171
Gaiffe 184
Grisson 184
Kinraide 181-183
Tesla 180
variable primary ("jumbo")
178, 179
without interrupter 184
Induction, laws of 169
mechanism of 170
principles of 71
Influence machine 46
of Holtz 49
of Voss or Toe pier 50
of Wimshurst 47
(See Static machine.)
Influence of electricity on motor
nerves and on muscles 92
of photodynamic substances on
the action of the X-rays 443
of radium on agglutination 502
Installation of X-ray apparatus and
the management of its various
parts 204-207
Intensifying screens 220
Interpretation of X-ray negatives .... 234
Interrupted insulation 57
Interrupter 73
electrolytic 175
Caldwell and Simon's 17.8
Friedlander's 177
W.-lmelfs 175,176
mechanical 172
Davidson's rotary contact-
breaker 174
disk 174
independent vibrating ham-
mer 172
jet 175
Johnston's 174
platinum 172
Interrupter, mechanical, self-starting 173
Vril 17:!
: Intra-oral method in dental skiagra-
Phy 370
lonization method of measuring X-
ray dosage 436
Jagn, on the influence of radium on
agglutination 502
Jameson, on the radiotherapy of
xeroderma pigmentosum 455
Jaumann's theories of the cathode
rays 159
Jet interrupter 175
Johnston, mercury interrupter of. ... 174
on fluorescence of screen as a
measurement for X-ray dosage 440
on keratoses, the result of X-ray
dermatitis 406
Jones, on the probable physiological
action of high-frequency currents . . 148
Joule 38
Jutassy, on the X-rays in hypertricho-
sis 447, 448
Kaposi's views on dermatitic changes
caused by the X-rays 405
Keen's experiments with the X-rays
on bacteria 389
Kibbe, on the histological changes in
the skin due to the X-rays 395
Kienbock, his classification of the de-
grees of vacuum. . . . 196
of X-ray dermatitis. . . . 401
his experience with the X-rays in
sarcoma 475
quantimeter of 434
Kienbock and Benedikt, on the X-
rays in cerebral affections 280
Kohler, his thermometric method for
X-ray dosage 441
Kothe, on the influence of photody-
namic substances on the action of
the X-rays 443
Krause, on the skiagraphic examina-
tion of the heart 332
Kummel and RumpePs conclusions
on renal skiagraphy 354
536
INDEX.
Labile applications 67-68
Lacaille's apparatus for measuriug X-
ray dosage 430
Latent stage of X-ray dermatitis 401
Laws of Faraday 169
of induction 169
Lead iris diaphragm 221
Leclanche's cell 64
Leduc, on the electrolytic introduc-
tion of salicylic ions in cases of
neuralgia '. 117
Lenard, on the properties of cathode
rays 157
Leonard, his double-focus-tube
method for localization 302
his prophylaxis against X-ray
dermatitis 407
on renal skiagraphy 353
on the analgesic action of the X--
rays in neuralgia 493, 494
views of, concerning X-ray in-
fluence on diseased tissue. . . . 416
Leukowitsch's ophthalmological ex-
periments in locating foreign bod-
ies 289
Leven and Barret, on a study of the
outlines of the stomach with the
fluoroscope 343
Levy, R., selenium photometer of . . . . 439
Levy-Dorn's orthodiagraph 328
Leyden jar 52
" Life " of the tube 198
Light, action of, on bacteria 511, 512
on man 512
on plants 511
for photography 221
nature of 510, 51 1
therapeutic action of 513
treatment by artificial 514-521
by blue 520,521
by natural 514
by red 517-520
Light-therapy among the ancients. . . 513
Liver, fluoroscopic examination of . . . 346
Local reduction of the negative 230
Localized faradization 74
Lossen and Morawitz, on the clinical
and histological findings in leukae-
mia, after irradiation 486.
Lovett and Brown, on X-rays in cox-
M
McGuire, on the value of radiotherapy
in varicose veins 457
Macintyre, on the X-rays in rhinology 367
Magnetic units 36
Magnetism, nature and properties of. 33
Manders, on radio-active medication
of rheumatism 509
on the X-rays in epilepsy 496
Marie and Ribaut, their formulae and
table f or stereo-skiagraphy. . . . 246, 247
Marx, E., on velocity of the X-rays. . 168
Massey, "The Apostoli Treatment of
Fibroids " 77
Matignon, Maj., on the X-rays in war. 286
Maxwell, Clerk, on the electro-mag-
netic theory of light 156
Mayo, on the value of the X-rays in
exophthalmic goitre 490
Mechanical interrupters 172-175
regeneration of vacuum tubes. .. 194
Mechanism of induction 170
Medical and surgical affections of the
kidney, studied skiagraphically . . . . 351
Medical induction coil 71-72
Medico-legal aspect of the X-rays, in
relation to ossification and age 380
aspect of X-ray sterility. . . . 387, 388
considerations of the X-rays 375-388
questions bearing on the X-
rays 379, 380
Medium tubes 195
Methods of measuring X-ray dosage . . 427
(See X-ray dosage, measure-
ment of.)
of viewing stereo-skiagrams. . . . 249
Meyer and Eisenreich, on the X-ray
treatment of leukaemia 483
Mica plates for static machines 52
Military surgery, X-rays in 285, 286
Milliamperage of the secondary in-
duced current, in X-ray dosage 427-429
Milliamperemeter 66
Mills' views concerning the electrical
treatment of neurasthenia 120
Minck and Gocht, on the action of X-
rays on typhoid bacilli 390
Minin's views on the anaesthetic effect
of colored light 520
Modes of application of static current . 57
Modus operand! of photographic de-
velopment 224-226
INDEX.
537
Monopolar bath 79
Moritz, orthodiagraph of 325-328
table of, showing the relation be-
tween the size of the heart and
stature 330
views of, on orthodiagraphy in
acute cardiac dilatation 331
Morton, "static induced current"
high-frequency apparatus of. . 140
value of fluorescence artificially
produced in the human
body 442, 443
wave current of 58, 59
Moscowicz, on the X-ray treatment
of prostatic hypertrophy 492
Motor points 81
in the chest and abdomen. . 87
in the face 85
in the lower limb 85
in the neck 85-87
in the upper limb 82-85
Mounting of photographs 233
Muffler, for the static machine 54
Miiller's regulation tube 192
Musham, on the X-rays in general
and localized tuberculosis 390
N
Nature of light 510,511
of radium emanations 501
Negative. (See Photographic nega-
tives.)
Nerves of special sense, electrical re-
action of 91
New radiometer of Freund, for meas-
uring X-ray dosage 435
Newcomet's device for simultaneous
treatment with the X-rays 424
Newcomet and Krall, on the X-ray
treatment of a case of trachoma . . . 488
Occurrence of radium in nature 498
Ohm 37
Ohm's law 39
Orthodiagraph of Levy-Dorn 328
of Morwitz 325-328
Orthodiagraphic localizer of
Grashey 303-305
Osmosis regulating tube 194
Osteoscope of Beck 196
Oudin, resonator of 143, 148
Oudin, Barthelemy, and Darier, on
alopecia due to the
X-rays 396
on cutaneous changes
due to the X-rays. . 405
Pancoast, on the X-rays in tubercu-
losis 479,480
" Parallel " arrangement of cells. ... 40, 63
Pardo, on X-ray treatment of tra-
choma 488
Partial reaction of degeneration 91
Pathological physiology of electric
currents in disease 98
of X-ray dermatitis 404
Pearce, on " Epiphenonena of Cere-
bral Hemorrhage " 281
Pelvimetry, as studied by the X-
rays : 362-367
Penetrability of urinary calculi by
the X-rays 350
Penetration method of studying X-
ray dosage 429
Penetration of radium 500
Pennington, on irradiations for pru-
ritus ani 455
Permeability of the X-rays 287
Pfahler, on cerebral skiagraphy 279
on value of X-rays in tubercu-
losis 479
Pfahler and Schamberg, on X-ray
filters 426
Pfliiger's laws of contraction 92-93
Philipp, on X-ray sterility 413
Phillips, radio-active standard of. ... 437
Photographic negatives, drying of . . . 228
faulty, causes and preven-
tion of 231
general reduction of 230
hardening of 229
improvement of 229
local reduction of 230
stains and spots on 231
washing of 228
(See X-ray negatives.)
Photography, accelerating solutions
employed in 223
author's tank for 228
dark room for 221
developers employed in 222, 223
developing papers for 232
538
Photography, dodging in 'I'.l'l
Envelo developer for ~~7
fixing in 227
fixing bath, acid chrome for. . . . 227
ground-glass substitute in 232
light employed in -21
modus operandi of development
in 224-226
mounting in 233
plates, care of the, in 222
positives in 233
printing, toning, and mounting
in 231
reducers employed in 222
restraining solution used in 224
rules in handling developers for. 227
sensitive plates and films in. ... 222
tank development in 226
toning process in 233
transparencies and lantern slides
in 234
Photometric methods of measuring
X-ray dosage 438
Phototherapy 510-521
Physical properties of radium 500
Physician's responsibility in cases of
X-ray burns 382-387
Physico-chemical method for measur-
ing X-ray dosage 431
Physiological action of radium 502
Physiology, uses of X-rays in .... 255, 256
Piffard, his principle of ionization for
X-ray dosage 437
Plastographic method in stereo-ski-
agraphy 250
Plates for skiagraphy, preparation,
size, protection, etc., of 217, 218
Platinum interrupter 172
Polar method of examination in elec-
t ro-physiology 93
Polarity and connections of the X-ray
tube 207,208
of the battery 64
of the static current 54
Porter, on the degree of vacuum of
tubes 195
Position of the tube and patient in
fluoroscopic examinations. 21 2, 213
of the vacuum tube for therapeu-
sis 424
Positives in photography 233
Potential, theory of 34
Precipitation test, for measuring X-
ray dosage 436
Preparation of the patient for screen
examinations 211
for skiagraphic exami-
nations 216
for static treatment .... 54
Preutz, on skiagraphy of hepatic ab-
scess 278
Prevention of the secondary or Sag-
nac rays 220
Preventive measures against X-ray
dermatitis 407
Principles of induction 71
Printing, toning, and mounting 231
Prostatic calculi, X-ray examination
of 360
Protection of healthy parts during
irradiation 422, 423
of operator against X-ray derm-
atitis 407,408
Punctograph for the localization of
foreign bodies 299
Puncture of the anti-cathode 198
Pusey, on the radiotherapy of oesoph-
agea! carcinoma 469
Pyelography 358
Q
Quality of the X-rays 195, 220
Quantimeter of Kienbock, for meas-
uring X-ray dosage 434
Queirel and Acquavita, on the evolu-
tion of the osseous system skia-
graphically studied 366
R
Radio-active standard of Phillips, for
measuring X-ray dosage 437
Radiochromometer of Benoist, for
X-ray dosage 429
Radiometer of Courtade, for measur-
ing X-ray dosage 438
of Freund, for measuring X-ray
dosage 435
of Sabouraud and Noire" 432
Radium, bactericidal action of 501
chemical and photographic ef-
fects of 498-500
effects of, on the eye 502
on the nervous system 502
fluorescence and luminosity of. . 500
INDEX.
539
Radium, influence of, on agglutina-
tion 502
occurrence of 498
penetrating power of 500
physical properties of .500
physiological action of 502
theoretical considerations con-
cerning 501
Radium treatment of cutaneous dis-
eases 503-506
of exophthalmic goitre 507
of naevus 507
of rabies 507
Ransom, on the X-rays in the treat-
ment of tuberculosis 47',)
Reaction of degeneration 90
Reid, on a new method in renal skiag-
raph}' 357
Remote and indirect action of the X-
rays 412
Remy's method for the localization of
foreign bodies 300
Renal skiagraphy 352-355
Reports of scientists on the results of
Finsen's method in smallpox 519
Repumping the vacuum tube 198
Resonance, as a factor in high-fre-
quency studies 146
Resonator, Grisson's 185
Hertz's 146
Oudin's 143,146,148
Restraining solution 224
Rheostat 66
Rheotome 73
Richardson, on "Electricity in Otol-
ogy" 132-134
Rieder, action of the X-rays on bac-
teria 390,392,393
technic of, in gastric skiagraphy. 340
Rinehart, on the necessity of produc-
ing an X-ray dermatitis for the cure
of disease 417
Rockwell, on the relation between
galvanism and cataphoresis ... 75
on the treatment of suppuration
of the middle ear by the gal-
vanic current 131
Rontgen, Professor, his discovery of
the X-rays 157
sketch of the life of 157, 158
Rontgen apparatus. (See X-ray ap-
paratus.)
Rontgen rays. (See X-rays.)
therapeutics. (See X-rays in
treatment, etc.)
Rudis-Jicinsky, on the destructive ac-
tion of the X-rays on bac-
teria 393
on the X-rays in intestinal
obstruction . 345
S
Sabouraud, on the X-ray treatment
of ringworm 450
•>u brazes and Riviere, on the action
of the X-rays on the bacillus pro-
digiosus 391
Salomonson, on the measurement of
X-ray dosage 428
Sarcoma, its treatment by the X-
rays 473-477
Sayen's self-regulating tube 190
Scheppegrell, on the radiotherapy of
laryngeal carcinoma 470
Schiff and Freund, on the X-rays in
hypertrichosis 448
Schnee's battery for hydro-electro-
therapy 80
Scholtz, on changes induced in dis-
eased tissues by the X-
rays 415,416
on dermatitic changes due to the
X-rays 397
Schultze and Beck, on the action of
X-rays on bacteria 390
Schwartz, precipitation test for meas-
uring the strength of the X-rays.. . 436
Screen method for the localization of
foreign bodies 299
(See Fluoroscope.)
Secondary batteries 41
or Sagnac rays, prevention of . . . 220
Selection and installation of X-ray
apparatus 203-207
Selenium photometer for measuring
X-ray dosage 439
Self-regulating and regenerative
vacuum tubes 189
Self-starting interrupter 173
Senn, on the X-ray treatment of leu-
kemia 483
Sensitive plates and films 222
Sensory system, electrical reactions of 91
540
INDEX.
Sequeira, on the telangiectases in
dermatitic X-ray areas 406
" Series " arrangement of cells 40, 63
Sharp, on the thorium treatment of
tuberculosis 508
Shenton, method of, for the localiza-
tion of foreign bodies 301
on fluoroscopy for ureteral cal-
culi 356
Shober's radiode for radium ther-
apy 506, 509
Shoemaker, G. E., a study of the
X-rays in a case of sarcoma of the
abdominal wall 474
Shoemaker, J. V., his electrode for
prostatic hypertrophy 113
Silbergleit, on cardiac (lateral) dis-
placement 329
Sinusoidal current 69
Size, shape, and intensity of image on
the screen 213
Sjorgen and Sederholm, on the reac-
tion of blondes and brunettes to the
X-rays 402
Sketch of the life of Wilhelm Conrad
Rontgen 157, 158
Skiagraph, differentiation between it
and an ordinary photograph 214
Skiagrapher's preparation for court . . 378
Skiagraphic table 200
Skiagraphy 214-218
advantages of the print in 231
data on the negative in 218
immobilization of the part for. . . 217
plates, preparation, size, etc., for 217
position of the Crookes tube
in 216,219
of the plate for 216
preparation of the patient for. . . 216
synonyms for the word 214
(See X-ray diagnosis and treat-
ment; also Fluoroscopy.)
Skiameters and penetrometers for
measuring X-ray dosage 431
Skinner, on radiotherapy of a sarco-
ma of the abdominal wall 475
Snow, on the electrical treatment of
neurasthenia 121
Soddy, on the relative values of radi-
um and thorium therapy 502
Soft, medium, and hard tubes 195, 422
Solenoid, auto-conduction by 147
Sormani, on the action of the X-rays
on bacteria 390
Sources of electrical energy 39
Spintermeter for measuring X-ray
dosage 429
Spinthariscope for studying the flu-
orescence of radium 500
Sprengel, Hermann, invention of mer-
cury air-pump 157
Stabile applications 67, 68
Stains and spots on the negative 231
Starr, on the relation of nerve roots to
muscles 87-88
Static current, dosage of 56
idiosyncrasy to 55
modes of application of 57
polarity of 54
preparation of the patient
for 54
machine. (See Influence ma-
chine.) 46
accessories to 52
advantages of, for X-ray
work 208
care and manipulation of . . . 51
disadvantages for X-ray
work 208
electro-motive force of 52
glass plates for 52
mica plates for 52
principles of 46
theory of action of 48
(For the various forms of
static current, see Static
current, modes of appli-
cation of.)
modalities, chart of 60-61
Stationary vacuum tubes 189
Steinwand, on X-ray treatment of a
case of pseudo-leuksemia 483-485
Stephenson and Walsh, on the X-ray
treatment of trachoma 487
Stereo-fluoroscopy 243
and skiagraphy, history and
principles of 242
Stereoscopic method for the localiza-
tion of foreign bodies 303
Stereo-skiagraphy, advantages of. ... 251
author's table for rearrang-
ing negatives for 248
Brewster's refracting stereo-
scope for 249
IXDEX.
541
Stereo-skiagraphy, history and prin-
ciples of 242, 243
methods of viewing in 249
plastographic method in. ... 250
technic of 244-249
AVheatstone's reflecting
stereoscope for 249
Sterility caused by the X-rays. . . 412—414
Stern, on localizing foreign bodies in
the eye 289
Stokes, Sir G. G., on the probable
nature of X-rays 164, 165, 166
Stomach, behavior of, during diges-
tion, as seen by the X-rays. . . . 342
fluoroscopic examination of, by
bismuth subnitrate. . 338
by gaseous distention. . 337
by mechanical means. . 337
by transillumination. . . 341
position of, as seen by the X-rays 342
skiagraphic examination of 338
time of exposure in .... 339
transillumination meth-
od in 341
Storage battery 41
capacity of 41
care of 41
charging of 41, 45
Stover, on irradiations in cases of
kraurosis vulvae 458
Swain's study on the penetrability of
urinary calculi 350, 351
Sweet, method of, for localization of
foreign bodies in the eye . . 290-295
on the analgesic action of the X-
rays 493
Synonyms for the word "skiagraphy" 214
Table, skiagraphic 200
author's 200
Tank or slow developing photographic
process 226
Taylor, on the medico-legal aspect of
the X-rays 379
Technic of dental skiagraphy 370
of medico-legal skiagraphy. 377, 378
of renal skiagraphy 352
(For detail of technic, see X-ray
diagnosis; X-rays as a diagnos-
tic agent; X-rays in the treat-
ment of.)
Tenny, on the X-rays in cases of ure-
teral calculi 355
Tesla, high-frequency apparatus of . . . 142
his experiments with high-fre-
quency currents 139
oscillator of 181-183
Theory of potential 34
Thermometric method for measuring
X-ray dosage 441
Thomson, J. J., on radiant matter. . . . 157
Thomson, Sir William (Lord Kelvin)
on the relation between gas pressure
and spark length 156
Tizzoni, on the radium treatment of
rabies 507
Toning process 233
Tousey, newr film-carrier of, for dental
skiagraphy 371, 372
on fluorescence, in conjunction
with the X-rays, in stomachic
examinations 342
on X-rays in tuberculosis 480
Tracy, on high-frequency currents in
epilepsy 153
on radio-active treatment with
thorium 508
Transformers 184
Transparencies and lantern slides or
diapositives 234
Treatment of X-ray dermatitis. . . 408^12
Triangulation method for the localiza-
tion of foreign bodies 303
Tube, X-ray. (See Vacuum tube.)
Tube-holder 201
author's 201
Types of cells 63
of vacuum tubes 189
Units of electrical measurement 36
Unna, on microscopy of dermatitic
X-ray areas 405
on pigmentation of the skin, due
to the X-rays 396
Urinary bladder, X-ray examination
for calculi in 359
Uskoff, on the action of light on ciliary
movement 512
Vacuum tube, Bauer's 194
blackening of 197
542
Vacuum tube, Cald well's cavity .... T_'l
care of 196, 197
consumption of 198
Cossar's cavity 424
Crookes's 187,429
position of 216,221
selection of, as to the
requirements of the
case 218
degree of vacuum of. ... 195, 196
distance of , from the plate .. 219
in therapeusis 424
Ducretet's self-regulating. . . 192
electro-static regeneration of 195
essential features of 188
explosion of 198
fluorescence of, and appear-
ance of the electrodes, for
X-ray dosage 440
hard, soft, and medium. . . . 195
Hirschmann's monopol 194
life of 198
mechanical regeneration of. 194
Muller's regulation 192
osmosis regulation 194
polarity and connections
of 207, 208
position of, for therapeusis . . 424
puncture of anti-cathode of . 198
repumping of 198
Sayen's self-regulating 190
self-regulating and regener-
ative 189
stationary 189
types of 189
ventril 197
water-cooling 195
Van Allen, on the value of the X-rays
in lupus vulgaris 446
Variable primary induction coils. . 178, 179
Varnier, on the skiagraph in pelvim-
etry 362, 363
Vieruzhsky, on the diagnosis of tuber-
culosis by the X-rays 319
Viewing-box for X-ray negatives 236
Villard, remarks of, on ventril tubes. . 197
Violet and ultra-violet rays in tuber-
culosis 479, 480
(See Light.)
Voelcker and Lichtenberg, on py-
elography 358
Volt 37
Voltaic alternatives 07-68
Vose and Howe, on t he microscopy of
cancer after irradiation 419
Voss or Toepler influence machine. ... 50
Vril interrupter 173
w
Wall cabinet 64
Walsham's sign in aneurisms 334
Walters, on X-ray filters 426
Washing the negative 228
Water-cooling vacuum tubes 195
Watt 38
Wave current 58
Wehnelt's interrupter 175, 176
Wells, on the multiple connection of
Crookes tubes in series 425
Wet cells 63
Wheatstone's reflecting method in
stereo-skiagraphy 249
White's circular, on the value and
medico-legal relationship of the
X-rays 380-382
Wiedemann, on radiant matter 157
Wilkinson, his studies of the X-rays
in leprosy 459
Williams, C., on the X-rays in the
treatment of tuberculosis 478
Williams, F., fluorometer of 438
on the screen examination of
the normal heart and dia-
phragm 308
on the skiagraph in pelvim-
etry 365
on the study of fifty cases
treated with radium bro-
mide 503,504
Wimshurst influence machine 47
Wolfenden and Ross, on the action of
the X-rays on the bacillus prodigi-
osus. . . 390
X-ray apparatus, hospital outfit. . . . 204
portable outfit 204
selection, care, and installa-
tion of 203-207
dermatitis 395
acute form of 400
causes of 398, 399
chronic form of 400
classification of. . . 399
INDEX.
543
X-ray dermatitis, duration of the
chronic form of 406, 407
frequency and susceptibility
to, and latent stage of 401-404
pathological physiology
of 404-406
physician's responsibility in
cases of 382-387
preventive measures against
407, 408
diagnosis of biliary calculi . . . 346, 347
of prostatic calculi 360, 361
of ureteral calculi 355-359
of vesical calculi. . . 350-355, 360
(See X-rays as a diagnostic
agent.)
dosage, the measurement of, by
chromoradio meter
of Bordier. 433, 434
of Holzknecht 432
by Contremoulins'
method 439
by cryptoradiometer of
Wehnelt 431
by current to the pri-
mary coil 427
by fluorescence of the
tube and appearance
of the electrodes. . . . 440
by fluorometer 438
by Guilleminot - Cour-
tade method 438
by ionization of con-
fined gases 436
by milliamperage of the
secondary induced
current 427, 428
by precipitation test . . . 436
by quantimeter of Kien-
bock 434
by radio-active stand-
ard of Phillips 437
by radiochromometer of
Benoist 429-431
by radiometer of Cour-
tade 438
of Freund 435
of Sabouraud and
Noire 432,433
by selenium photom-
eter 439, 440
X-ray dosage, the measurement of, by
skiameter and pene-
trometer 431
by spintermeter 429
by the thermometric
method 441
exposure, factors varying time of 220
negative, author's examining box
for 236
how to view 234, 235
proper light for 235
when it is to be regarded as
satisfactory 234
(See Photographic negative.)
negatives, interpretation of, in
diseases of the ali-
mentary tract 240
in diseases of the soft
structures 238
in diseases of the tho-
rax 238-240
in diseases and tumors
of bone 238
in genito-urinary affec-
tions 240-242
inlocatingforeign bodies 236
X-rays, action of, on bacteria. . . 389-395
analgesic action of 493
charging action of 168
chemical and photographic ef-
fects of 166
diagnosis by. (See X-ray diag-
nosis; X-rays as a diagnostic
agent.)
discovery of 157
fluorescence and phophores-
cence of 161, 162
in forensic medicine 375-388
in military surgery 285, 286
physiological effects of 167
production of 160
quality of 220
radiability and penetrability of . . 160
reflection, refraction, polarization
and interference of. .162, 163, 164
table of permeability of 287
theories accounting for the proba-
ble nature of 167
uses of, in anatomy 252-255
in physiology 255, 256
value of, in a differential study of
bones and joints 258
544
INDEX.
X-rays, value of, in fractures 259
varieties of foreign bodies, as re-
gards 286
velocity of 168
velocity of propagation of. . . 167, 168
visibility of 167
X-rays as a diagnostic agent in'callus
formation 259, 260
as a diagnostic agent in dentis-
try 372-374
in abscess of the antrum 373
in alveolar abscess. . . . 374
in ankylosis of the infe-
rior maxillary articu-
lation 373
in detecting pieces of
broken instruments. . 373
in fracture of the infe-
rior maxillary bone . . 373
in necrosis of the max-
illa 372
in orthodontia 374
in root-canal fillings .... 373
in unerupted teeth 372
as a diagnostic agent in diseases
of the alimentary
system 336-349
of the intestine 344-346
of the liver.... 346,347
of the oesopha-
gus 336,337
of the pancreas .... 348
of the spleen 348
as a diagnostic agent in diseases
of the bronchi
and lungs . . 313-321
in abscess and gan-
grene 321
in acute miliary tu-
berculosis 319
in asthma 314
in atelectasis 320
in bronchiectasis . . 313
in bronchitis 313
in broncho - pneu-
monia 315
in cavitation 318
in emphysema. ... 315
in pneumonia 320
in pulmonary tu-
berculosis. . . 315-318
X-rays as a diagnostic agent in dis-
eases of the bronchi and lungs:
in thoracic tumorsand enlarged
glands 323,324
as a diagnostic agent in diseases
of the circulatory
system 324-335
in aortic aneurism . 333
in atheroma 335
in cardiac atrophy,
hypertrophy, and
dilatation 331
in dilatation of the
aorta 335
in displaced aorta. 330
in displaced heart. 330
in enlarged glands . 335
in neoplasms 335
in pericarditis 332
in pulsating empy-
ema 335
as a diagnostic agent in diseases
of the joints 282-285
as a diagnostic agent in diseases
of the pleura 321-324
in empyema 322
in hydro-pneumo-
thorax and pyo-
pneumothorax. . 323
in pleurisy with ef-
fusion •. 321
in pneumothorax . . 323
in subphrenic ab-
scess 323
as a diagnostic agent in frac-
t ures and disloca-
tions 258-270
of the lower extrem-
ity 266-270
of the os innominatum,
sacrum, and coccyx. . 270
of the ribs and sternum . 272
of the spinal column. . . 271
of upper extremity. 260-266
as a diagnostic agent in genito-
urinary diseases 349-361
in closure of the bladder 360
in prostatic calculi . 360, 361
i nureteral calculi. . 355-359
in vesical calculi 360
as a diagnostic agent in gynae-
cology and obstetrics 362-367
IXDKX.
545
X-rays as a diagnostic agent in intes-
tinal affections. . 344-346
in abdominal new
growths 346
in obstruction 345
in rectal imperf oration . 345
in sounding and radiog-
raphy 344
as a diagnostic agent in osseous
diseases, tumors, and
deformities 272-277
(See X-rays as a diag-
nostic agent in frac-
tures and disloca-
tions.)
as a diagnostic agent in patho-
logical dislocations 270
as a diagnostic agent in rhi-
nology, laryngology,
and otology .... 367-369
in abscess of the antrum
and frontal sinuses. . 368
in abscess of the mas-
toid process 369
in foreign bodies in the
ear 369
in foreign bodies in the
larynx 369
in ossification of the la-
ryngeal cartilages . . . 369
as a diagnostic agent in sto-
machic affections 342-344
in gastroptosis 343
in stenosis of the pylo-
rus 344
as a diagnostic agent in tumors
of soft tissues 277-282
X-rays in the treatment of constitu-
tional diseases 477-487
in leukaemia. . 482-487
in tuberculosis 477-482
in the treatment of cutaneous
affections . . 444—460
of acne 452
of acne rosacea 453, 454
of acne vulgaris . . . 453
of alopecia areata . 447
X-rays in the treatment of cutaneous
affections: of ec-
zema 451
of favus and tinea
tonsurans 449
of hyperidrosis . . . 458
of hypertricho-
sis 447-449
of kraurosis vulvae . 458
of leprosy 459
of lupus erythema-
tosus 444
of lupus vulgaris . . 444
of njEVUs 446
of pruritus ani and
vulvae 455
of psoriasis. . . 456, 457
of senile leg ulcers . 457
of sycosis 454, 455
of varicose veins. . . 457
of xeroderma pig-
mentosum . . 456, 457
in the treatment of malignant
growths 460-477
in carcinoma of the
breast 465-469
of the larynx 470
of the oesophagus . . 469
of the sternum .... 469
of the stomach and
intestines 470
of the uterus. . 470,471
in sarcoma 473—477
in the treatment of various af-
fections 487-495
of epilepsy 495
of exopthalmic
goitre 490-492
of hypertrophied
prostate 492
of keloid 489
of trachoma . . 487-489
Zeisler, on the radiotherapy of acne 453
Zeit, on action of the X-rays on bac-
teria.. - 391
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