A STUDY 
OF THE 
ADAPTATION OF THE X-RAYS 
TO 
MEDICAL PRACTICE 
BY 
FRANCIS H. WILLIAMS, M.D. 
BOSTON 
[.Reprinted from Medical and Surgical Reports of the 
Boston City Hospital, January, 1897.] A STUDY 
OF THE 
ADAPTATION OF THE X-RAYS 
TO 
MEDICAL PRACTICE 
BY 
FRANCIS H. WILLIAMS, M.D. 
[Reprinted from Medical and Surgical Reports of-ihe -iiosloii rS^f 
BOSTON 
Press of Rockwell and Churchill 
1897 A STUDY OF THE ADAPTATION OF THE X-RAYS TO MEDI- 
CAL PRACTICE AND SOME OF THEIR USES. 
Francis II. Williams, M.I). 
In the winter of 189G, not long after the announcement in 
America of Professor Roentgen’s discovery of the X-rays, I 
was impressed with their possibilities for usefulness in the 
practice of medicine, and as soon as I had gained some 
familiarity with the physics of the subject I began to 
examine my patients by their means, and have done 
so constantly ever since. The number I have thus far 
examined amounts now to more than two hundred and 
fifty, and the more extended my experience litis become in 
making these examinations, the more valuable have 1 found 
the rays in diagnosis in suitable cases. 
During the progress of this study I have from time to 
time reported my results at medical meetings 1 or by published 
articles,2 but only in outline, and 1 shall now endeavor to 
present more fully, at least a part of my work at the 
Boston City Hospital. The use of the X-rays in medicine 
was so new that apparatus and methods had to be devised 
before patients could be examined satisfactorily, and as 
members of the profession from various parts of the country 
have been interested in seeing my methods, it will perhaps 
be useful to describe for others some of the apparatus used, 
before taking up the medical side of the subject. 
Of the various forms of apparatus employed to excite the 
Crookes tube I have found the static machines, although 
1 Meeting' of the Suffolk District Medical Society, April, 1896. 
Meeting of the American Association of Physicians, April 30, 1896. 
Meetings of the Boston Society for Medical Improvement, and of Medical Society 
of the Boston City Hospital, October and November, 1896. 
2 “ Proceedings of the American Association of Physicians,” 1896. “Boston 
Medical and Surgical Journal,” Oct. 1, 1896. ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
3 
at a disadvantage in moist air, the most satisfactory, and of 
these prefer that known as the Wimshurst. The one I have 
principally used was designed by Mr. C. L. Norton and 
Mr. R. R. Lawrence, of the Massachusetts Institute of 
Technology (see Fig. 1), and has twelve glass plates, 2(i 
inches in diameter, which are run at about 200 revolutions 
per minute, and is boxed in order to keep out the dampness. 
I have ordinarily used it without condensers in making 
examinations with the fhiorescope, but in taking radiographs 
Fig. 1. — Static machine and stretcher, with tube holder below; large fluorescope at left 
of picture. This cut shows method of examining a patient. 
condensers are an advantage. It may be of interest to 
state here that I found the surface of the glass plates was 
loss susceptible to dampness when a few drops of castor-oil 
were added to the thin shellac with which they were coated. 
Vulcanite plates may be used instead of glass plates, but 
they do not seem to be as good electrically, although, of 
course, they are less likely to be broken; still, with ordi- 
nary care, there is not much danger to glass plates while 
handling the machine, and those of 2(i inches in diameter 
I have run, in order to test them, at 900 revolutions a minute 
without breaking them, even though not carefully centred, 4 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
while those of a smaller size, if carefully balanced, may be 
run at a much higher speed. Attachments to the Crookes 
tube for lowering the vacuum are not necessary when using 
this machine, as the vacuum is only slowly raised. 
The Crookes tube does not seem to require a large 
amount of electricity for its successful use. The prevention 
of leakage — and this leakage is very great in moist air — 
is the practical difficulty to be overcome. To this end, all 
parts of the machine should be carefully insulated, and 
leakage from the conducting wires and connections reduced 
as much as possible. The tube should be exhausted to the 
degree of pressure suitable to the apparatus used, a large 
static machine requiring a tube with a high degree of ex- 
haustion. The resistance of the tube increases after it has 
been used for some hours, but this resistance may be re- 
duced by heating the tube over a flame while turning it 
in the hand. This does not require to be done often. 
There are certain limits in the vacuum between which the 
X-rays are given off: if the vacuum is too low there are no 
rays; if too high the resistance of the tube is so great that 
it cannot be overcome and no fluorescence is produced on 
the screen. The best results seem to be attained when the 
vacuum is as high as the tube can be made to work success- 
fully. The following suggestions from the experience of 
Mr. (i. A. Frei are sometimes serviceable: If the vacuum 
is a little too low it may be made higher by running the 
tube with a closed spark-gap; if too high it may be lowered 
by running the tube with a closed spark-gap and with the 
current reversed. If there is not time to lower it in this 
manner the difficulty may sometimes be overcome for the 
moment by grounding the anode. 
To do the best work, good Crookes tubes are necessary, 
and an abundant supply of suitable electricity, more or less 
of which can be used as the conditions of the moment 
require. 
Next in importance to a good machine for exciting the 
X-rays and a good Crookes tube comes the fluorescopo. 
Fluorescopcs with screens made of tungstate of calcium have 
generally one great disadvantage ; namely, the screen remains 
bright, and the image of the object persists sometimes for ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
5 
several minutes after the fluorescope is taken away from the 
tube; but from the tungstate of calcium screen, which is 
the result of the patient and laborious investigation of Mr. 
T. B. Ivinraide, of Jamaica Plain, Boston, Mass., the image 
disappears as soon as the fluorescope is removed from the 
tube. 1 use three sizes : one 3 by 4 inches, one 7 by 1) 
inches, and the third 1 1 by 14 inches. 
Being now supplied with satisfactory apparatus, how can 
we use it to obtain the best results, and at the same time 
render the patient most comfortable during the examination ? 
Fig. 2. — Holder for Crookes tube; metal plate with rectangular opening lying on base 
of holder. 
The in which the examination takes place should be 
darkened, and, for further facilitating the end we have in 
view, I have devised the following appliances : First, the 
use of a canvas stretcher (see Fig. 1), which is placed when 
needed on supports connected with the table on which the 
static machine stands, and which may be drawn out or 
pushed in at pleasure. The patient rests easily on this 
stretcher, and may turn from side to side if required, and 
all portions of the body can thus be readily examined. 
Second, an adjustable stand for holding the Crookes tube 
(see Fig. 2), the arm of which may be raised or lowered, 
shortened or lengthened, as desired. This may be placed 6 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
under the stretcher, and as the X-rays penetrate the canvas 
as easily as they do the clothing, the patient is, as it were, 
suspended in the air over the tube, and all portions of the 
body are accessible. While examining the patient through 
the fiuorescope held in one hand, the other is free to change 
the intensity of the light, which is readily done by varying 
slightly the length of the spark-gap. It is important to 
have sufficient light, but it is equally important not to have 
too much light. It is also sometimes advantageous during 
an examination with the fiuorescope to move the Crookes 
tube from side to side, and by thus changing the posi- 
tion of the shadow of the part or foreign body more is 
learned than by one view. 
Third, a device which enables us to overcome the diffi- 
culty which we sometimes encounter, of getting a sharp 
definition and excluding unnecessary rays even when using 
the best fiuorescope. This appliance consists of a piece of 
sheet metal (e.g., brass) six inches wide by twelve inches long, 
and thick enough to prevent the passage of the X-rays, 
toward one end of which is cut a rectangular opening — 
this is preferable to a circular one — about two by three inches 
being a convenient size. After taking a general survey with 
the fiuorescope, the part of the body that is to be carefully 
examined is selected, and the metal plate held close under 
the stretcher in such a position that the X-rays coming from 
the Crookes tube fall directly through the opening, while the 
surrounding area is shielded by the metal. The fingers 
should be protected from the rays while holding the plate, 
and to accomplish this object leather straps are fastened on 
to the plate, so that the fingers may be inserted under them 
on the upper side ; the plate may be moved about and any 
special part examined. A diaphragm may be used near the 
Crookes tube, instead of the plate, made of sheet metal with 
a circular opening from about one to two inches in diameter, 
which may be slid into the grooves of the wooden pieces on 
each side of the tube. When in a groove near the tube the 
cone of rays is broad, when farther away it is narrower. 
Fourth, a pencil for tracing the outlines of a given organ 
or object during the examination of the patient with the 
fiuorescope. This pencil is made of metal, with a crayon ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
7 
point suitable for marking the skin, and along one side 
is a strip of lead wire which is held in place by means of 
sticking-plaster wound around the pencil. Were it not for 
this lead the X-rays would pass through the crayon so 
that it would not be visible, but by its means a dark 
shadow is cast, and one can see, as it were, the end of 
the crayon. 
The radiograph and fiuorescope are both useful in prac- 
tice. In taking the former it is most convenient to place 
the Crookes tube above the portion of the body of which a 
picture is desired, and the best direction of the part with 
regard to the tube in other respects may be frequently 
learned by previously examining the patient with the 
fluorescope. The nearer the part to the photographic 
plate, and the greater the distance of the tube, the sharper 
the picture. As in practice it is requisite to spare the time 
of the practitioner as much as possible, photographic plates 
wrapped in dark paper and enclosed in envelopes to protect 
them from the light are convenient, because, after being 
exposed, they may be sent, without opening the envelope, 
to the photographer to be developed. If it is desirable to 
have a picture within a few minutes, bromide paper en- 
closed in dark envelopes may be used, and developed 
directly. This is, I believe, the readiest way of obtaining 
a permanent record by means of the X-rays. If other 
copies are desired, the bromide paper may be coated with 
oil or paraffine, and prints may be made from it as from a 
glass negative. If two or three pieces of bromide paper are 
placed in the same envelope with a glass photographic plate, 
which, as already stated, is first wrapped in dark paper, the 
advantages of both methods are combined. A fluorescent 
screen is sometimes placed against the photographic plate in 
order to shorten the time of exposure. The objection to this 
method is that the radiographs are somewhat mottled and 
the picture loses in clearness. The following method is 
useful and satisfactory in taking radiographs. The sensitive 
side of a sheet of bromide paper is placed upon a thick 
screen of tungstate of calcium made of uniformly fine crys- 
tals "and with a perfectly smooth surface. The rays pass 
readily through the paper, act first upon its coating, and 8 
ADAPTATION OF X-liAYS TO MEDICAL PUACTICE. 
then cause the tungstate of calcium to fluoresce. This 
fluorescent light also acts photographically upon t he bro- 
mide paper, and the total effect of the action ot the rays is 
very much increased. 
The radiograph gives the permanent record, and makes 
finer distinctions possible, but, in the nature of things, 
affords only one view of a given organ or bone; whereas 
the fluorescope enables us in a moment to see these from 
different points of view, and we can thus get a better idea 
of the conditions present in a short space of time. The 
fluorescope is likewise peculiarly applicable to moving 
organs, such as the heart and lungs. 
An examination with the fluorescope may give an erro- 
neous idea of the size and position of a given organ unless 
the relation of flit' position of flu1 Crookes tube to the body 
is understood. By position 1 include distance and direc- 
tion. This must also be borne in mind when taking 
a radiograph. In an examination of the heart, for instance, 
when the Crookes tube is about six inches behind the back 
of the patient and the screen of the fluorescope is directly 
over the chest, it is obvious that the shadow of the heart 
will be much larger than the heart itself. To gain an exact 
knowledge of the size of the heart the Crookes tube should 
be two feet or more from the screen of the fluorescope, 
which should be held close to the body. 
Let me describe the method pursued in one of the 
simplest practical uses of the X-rays; namely, that of 
locating a bullet, whether in the head, body, or extremities. 
If unable to walk, the patient is brought in on a stretcher, 
which is placed directly on the supports attached to tlu' 
static machine table (all the hospital stretchers are of 
the same size and tit the grooves in the supports), and the 
Crookes tube is placed underneath. If the physician has 
just come into the dark room from bright daylight, he must 
wait until his eyes accustom themselves to the darkness ; the 
machine is then started, and the spark-gap adjusted to the 
length most suitable to the condition of the tube, this length 
being determined by examining the patient through the fluo- 
rescope. 
Everything being now in readiness, the fluorescope is ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
9 
placed directly on the thigh (let us suppose the bullet is 
there), and the examination is begun. After looking a 
moment the spark-gap may be changed a little in order to 
increase or diminish the light, as by means of this variation 
more can be seen, certain things showing better in a bright 
light and others in a less brilliant one. With a bullet it 
is generally well to use a considerable amount of light. 
After the thiorescope has been moved about a little, the 
shadow of the bullet is found, and the spark-gap may again 
be changed in order to get as clear a shadow as possible. 
The physician, while still looking through the thiorescope, 
then makes with the pencil already described a mark over 
the place where the bullet seems to be, and directly under 
the thiorescope ; he then makes a corresponding mark on the 
side of the thigh nearest tin1 Crookes tube, over the shadow 
of the bullet, and draws 1 and 1 by the side of each of 
these two marks. Then, while still looking through the 
thiorescope, the Crookes tube should be moved horizontally 
a few inches to and fro in order to learn how deeply the 
bullet is imbedded, for if the shadow of the bullet moves 
considerably in tin* thiorescope the bullet is some distance 
away. If it moves very little it must be near the thiorescope 
and the surface of the skin. If far from the surface its 
shadow will, of course, be ill-dctined; if near, it will be 
very sharply defined. Next, the patient should be turned 
so as to allow the physician to look through the thigh in a 
direction about at right angles to that first taken, and, as 
before, a mark should be made with the pencil over the 
place where the bullet seems to be, both when the point of 
the pencil is held directly under the thiorescope and on the 
side of the thigh nearest the Crookes tube. These points 
should be marked 2 and 2, and the bullet will be found at 
the point where the line drawn from 1 to 1 intersects that 
drawn from 2 to 2. I have used this method for locating 
bullets in different parts of the extremities, and in the neck, 
thorax, back, and abdomen, and usually the situation of the 
bullet is readily determined by this means. The first bullet 
I located in this way was in April, 1896. 
Let us now consider the principles upon which the use of 
tin' X-rays depends. These rays are probably, so far as our 10 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
present knowledge goes, ether waves, hut shorter than the 
waves of light, perhaps J(j to as long. Two properties 
of these rays interest us especially, and upon them depends 
their usefulness in medicine : First, their power of exciting 
fluorescence in certain substances. When the X-rays strike 
tungstate of calcium in a dark room it is seen to fluoresce, 
and the greater the number of rays which come into con- 
tact with it the greater the fluorescence. Second, the 
difference in their ability to penetrate different substances. 
It is more difliculf for fhese rays to penetrate bone than 
muscle, for instance ; hence more are intercepted in their 
passage through the former than the latter, with f he re«- 
sult thaf a darker band is seen upon the bright screen in 
the one case than in the other. The picture we get in fhe 
fluorescope and the impression made upon flic photographic 
plate depend, then, upon the greater or less resistance 
which the various parts of the body offer to the Roentgen 
rays. Let us therefore consider briefly the principal causes 
of this difference in permeability. First, bulk: a thin layer 
of a given substance will be more readily penetrated by the 
rays than a thicker one; second, chemical composition. 
The first needs no comment; but the second deserves atten- 
tion, as a clear appreciation of the possibilities and limita- 
tions of the X-rays in distinguishing between healthy and 
diseased parts is based largely upon a knowledge of the 
chemical composition of these parts. This knowledge leads 
us to avoid mistakes and disappointments on the clinical side 
which would not be experienced did physicians and surgeons 
appreciate fhe relation of the X-rays to chemical composi- 
tion, and points out certain ways in which these rays are 
capable of rendering aid. 
The following experiment with calculi illustrates in a 
striking manner how important to us is a knowledge of the 
chemical composition in our use of the Roentgen rays in 
medicine. Before attempting to detect any form of calculi in 
the body, I first placed several different kinds over a pho- 
tographic plate, which was enclosed in dark paper to shield 
it from the light, and exposed them for a few minutes to the 
X-rays. The rays penetrated the calculi made up of uric 
acid, of cholesterine and biliary salts, very readily, but were ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
11 
obstructed by calculi containing oxalate of calcium in con- 
siderable proportion, phosphate of calcium, or other inor- 
ganic constituents. Further study showed that organic 
substances are quite as readily penetrated by the X-ravs as 
the soft tissues of the body, and therefore it is obvious 
that any attempt to detect in the body calculi made up of 
organic compounds would, so far as our knowledge now 
goes, be futile, whereas those of inorganic origin might 
be detected. 
If diagnosis by some other means than the X-rays shows 
that there is a calculus in the bladder, for instance, which 
cannot be demonstrated by a good radiograph taken by 
o 
~n 
co 
-n 
o 
CD 
X 
X 
Fig. 3. — Instrument for radiographing a calculus in bladder 
means of an instrument described below, we know it is made 
up of uric acid or some substance composed chiefly of organic 
constituents. Calculi may occur made up of substances some 
of which are, and some of which are not, permeable by the 
X-rays. The instrument just referred to was devised by 
Dr. William II. Rollins, of Boston, and consists of an alumi- 
num tube 9 inches long and 1 inch wide, a cross section of 
which bears some resemblance to a crescent, one-half of its 
outline being in a general way parallel to the other half. 
The tube is closed with a solid piece of metal at one end, and 
to the other is fitted a handle which screws on (see II and 
II, Fig. 3). FC is a thin piece of metal with grooved edges 
which holds several pieces of photographic film or pieces of 
bromide paper which should be about as wide as the tube 12 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
and about half as long. To put the films in place tlie slid- 
ing piece FS is removed from FC, the tilms slid into 
the grooves and pushed to the end as far as they can go, 
after which the piece FS is put hack to hold the films in 
place. The whole is then pushed inside of HB and the 
round handle II screwed on; this must he done in a dark 
room. The instrument carrying the films, with the convex 
side up, is then inserted into the rectum of the patient, who 
is placed on his hack, and the instrument is held in such a 
position that the films are brought just below the bladder. 
The rays from the Crookes tube, which is placed over the 
bladder and some inches from the abdominal wall, penetrate 
the tissues and the aluminum wall of the tube and act upon 
flic film. After an exposure of a few minutes the instrument 
is withdrawn and the films taken out in a dark room and 
developed like any photographic plate. In the two cases in 
which I have used this instrument nothing was found on the 
films ; the calculi were removed and proved on analysis to 
he made up of uric acid. 
Fig. 4 is taken from a radiograph of the various calculi 
already referred to, which were lent to me by Dr. William 
F. Whitney, from the Harvard Medical School, and at his 
suggestion I added to the plate a dry hone, an incinerated 
hone, and a decalcified hone. The removal of the organic 
matter from the incinerated hone made little difference in 
the penetration of the rays, whereas the removal of inor- 
ganic matter (mineral salts) in the decalcified hone allowed 
the rays to pass readily. 
In order to gain some conception of the susceptibility of 
the various constituents of the body to the X-rays, I made 
several radiographs of a considerable variety of substances, 
and one of them 1 have had reproduced here. The condi- 
tions of this experiment, the result of which is shown in 
Fig. 5, were as follows : Equal hulks of substances which 
represented in a general way the chemical constituents of 
the body were placed in small pasteboard boxes of the 
same size, namely, 15mm. in depth, 38mm. in length, and 
25mm. in width, those containing liquids being first coated 
inside with shellac, and the weights and contents being noted 
on each box. The boxes were then placed on a photographic ERRATUM. 
Page 12, 12th line from top of page, for “inches” read 
“ distance.” ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
13 
plate enclosed in dark paper, and exposed for about two 
minutes to the action ot the rays at a distance of two feet. 
Fig. 4. — The two upper rows of objects in this radiograph are calculi. The two calculi 
on the left are composed of uric acid and urates; those on the right of phosphates; and the 
two in the middle of oxalate of calcium and uric acid, the upper one of these last two having 
an outside coating of urates. In the centre of the picture is a round aluminum cup, contain- 
ing water, one inch in depth, and on either side of this cup is a group of gall stones, and to 
the right and below the cup a single large gall stone is seen indistinctly. In the left-hand 
lower corner is a decalcified bone, bent into the shape of fl, with a lead tag attached by a 
copper wire. The decalcified bone surrounds an incinerated bone, which is lying on a piece 
of cotton wool in a wooden box with a glass side. In the right-hand lower corner is a dry 
bone; in the extreme right-hand corner is a triangular piece of lead. The picture is reduced 
to one-third of its original size. 
The result here also showed that the organic substances are 
more readily penetrated than the inorganic, and that some 14 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
of these latter, notably the salts containing considerable 
calcium or chlorine, for example, most obstructed the pas- 
sage of the rays. In many radiographs which I have taken 
of patients, different tissues may be recognized, owing in 
part to variation in chemical composition ; one sees, for 
8 7 6 y *- 3 z ' 
/5~ /V '3 /Z // /c 9 
zc // /* // 
Fig. 5. — Iiadiograph of equal bulks of various substances which represent the constit- 
uents of the body in a general way. 
Weight. 
Weight. 
1. 
Carbonate of magnesium, 
1.6 grammes. 
5. Gelatin 
2. 
Stearic acid 
3.8 
6. Dried egg albumen . . . 
6.4 
3. 
Oleic acid 
7. Carbonate of sodium . . 
5.9 
4. 
Palmitic acid 
4.4 
8. Milk sugar 
11.7 
9. 
Glycerine 
13. Phosphate of calcium . . 
2.6 grammes. 
10. 
Water 
14. 
14. Sulphate of sodium . . 
10.8 “ 
11. 
Oxalic acid 
12.2 
15. Magnesium ammonium 
12. 
Phosphate of sodium . . 
10.6 
phosphate 
12.5 
16. 
Chloride of sodium . . 
8.6 grammes. 
19. Carbonate of calcium . . 
15.3 grammes. 
17. 
Sulphur 
20. Fluoride of calcium . . 
11.7 
18. 
Chloride of potassium 
10.1 “ 
example, the skin, a layer of adipose tissue, muscles, normal 
bone, and chemical changes in bones due to disease. 
The radiographs1 of the teeth first taken by Dr. Rollins 
show beautifully the bone of the jaw, the enamel of the 
tooth, the dentine, and the tooth canal. This is probably 
largely a question of chemical composition. 
1 “ Boston Medical and Surgical Journal,” Vol. 135, page 90, 1896. ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
15 
Let us see what further light may be had on this subject 
from a chemical standpoint. It is known that the chemical 
elements vary, generally speaking, in the ease with which 
they are permeable by the rays according to their atomic 
weights. These weights range from 1 to 288.5. We do 
not find all these elements in the body, but only those, in 
any considerable amount, which are given with their atomic 
weights in Table I. 
TABLE I. 
Element. 
Atomic weight. 
Hydrogen .... 
1. 
Carbon .... 
12. 
Nitrogen .... 
14. 
Oxygen .... 
16. 
Fluorine .... 
19. 
Sodium .... 
23. 
Magnesium 
24. 
Phosphorus 
31. 
Sulphur .... 
32. 
Chlorine .... 
35.5 
Potassium .... 
39. 
Calcium .... 
. 
. 
40. 
Iron (to small amount only) 
55.9 
Further, about two-thirds of the body by weight is water 
(molecular weight, 18), and the soft tissues are largely 
made up of it. 
Ligaments contain about ..... 
Water. 
77% 
The voluntary muscles, about .... 
75% 
(They contain nearly one-half the water of the body.) 
Cartilage ........ 
55% 
Bones ........ 
13% 
Teeth ........ 
10% 
Epidermis ....... 
3% 
The various fluids formed in the body in health or disease, 
such as the blood, ascitic and pleuritic fluid, the urine, 
pus, fluid from hydrocele, etc., are made up chiefly of water, 
and are found to offer about the same resistance to the pas- 16 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
sage of the rays as does water when compared under the 
fluorescope. That is, the difference in the amount of light 
as seen in the fluorescope which passed through each of these 
fluids when placed respectively in a vulcanite cup, compared 
with an equal amount of water in a vulcanite cup, was not 
marked. From such observations and from our knowledge 
of the composition of the constituents of the body we can 
infer that its soft tissues, except adipose tissue, will present 
about the same resistance to the passage of fhe rays as an 
equal bulk of water, whereas the denser tissues which differ 
from water in their chemical composition and contain ele- 
ments of a higher atomic weight than oxygen, the chief 
weight of water, will present a greater obstacle than water 
to the passage of the rays. It will occur to those familiar 
with the composition of the various tissues of the body that 
in some, muscle, for example, the organic constituents made 
up of carbon, hydrogen, and nitrogen would tend to make 
it more penetrable than water, whereas any small amount of 
mineral matter would diminish its permeability; that is, the 
average of the soft tissues would not be far from water. 
There is one other point which must not be overlooked 
in this connection, and that is the* difference in resistance 
which air and water offer to the passage of the X-rays. 
The rays pass through air much more readily than through 
water, and as air makes up a certain bulk of the body, a 
large part of the chest is filled with it, while water enters 
into the composition of all parts of the body and forms the 
chief constituent of the soft parts, if is readily seen of how 
much importance is this difference in permeability of air and 
water by the rays, on account of the great contrast which is 
thereby afforded in health between the lungs and their adja- 
cent tissues or organs. Further, as will be shown later, one 
of the best opportunities for the advantageous application 
of the X-rays is obtained from the contrast of the normal 
lung tissue with that offered by pathological conditions 
which occur in the thorax, involving chiefly increase in den- 
sity in the lungs or in fhe space usually occupied by them. 
To use the Roentgen rays successfully in practice, it is 
first essential that the physician become familiar with the 
appearances in the fluorescope which present themselves in ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
17 
health. This applies particularly to the thorax, and the 
picture of this part of the body when seen in the screen 
of a large tluorescope presents so much that it should be 
studied systematically. The trunk appears lighter above 
than below the diaphragm, and the rise and fall of this muscle, 
which appears dark in the tluorescope, are distinctly seen. 
The chest is divided vertically by an ill-defined dark band, 
which includes the backbone, on each side of which the lungs, 
forming the brightest part of the picture, are crossed by the 
darker ribs. The pulsating heart is seen, especially the 
dark ventricles, and, under favorable conditions, the lighter 
right auricle, and on the left side above the ventricles the 
pulmonary artery is made out. A small portion of one side 
of the arch of the aorta may be observed in the first inter- 
costal space to the left of the sternum. After this general 
view has been taken, the outline of the lungs should be noted 
during full inspiration and expiration, and the excursion 
made by the diaphragm during quiet breathing and during 
full inspiration and expiration. The lungs usually appear 
brighter during deep inspiration ; in young persons brighter 
than in older persons, as the tissues of the former are more 
easily penetrated by the rays. In the thin, the lungs 
appear lighter than in the heavy, because the outlines arc 
dulled, as it were, by a thicker layer of tissues, which con- 
tain much water. It has seemed to me that the right apex is 
normally darker than the left apex. The normal brightness 
of the lungs and the normal outlines of the clavicles and 
ribs should be observed, for as we note different degrees of 
pallor by reference to our standard of color in health, in the 
same way is it necessary to know the normal amount of 
light which should penetrate any given part in order to rec- 
ognize variations from the normal. The eye must be 
trained in the use of the X-rays as is the ear for auscultation 
and percussion. In Fig. (i the two upper lines on either 
side of the chest indicate the position of the top of the 
diaphragm during expiration and inspiration respectively in 
quiet breathing ; the lower on either side, the top of the dia- 
phragm in full inspiration ; the line of complete expiration 
nearly coincides with that of expiration in quiet breathing. 
The spot below the nipple is where the apex beat was felt. 18 
ADAPTATION OF X-RAYS TO MEDICAL PHAOTICE. 
The Crookes tube was directly under the junction of the 
ensiform cartilage with the sternum. 
In six men with healthy lungs the diaphragm moved on 
an average two and three-fourths inches on the right side 
and two and one-half inches on the left side. In eighteen 
patients with tuberculous lungs the average excursion of the 
diaphragm was one and one-fourth inches. In health the 
diaph ragm is less sharply defined in expiration than in in- 
spiration. 
The heart in some healthy persons moves in deep inspi- 
Fig. 6. —Chest of man, showing diaphragm lines in quiet breathing and deep inspiration, 
and part of the outline of the heart. 
ration downwards and toward the median line about one-half 
an inch. 
To test, the possibilities of an examination with the fluore- 
scope in certain conditions of the lungs, as when congestion 
or more or less oedema or pleurisy was present, I tried 
one or two simple experiments. On full inspiration in 
healthy patients 1 found the pulmonary area lighter than in 
other stages of respiration, and the ribs stood out in greater 
contrast, thus showing that there must be less blood in 
the lung during the former period, and that if any part of 
the lung is much congested, or if oedema is present, il 
would naturally appear darker than the normal lung; also, 
when I held a small pasteboard box, about one-half inch ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
19 
deep and full of water, over one side of the thorax of a 
well-developed and muscular man with a large chest, I could 
see its shadow in the fluoreseope during about full inspira- 
tion, but not at other times. 
In order to get further suggestions in regard to the possi- 
bilities of the X-ray examinations in diseases of the lungs, 1 
took a number of radiographs of healthy and diseased lungs 
just after death. As a specimen of the latter, see Fig. 7, 
which shows the lungs of a patient who died of pneumonia. 
The darker was more affected by the process than the 
lighter; the lightest portion is healthy. These lungs were 
kindly sent to me for a few moments by Prof. W. T. 
Councilman. The autopsy of one of my patients showed he 
had perfectly healthy lungs. 1 had examined the chest of 
this man with the fluoreseope two days before his death, and 
found his lungs perfectly clear and the outlines well defined. 
The outlines also of the front and back portion of the ribs, 
forming a lattice work as shown in the fluoreseope, were well 
seen. 
We shall see later that in certain diseases parts or the 
whole of one or both lungs appear darker or lighter than in 
health, and that their volume may be greater or less than in 
health, "flic respiratory excursion of the diaphragm may 
vary from tin1 normal on either or both sides of the chest, 
in position ; that is, it may be higher or lower in the body, 
and in amplitude. In making examinations, changes in the 
amount of light seen in the fluoreseope should be carefully 
observed; for example, whether or not one lung is darker 
than the other. In pathological conditions the indications of 
change in density, shown usually by diminished brightness, 
may be estimated by comparing the two sides and observing 
whether the outlines of the organs, and whether the ribs and 
clavicles, are more clearly seen on one side than the other. 
When both sides are diseased the opportunity for direct 
comparison with the normal is lost, and one is obliged to de- 
pend upon the recollection of the normal in an individual of 
the same build. 
The position, excursion, and curve of the diaphragm 
should also be carefully noted. If these are normal there 
is little probability that the lungs are diseased ; but in tuber- 20 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
culosis or pneumonia, when the lung, which should be well 
tilled with air, is made denser by some pathological process, 
Fig. 7. — Lungs from a patient who had died of pneumonia. The darker lung has been 
more affected by the pneumonic process than the lighter. 
or, if the elasticity of the lung is diminished, the excursion 
made by the diaphragm will be less than in health, and will 
be reduced from the lower side; that is, the diaphragm ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
21 
would not reach so low a point in the chest. In emphy- 
sema, on the contrary, although the excursion of the dia- 
phragm is also less than in health, it goes further down into 
the chest than when the conditions are normal. When 
there is fluid in the pleural cavity the outline of the dia- 
phragm is obscured. 
I have thus far considered some general principles and de- 
scribed a few simple experiments which have a bearing upon 
the practical applications of the X-rays to medical practice, 
and have indicated some of the inferences which may be drawn 
from them, and will now consider the clinical side of the 
subject. 
By the courtesy of my colleagues of the hospital stall*, 
under whose care most of these patients were, I give a brief 
outline of the physical examination of a number of them, 
and have added what I found by the X-ray examination. 
We will consider first cases of pulmonary tuberculosis. 
Most of these patients presented well-marked signs of 
the disease when they entered the hospital, but in private 
practice the proportion of patients who are seen in the 
early stages, when there is greater opportunity for success- 
ful treatment, is larger, and therefore the earlier diagnosis 
which the fluorescope assists us to make would be of special 
value in these eases. 
In tuberculosis of the lungs the fluorescope indicates dis- 
ease in the following ways : 
A diminution in the volume of the diseased lung is 
shown by the position and movement of the diaphragm, 
and increase in density by a diminution in the normal 
brightness, the degree and extent varying in accordance 
with the increase in and extent of the density. The lung 
may become so dense that no more rays pass through it than 
through the liver. The brightness or light in the lungs 
indicates the amount of air present in them. 
The following cases of tuberculosis taken from those I 
have examined, more than fifty in number, illustrate several 
points : Correspondence between the physical signs and the 
X-ray examination in a considerable number of cases; more 
extensive disease than was shown by the physical examina- 
tion in certain cases ; an earlier increase in density in the 22 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
lungs than was detected by the physical examination in 
still other cases; in one of these no signs in the lungs 
were detected prior to that found by the fluorescope, while 
in some, although one lung was ascertained by the physical 
examination to lie seriously involved, its companion was 
not suspected until the X-ray examination revealed its in- 
creased density; fourth, three cases suggest that increase 
in density was not present where the physical signs inti- 
mated it. In a few cases the physical signs gave more 
information than the X-ray examination, but these were 
cases that were examined before I had had much experience 
in the use of the fluorescope. It will be noticed that in 
some of these cases nothing essential was learned by the 
X-ray examination that the physical examination had not 
already shown, but it should be said that in the beginning 
of my study it was instructive to examine any tuberculous 
patient, for if the correspondence between the physical 
signs and the X-ray examination had proved not to be 
evident in well-marked cases, it would have been useless 
to pursue the subject farther. At first, in order to make 
the X-ray examinations without bias, I examined the 
patients with the fluorescope before knowing anything of 
the physical examination. My object was to seek for any 
method that would assist in making a diagnosis as early as 
possible, and the X-ray examination is of service, to recapit- 
ulate somewhat, if it reveals to us changes in the lungs 
earlier than we have been able to learn of them in other 
ways ; and if it will assist us to ascertain better than here- 
tofore the extent to which the lungs are involved, whether 
to a greater or a less amount; in cases where the physical 
examination seems to show that the lungs are denser 
than normal, but the fluorescope shows that they are clear, 
we may be enabled by the aid of the X-rays to make a 
more favorable or more guarded diagnosis. Obviously, in 
a well-marked stage of tuberculosis of one or both lungs, 
it is useless to make an X-ray examination for purposes 
of diagnosis, although in these cases it is serviceable in 
estimating the extent of the disease. When no signs, or 
only doubtful ones, are found by auscultation and percussion, 
the X-ray examination should be made, and in such cases 23 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
we usually have the opportunity of coni}taring a diseased 
with a healthy lung. It should be borne in mind that 
in the use of the fluorescope we are not wholly dependent 
on the recognition of increase in density to suspect disease 
in a lung, but have also a way of judging whether its 
volume and elasticity are normal or not by observing 
carefully in the fluorescope the movement of the diaphragm 
during respirations. 
Some of these tuberculous patients in whom the disease 
was advanced died while in the hospital, but as there were 
no autopsies, it has not been possible to know how far what 
was seen in life under the fluorescope corresponded to the 
appearances after death. 
In the following 18 cases the examination with the 
fluorescope showed that the disease was more extensive 
than the physical examination indicated; it also showed in 
cases 1, 2, 8, 4, 5, (>, an earlier increase in density than 
was indicated by the physical examination. In cases 2, 3, 
4, 5, 6, the physical examination indicated disease in one 
lung, but did not show that the other was likewise involved, 
as did the examination with the fluorescope. 
In case 7 the fluorescope showed increase in density at 
the left apex when il was doubtful by auscultation and 
percussion. 
In case 17 appearances in the fluorescope suggested a 
cavity in the upper part of the lung; the physical signs 
noted, after the examination with the fluorescope, corre- 
sponded with this observation. 
Examination with fluorescope showed increase in density 
in the tirst six cases earlier than the physical examination : 
1. M. M., 23 years. Tuberculosis. Family history tubercular. History 
of haemoptysis, physical examination negative except a few clicks at the 
junction of second rib and sternum on right, and at left apex behind. 
Examination with liuorescope : Darker over three-fourths of right lung, 
and also at left apex to second rib; on the right side the thorax was 
darker than normal nearly to line of liver; on deep inspiration the 
lower portion of the right lung was clearer than the part above. 
[Three weeks after X-ray examination there was found slight dulness 
at left apex back and front, with harsh respiration and increased voice- 
sounds.] 24 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
Examination with fluorescope showed in the following five 
cases that not one, but both lungs were involved: 
2. B. J., 27 years. Tuberculosis. Tubercular family history. 
Haemoptysis. During past month dyspnoea, weakness, night-sweats, 
little cough. Marked signs of tuberculosis below second rib over whole 
left side ; right lung negative. 
Examination with fluorescope: Whole of left lung much darker than 
normal, no heart outline, no diaphragm outline seen on left side. 
Right apex darker than normal to lower border of second rib. 
3. L. C., 44 years. Tuberculosis. Dulness, with rales over left side 
down to third rib in front and middle of scapula behind. 
Examination with fluorescope: Somewhat darker at both apices 
down to lower border of third rib, and to some extent below; excursion 
of diaphragm much less than normal, | inch on right side, 1 inch on left. 
4. II. A., 20 years. Tuberculosis( ?) Duration, four weeks; family 
history not tubercular. Medium dry rales at left apex, with slight 
dulness ; right apex normal. 
Examination with fluorescope: Left lung extending to level of the 
fourth rib very dark; there is also some involvement of right apex. 
The maximum respiratory movement of the diaphragm on the left side 
is only J inch; on the right side 1 inch only. This is less than half the 
normal. 
[Later tubercle bacilli were found.] 
5. R. J. M., 44 years. Anorexia; loss of flesh ; percussion, dulness 
at right apex, front and back, to third space and middle of scapula; ex- 
piration prolonged, rales; increased voice-sounds; left side normal. 
Examination with fluorescope: Right lung darker to fifth rib; left 
lung darker than normal as far as second rib. 
[Tubercle bacilli found later.] 
6. S. S., 35 years. Tuberculosis. Mitral stenosis. A few scattered 
sonoi-ous rales. In left back from 1 inch below angle of scapula are 
many fine and medium moist rales. Two negative examinations for 
tubercle bacilli. 
Examination with fluorescope: Right lung to level of nipple darker 
than lower portion of right lung; whole of right lung denser than left 
lung. Left lung at apex (to second rib) rather darker than normal; 
lower part of left lung the clearest part of the chest. 
7. R. M., 24 years. Pleurisy-]- . Signs in right apex and friction 
rub at right base, a question of left apex ; slight haemoptysis. 
Examination with fluorescope: Both apices darker to third rib on 
right side, not so far on left. [Five weeks later dulness in both apices, 
more in the right apex.] ADAPTATION OF X—RAYS TO MEDICAL PRACTICE. 
25 
8. F. J., 26 years. Tuberculosis. Marked dulness of right apex 
above clavicle ; less dull to third rib ; increased voice-sounds ; respira- 
tion slightly harsh ; expiration prolonged ; moist rales at apex. 
Examination with tluorescope: Whole of right side darker than left 
side, especially upper half of right lung; ribs in upper half of right 
chest seen very indistinctly ; ribs seen very clearly on left side; outline 
of diaphragm distinct on left side during expiration; outline of dia- 
phragm not distinct on right side; in fact, not well made out. 
9. L. J., 23 years. Tuberculosis( P) Family history tubercular. 
Haemoptysis. Lost fifteen pounds; dulness under right clavicle, with 
fine moist rales after cough ; practically no other abnormal signs. 
Fluorescope: Increased darkness on right side to lower border of 
third rib; also on left side darker than normal. 
10. T. M., 31 years. Tuberculosis. Night-sweats and loss of flesh ; 
fair resonance over both fronts; over upper third of right front respira- 
tion is rather harsh ; on the left above the clavicle and down to fifth rib 
are numerous coarse, moist rhles; left back: resonance somewhat defi- 
cient throughout. 
Examination with fluorescope: Both apices darker than normal to 
upper border of third rib on right, and to upper border of fifth rib on 
left side ; outlines of ribs at apices not defined ; left border of heart not 
defined on account of increased density of lung. 
11. M. W., 17 years. Family history tubercular. Duration, six 
months. Right apex dull above second rib in front and angle of scapula 
behind ; expiration slightly prolonged ; mostly dry rales in this region ; 
voice-sounds, especially at right apex in front, increased; rales of same 
character in left upper front. 
Examination with fluorescope : On right side darker than on left from 
second to fourth rib; diaphragm moves on right side 1 inch, on left 1R 
12. G. II. Tuberculosis. Both apices dull in front; right more so 
behind; respirations harsh, moist and dry clicks after cough; tubercle 
bacilli found. 
Examination with tluorescope: Upper half of right lung darker 
than normal, and apex of left lung. 
13. N. E. Tuberculosis. Tubercle bacilli found; deficient reso- 
nance over left front; fine crepitations over lower half of right axilla, 
over upper two-thirds of scapula, and between scapula and spine; 
numerous squeaks which seem close to the ear; a few also heard between 
border of right scapula and spinal column ; few fine r:\les at right base. 
Examination with fluorescope : Whole of both lungs somewhat darker 
than normal; the darkest portions are from right apex to second rib, 
left apex to third rib. 
14. P. 1)., 48 years. Tuberculosis. Duration, two months. Fair reso- 
nance over both lungs except at left base behind, where there is slight 26 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
dulness; respiration somewhat jerky over upper half of both fronts, 
slightly bronchial over upper half of left; over left front to the fifth rib 
are numerous medium and fine moist rales after cough ; a few I’ales over 
upper right front; at left base are numerous fine crepitations Tubercle 
bacilli found. 
Examination with fluorescope: Left lung darker throughout than 
right; outline of diaphragm and of heart on left side ill-defined; lower 
portion of left lung (below a line running directly outwards from 
junction of fifth rib and sternum) is much darker than above this. 
15. D. J. 1)., 32 years. Tuberculosis( ?) Bronchitis. Pleurisy. 
Considerable expectoration, loss of flesh, pain in left side, flatness at 
left apex above the clavicle; a little dulness just below outer end of 
left clavicle ; slight dulness above right clavicle ; patient breathes feebly 
on account of pain in lower left chest; increased vocal resonance at left 
apex, and in small patch below and just outside right nipple; moist 
rales throughout upper left chest. 
Examination with fluorescope: Left side a little darker than right 
side down to third rib; movement of diaphragm on left side | inch, on 
right side 2k inches. 
16. C. M., 45 years. Tuberculosis. Fair resonance over right chest, 
some dulness over left chest, with many fine, moist, sonorous, and 
sibilant rales, also occasional coarse moist rilles ; slight increase in vocal 
fremitus throughout the left side and whole upper chest front and back. 
Examination with fluorescope: Left apex as far as lower border of 
second rib is a little darker than corresponding portion of right side. 
Diaphragm on right side moves 2k inches, on left If. 
Second examination with fluorescope, seven weeks later: Right 
clavicle seen only indistinctly ; first and second ribs seen less distinctly 
than normal; diaphragm moves 2\; left, no clavicle seen; first and 
second ribs indistinctly; diaphragm moves If. 
17. G. A., 35 years. Tuberculosis. Good resonance on right chest 
except at apex, where resonance is lacking; breathing is rather high 
pitched, and there is an occasional crackling rale after cough; left lung 
resonance high pitched at apex, becoming markedly dull below on front 
and back; breathing, broncho-vesicular; increased tactile and vocal 
fremitus and whispered bronchophony; numerous fine, moist, and 
crepitant rttles over whole chest. Tubercle bacilli found. 
Examination with fluorescope. On right side from apex to lower 
bolder of fifth rib the lung is darker than normal, though the outlines 
of the ribs are seen. On the left side the lung is dark throughout 
except between the first and third ribs, where there is a light area 
which suggested a cavity. The left border of the heart is not seen ; the 
diaphragm on the left side is barely made out. 
After the X-ray examination another physical examination gave: 
left apex: percussion rather high-pitched and tympanitic in qualit}7; 
breathing amphoric. ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
27 
18. T. H., 32 years. Ill fifteen days before entrance to hospital; 
never been ill before. At entrance sputum appears to be merely saliva 
— no signs in lungs; seventeen days after entrance, dulness at left 
apex to third rib ; prolonged and harsh respiration. Left back : dulness 
above spine of scapula; harsh breathing ; voice-sounds increased ; fine 
crackling rales after cough. 
Examination with fiuorescope: Left lung dark from apex to fourth 
rib; outline of heart above fourth rib and the ribs themselves barely 
visible. Diaphragm moved 1 inch on left side, and 2 inches on the 
right side. 
The following seven cases show a general correspond- 
ence between the physical examination and the examination 
with the fluorescope : 
19. C. F. W., 21 years. Tuberculosis. Duration, two and a half 
years. Right side : marked dulness in front to second space, where note 
becomes higher pitched. At second space respiration somewhat am- 
phoric, with loud crackling rales and metallic tinkling at times; fine 
1’iiles to base ; fremitus and voice-sounds increased throughout; in back, 
dulness from apex nearly to base. Left side : x’esonance slightly dimin- 
ished at extreme apex front and back, with dry rales in front. 
Examination with fiuorescope: Right side dark to lower border of 
fifth rib in mammary line. Left side clear except at apex, but as right 
side is dark, there is no opportunity for comparison with normal. 
Diaphragm on right side moves \ inch only; on left side, 1| inches only. 
20. M. J., 44 years. Tuberculosis. Lungs: slight dulness at right 
apex in supra-clavicular space; high-pitched breathing; occasional 
crackling r&les after cough ; left side : in front, marked dulness at apex 
and in left axilla, with percussion note lacking over rest of left front; 
at apex, breathing is broncho-vesicular with increased vocal and tactile 
fremitus; numerous fine, moist, and crackling rales. 
Examination with fiuorescope: Ditlicult to estimate condition of right 
apex, as there is no opportunity for comparison with the normal; whole 
of left side darker than normal. First, second, third, and fourth ribs 
and clavicle not seen; below this ribs faintly seen. Diaphragm only 
faintly seen on left side; moves right side only \h inches. 
21. C. J., 29 years. Tuberculosis. Dulness over right lung down 
to fourth rib in front and as far as spine of scapula in back; broncho- 
vesicular breathing ; increased vocal and tactile fremitus ; bron- 
chophony ; numerous fine, moist rales. 
Examination with fiuorescope: Right side darker to third rib, very 
marked; moves diaphragm right side % inch, left side 1£ inches. 
22. L. C. F., 24 years. Had pleurisy on left side two weeks ago. 
Pulmonary tuberculosis. Right side negative ; left, slightly diminished 
resonance throughout lower half of left back; voice and fremitus also 28 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
diminished, with occasional friction ; no rales heard; rest of lung nega- 
tive. Tubercle bacilli found. 
Examination with tluorescope: Right ajjex seems a little darker 
than left apex as far as lower border of second rib; diaphragm moves 
]l inches on right side, 1| on leftside; outline of diaphragm on the 
left not quite as clear as on right side. 
23. II. J., 33 years. Cough one year. Pain in lower front chest; 
slight dulness at left aj)ex, front and back; occasional rAles; voice- 
sounds slightly increased; prolonged expiration. Tubercle bacilli 
found. 
Fiuorescope : One week later, upper part of both right and left chest 
darker as far as second rib; clavicles and first and second ribs not seen ; 
movement of diaphragm on right side, 2] inches; on left side, Id inches. 
24. C. J., 33 years. Tuberculosis. Duration of illness, two months. 
Right front by percussion tympanitic ; respiration diminished ; few rales 
scattered throughout; tactile fremitus diminished ; right back : dulness 
from apex to one inch below angle of scapula; fremitus same as left 
side ; respiration diminished throughout, less marked from angle down ; 
few fine rales over upper half; entire right back is dull, dulness in- 
creasing downwards; left front negative save for few sonorous rales at 
base; tubercle bacilli found. 
Examination with fiuorescope : Right side much darker than left side, 
which is clear and bright; the darker area extends over whole of right 
side. 
25. B. M., 30 years. Tuberculosis, haemoptysis. Tubercle bacilli. 
Left lung: dulness in front second rib, with bronchial respiration, and 
a few fine rales throughout the left back; dulness also in lower left 
back; increased vocal fremitus; right lung free except for small 
patch in back, opposite fourth dorsal vertebra, over which are heard 
bronchial breathing and occasional fine rales. 
Examination with fiuorescope : Left lung darker from apex to fourth 
rib; right lung darker from apex to lower border of second rib. 
Examination with the fluorescope suggested a more favor- 
able condition than was indicated by the physical signs : 
26. N. O., 27 years. Tuberculosis (?) Resonance and respiration 
fair on both backs ; right back below spine of scapula, dulness ; breath- 
ing diminished; vocal and tactile fremitus increased slightly; occa- 
sional rales. 
Examination with fiuorescope : Both sides clear. 
27. M. C., 29 years. Tuberculosis (?) Loss of flesh and appetite; 
for six weeks cough and expectoration; no dyspnoea, no night-sweats. 
Three examinations for tubercle bacilli negative. 
Examination with tluorescope: No difference in two sides; rays ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
29 
go through both chests well; outlines of diaphragm and heart show 
clearly. 
Later the signs of bronchitis cleared up. 
28. S. B., 20 years. Diagnosis: phthisis. May 1,1894, pain in chest, 
subject to colds; weak amenorrhoea, signs of consolidation at both 
apices, especially the left; numerous tine and medium rales. October 
16, 1894, signs at both apices; weight, pounds. December, 1894, 
weight, 105 pounds. July, 1895, slight dulness at both apices, front and 
back; few rales; weight, 102 pounds. September, 1896, cold hands 
and feet; no cough ; pain in chest, side, and back, especially after tak- 
ing any food or drink; patient is very nervous woman. 
Examination with fluorescope: No difference in the two sides, both 
clear; ribs and clavicles stand out clearly. 
Iii the following cases the examination with the fluorescope 
gave less information than the physical examination : 
29. B. J., 42 years. Tuberculosis. Uulness in both supra-clavicular 
spaces, especially the left; left back dull above the spine of the scapula ; 
below left clavicle some slight dulness with high-pitehecl breathing, 
tubular in character with prolonged expiration; vocal and tactile fremi- 
tus increased; numerous crackling rales; right apex, dulness to supra- 
clavicular space ; occasional rale at right apex. 
Examination with fluorescope: Left apex darker than right apex; 
no increased darkness detected at right apex; probably not as 
readily noticed, as the left side is already diseased, and therefore com- 
parison with a normal lung could not be made. 
30. L. M. Tuberculosis. Tubercular family history. Haemopty- 
sis, cough, pyrexia; dulness in right front down to fourth rib, with 
prolonged expiration, increased voice-sounds, line crackling rales, most 
marked after cough; dulness over whole right back, with increased 
tactile and vocal fremitus; left apex dull in front and behind, with 
high-pitched respiration and crackling rales. 
Examination with fluorescope: Both apices darker than normal; 
darkness more extensive in the right side. 
Pneumonia offers an opportunity of testing the value of 
the X-rays in recognizing increase in density in comparison 
with the usual physical examination. I have examined 
patients while they were convalescing from pneumonia, both 
by auscultation and percussion and by the fluorescope on 
the same day, and while by means of the latter I was able 
to recognize that the lungs were denser than normal, 1 failed 
to detect the continued increase in density by auscultation 
and percussion. iks the lungs improved the areas that had 30 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
been dark became lighter in the fluorescope, until finally 
the amount of light passing- through them appeared about 
normal. During all this time the movement of the dia- 
phragm was less than normal; that is, the expansion of the 
lungs was restricted, but increased as the condition of the 
lungs improved. When I could no longer recognize increase 
in density in the lungs with the fluorescope, I could easily 
see by means of this instrument that the diaphragm did not 
descend to its normal limit, thus showing that the lungs 
were still in an abnormal condition. Later, the normal 
limit was reached. 
The following cases of pneumonia taken from those I 
have examined show a general correspondence between the 
physical signs and what was seen in the fluorescope, but the 
brief description of these cases does not present to the mind 
how much these examinations conduce to a more accurate 
estimate of the condition of the lungs in some cases than 
has hitherto been possible in any other way. This method 
of examination enables us to judge better than any other 
way when the lungs have “cleared up” after an attack of 
pneumonia, and 1 am satisfied that it gives us the means of 
* recognizing an increased density in the lungs in pneumonia 
earlier than has been previously possible : 
1. B. G., 36 years. Pneumonia. Ten days before entrance to hos- 
pital, sudden pain in left axilla, cough, dyspnoea, fever. Physical ex- 
amination at entrance showed that there was dulness in left back one 
inch below spine of scapula, which extended downward and outward to 
axilla; over dull area bronchial breathing, increased voice-sounds, and 
tactile fremitus; numerous line rales after cough; resonance good 
over both fronts and axillae. Physical examination nine days later, at 
time of X-ray examination, showed dulness in left back from mid-scap- 
ula down, with bronchial breathing, increased voice-sounds, and a few 
medium rales. 
Examination with fluorescope : Left side from third rib downwards 
so dense that no outline of heart, ribs, or diaphragm is to be seen. The 
apex of the heart, although not seen, is felt in normal position, showing 
that the increased density observed in the fluorescope is due to changes 
in the lungs rather than to fluid in the pleural cavity; right side per- 
fectly clear, ribs and outline of diaphragm seen well. 
2. L. B., 19 years. Pneumonia. At entrance to hospital, on the 
fifth day of the disease, marked dulness over upper right chest, down 
to fourth rib. Bronchial breathing, increased vocal and tactile fremi- 31 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
tus, dulness in right axilla. Right back: dulness from apex to 
middle of scapula. Left: front and back good resonance; many fine, 
coarse, and moist rales at base and back. On seventh day of the dis- 
ease, right front dull from apex to lower border of second rib, shading 
to lower border of third rib; in back, dull to 2 inches below spine of 
scapula. Nineteenth day of disease, physical signs have cleared up. 
Examination with fluorescope: On seventh day of disease, right 
lung dark from middle of first intercostal space to fourth rib; the 
upper and lower border of this dark area were definitely marked ; out- 
lines in chest rather less clear than normal on both sides. Diaphragm 
moved I inch on right side, and 1| inches on left side. Fifteenth day 
of disease, diaphragm moved 1 inch on the right side; 2k inches on left 
side. Nineteenth day of disease, diaphragm moved 2 inches on right 
side; 2| inches on left side. Original dark area on right side not so 
bright as other portions of the lung. On the twenty-second day of the 
disease, diaphragm moved 2k inches on right side, and 3 inches on left 
side. 
3. Q. T. D., 32 years. Pneumonia. Three days before entrance to 
hospital, pain in right side and back and across the chest. Chills, 
sweating, fever, some dyspnoea. At entrance, slight dulness in right 
lower back, and diminished breathing at extreme base. Few fine and 
coarse moist rhles scattered over both backs; otherwise good respira- 
tion and resonance over all. A few days later, expectoration rusty. 
Diagnosis before entrance to hospital was pleurisy with effusion. 
Examination with fluorescope: Upper lobe of right lung darker than 
normal. Left side clear. Diaphragm moved 1 inch on right side; 2| 
inches on left side. Four days later, movement on the right side was 
3 inches; on left side, 2| inches. Eight side perfectly clear. Auscul- 
tation and pei’eussion did not show the location of the disease, b\it it 
was revealed by the fluorescope. It was largely a central pneumonia. 
4. C. A., 27 years. Pneumonia in the upper portion of right side. 
Eighteen days after entrance to hospital, percussion over front of the 
chest on both sides was good. In the right back, fremitus slightly in- 
creased from apex to angle of scapula; respiratory murmur shorter 
and fainter than on left. Respiration below angle of scapula on the 
right side better than above. Percussion over right and left back good. 
Examination with fluorescope: Eighteen days after entrance, whole 
of right side darker than left side; outline of ribs seen only faintly; 
diaphragm moved k inch. Left side rather darker than normal, from 
second to fourth ribs; diaphragm moved 1J inches. Two days later, 
right side not quite so clear as left; diaphragm moved 1 k inches on 
right side, and 2 inches on left side. 
5. S. N. Pneumonia. Attack began one week before entrance to 
hospital. Two weeks after entrance: Dulness in right back from 
middle scapula down, and in axilla from fourth rib down; breathing 
somewhat bronchial; numerous coarse and medium rales; voice-sounds 
increased over this area. 32 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
Examination with the fluorescope: Right side less clear throughout 
than the left side, but especially below the lower border of second rib, 
where the outlines of the ribs are much less clear, the outline of the 
diaphragm is not seen. Left side clear; outline of heart, ribs, and dia- 
phragm well defined. 
G. G. W., 23 years. Pneumonia of left lower lobe. Attack began 
three days before entrance to hospital. At entrance, dulness in left 
back from inches above angle of scapula, this line of dulness 
extending down and out to axilla at the seventh rib; over dull area 
bronchial breathing, tactile fremitus, and increased voice-sounds; no 
nlles. Six days after entrance, at time of X-ray examination, breath- 
ing a little diminished at lower part of left back; fine rifles at extreme 
base in front, in axilla, and in back; night-sweats; loss of flesh; hae- 
moptysis. 
Examination with the fluorescope: Left side darker than normal 
below the level of the fifth rib in mammary line; outline of heart on 
left side obscured, and outline of diaphragm not clearly made out; i*ight 
side darker than normal from second to fourth rib. 
7. C. J. Pneumonia. Attack began one week before entrance to 
hospital. At entrance, slight dulness in right back from angle of 
scapula down, with fairly numerous medium and tine rales; one week 
later, breathing over lower third of right back diminished, which is dull 
to percussion. 
Examination with the fluorescope : Right side below lower border of 
third rib darker than normal; outline of diaphragm on right side barely 
visible ; on left side very clear. 
In the following case what was found at autopsy con- 
tinued what was seen in the fluorescope : 
8. S. J., 61 years. Examination with fluorescope: Apex of right 
lung not as clear as lower part. Left side dark throughout; no outlines 
of heart, rib, or diaphragm seen; right border of heart two inches to 
right of sternum. 
Autopsy, one week later: In upper lobe of right lung, the tissue re- 
tracted ; in apex, small caseous nodule found; pericardium dilated, 
filled with opacpie yellowish fluid, and extended to right nipple line; 
heart enlarged in all its cavities. Left lung: entire posterior portion of 
lower lobe and large portion of upper lobe in a state of red pneumonic 
consolidation. 
The observations already referred to, namely, that the 
amount of rays passing through the lungs on to the screen 
ot a fluorescope is not the same throughout the whole of the 
respiratory cycle, that so small an amount of water as d inch ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
33 
obstructs the passage of the X-rays sufficiently to be seen in 
the fluorescope, the radiographs of the diseased lungs, and 
the cases I have given, demonstrate that we can recognize 
increase in density in the lungs by means of the X-rays, 
and therefore their serviceableness in lung diseases. The 
clinical test is, of course, the crucial one. The abnormal 
condition of the lungs in tuberculosis and pneumonia may 
be shown not only by the obstruction which they offer to the 
passage of the rays, but also by the restriction of the ex- 
cursion of the diaphragm. In some cases the latter is a more 
delicate test. 
In pleurisy with effusion we can estimate the amount ot 
fluid in a general way by the amount of light which passes 
through the thorax. When the effusion is large no more 
rays pass through it than through the liver, and the outlines 
of the diaphragm, ribs, and heart are obliterated on 
the side of the effusion. If there is a smaller amount of 
fluid the outlines of some of the upper ribs are seen, and 
with a small effusion the outlines low down in the thorax 
only are ill-defined. The fluorescope assists us to distinguish 
between an effusion and a thickened pleura. In some cases 
of effusion the fluorescope shows us displacement of the 
heart, to the left when there is a large effusion on the 
right side, and a much greater displacement to the right, 
and this displacement is of more frequent occurrence, when 
the effusion is on the left side. This displacement of the 
heart to the right may not be recognized by percussion even 
when it has been pushed much beyond its normal place. In 
one patient the heart was seen to be displaced more than 
two inches to the right, but no displacement was detected 
by percussion. While examining some cases of pleurisy 
with effusion by the fluorescope, I have found indications 
of tuberculosis in the lung where it was not previously 
suspected. 
Sixteen cases of pleurisy with effusion, seven on the left 
and nine on the right side, and one dry pleurisy. 
In one of the seven cases of pleurisy on the left side the 34 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
examination with the fluorescope showed that the heart was 
not displaeed to the right, in five that it was displaced to the 
right, and in one there was no record. 
In six of the nine cases of pleurisy on the right side the 
examination with the tiuoreseope showed that the heart was 
not displaeed, in two that it was displaced, and in one there 
was no record. 
In Cases 5 and <S the increased density of the lung and the 
limited excursion of the diaphragm suggest tuberculosis. 
In Case !> the diagnosis by physical examination was 
pleurisy with effusion or thickened membrane, the examina- 
tion with the tiuoreseope showed that it was pleurisy with 
effusion. 
Five eases of pleurisy on left side with displaced heart: 
1. I). J., 40 years. Pleurisy with effusion. November 4, three pints 
drawn from left side. Left side, dulness begins at seeond rib in front, 
becoming flat at fifth rib ; dulness in back at spine of scapula; flatness 
at angle of scapula; breathing and tactile fremitus lost just above 
angle; right side normal. 
Examination with fluorescope: November 9, whole of left side 
dark, no ribs seen, neither is the heart nor the outline of diaphragm. 
Right side: apex darker than normal above second rib; movement of 
diaphragm 2.j inches; right border of heart displaced 2£ inches to right 
of sternal border. This condition percussion did not show. 
2. V. H., 13 years. Dulness over left front from third rib down; 
liyper-resonant above third rib ; dulness throughout left axilla, becoming 
flatness over lower half; in axilla voice-sounds and tactile fremitus are 
diminished over dull and lost over flat area; dulness in left back from 
spine of scapula, becoming flatness at about the angle; tactile fremitus 
diminished over dull area; voice-sounds increased; whispered and 
spoken sounds heard distinctly to base; breathing somewhat dimin- 
ished, but bronchial in character, and heard nearly to base ; left side, a 
few coarse rales over upper left front; no rales in back; numerous 
tine crepitations in lower right axilla. 
Examination with fluorescope: Left side dark; outline of heart and 
diaphragm not seen on left side; only first and second ribs seen. Right 
side, outline of ribs and diaphragm seen clearly; heart displaced to 
right, extends 2-j inches to right of sternum. Fourteen days later, 
left side clear above outline of left border of heart, which is faintly 
seen; heart not displaced. 
3. B. G., 21 years. Pleurisy with effusion. Dulness on left side in 
front from third rib; in back, from mid-scapula, becoming flatness at ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
35 
angle. In back, breathing and tactile fremitus are diminished from 
above downward, being lost about 1 inch below angle of scapula; voice- 
sounds heard faintly nearly to base. Heart: apex not felt; left border 
not determined; right side of heart is at right sternal border. 
Examination with fluoreseope: Right side normal; left side dark 
below second rib; no outline of ribs, heart, or diaphragm to be seen ; 
heart displaced to the right \\ inches beyond the sternal border on a 
level witli the nipple. This fact could not be made out by percussion ; 
there was good resonance by percussion up to and rather inside of 
right sternal border. 
4. G. J., 24 years. Pleurisy with effusion. On left front and axilla 
dulness below fourth rib; in the back, dulness beginning an inch above 
angle of scapula ;■ voice-sounds in breathing heard faintly nearly to 
base; tactile fremitus lost at angle of scapula; on the right side car- 
diac area extends to 1 inch of right of sternal border. 
Examination with, fluoi-escope : Whole of left side darker than right 
side ; no ribs seen except faintly at top of chest; no outline of left side 
of heart or of diaphragm seen on left side. Heart displaced to right. 
5. A. C., 35 years. Pleurisy with effusion. Right lung hyper-reso- 
nant throughout; somewhat exaggerated respiration; sonorous, coarse, 
and moist rales. Left apex: diminished resonance from apex, front 
and back, increasing to flatness at third space in front, at fourth rib in 
axilla, 1 inch below spine of scapula in back, fremitus marked above; 
respiration diminished above, and lost just below line of flatness; 
friction sounds in back from spine of scapula nearly to angle of same. 
Examination with fluoreseope: Right side clear except at apex, as 
far as second rib, where it is less clear than normal. The diaphragm 
moves inches between full inspiration and complete expiration. 
Heart displaced to the right 1 inch beyond right border of the sternum. 
The increased density of the lung ht the apex and the limited excursion 
of the diaphragm suggest tuberculosis. Left side dark; clavicle and 
first rib seen faintly; no outline of heart or diaphragm. 
Pleurisy of left side, heart not displaced : 
6. H. J , 15 years. Pleurisy Avith effusion. October 3, dulness an 
inch below angle of scapula on left side. October 10, fair resonance to 
tenth rib ; few friction rubs still heard. Respiration heard to extreme 
base. 
Examination with fluoreseope, October 8: Outline of diaphragm on 
left side not quite so clear as on right side. Heart not displaced. 
7. 27. S. Pleurisy with effusion. Two days previous to X-ray 
examination with fluoreseope one quart of clear fluid was drawn from 
left pleura. 
Examination with fluoreseope: Left chest above fourth i'ib darker 
than normal; below this rib outline of heart and diaphragm hardly 
visible. 36 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
Two cases of pleurisy on right side, with displaced heart: 
8. B. D., 31 years. Pleurisy with effusion. Right side, dulness from 
second space in front and below spine of scapula behind, becoming flat; 
voice-sounds and fremitus diminished over dull area and absent over 
flat area; relative dulness from left edge of sternum to just inside 
nipple line ; left lung somewhat hyper-resonant throughout; otherwise 
negative. 
Examination with fluorescope: Right side dark throughout. From 
apex to diaphragm, ribs barely suggested in the middle of the thorax; 
darkness on the right side nearly the same as that of the hepatic area; 
left border of heart i of an inch outside the mammary line; left side: 
apex to fourth rib dark ; diaphragm moves li inches only. The dimin- 
ished excursion of the diaphragm and the increased density of apex 
of left lung suggest tuberculosis. 
9. M. P. Pleurisy with effusion or thickened membrane 
Examination with fluorescope: Right side much darker than left 
side ; ribs not seen below the third rib ; outline of diaphragm not seen ; 
heart displaced to left. This examination shows the pi'esence of fluid. 
Six cases of pleurisy of right side, heart not displaced. 
10. H. N., 59 years. Pleurisy with effusion. Tapped three weeks 
previously ; thirty-seven ounces withdrawn. Right front, ffatness from 
fourth rib down ; fremitus lost at sixth rib ; distant breathing heard to 
base; ffatness at right back to angle of scapula; breathing and fremitus 
lost at angle. 
Examination with ttuorescope: Right chest darker throughout; no 
outline of ribs or diaphragm seen; left side normal; heai’t not dis- 
placed; diaphragm moves inches. 
11. P. A.. 19years. Dulness in right chest from third rib downward 
in front, and in axilla, and from mid-scapula downward in back ; breath- 
ing, tactile fremitus and voice sounds diminished over lower part of dull 
area; friction rubs heard over upper third of right front. 
Examination with ttuorescope: Right side dark; neither ribs nor 
diaphragm seen; heart not displaced to left; left side clear. 
12. C. J , 37 years. Pleurisy with effusion. Dulness at both apices 
in front, with broncho-vesicular breathing; increased vocal resonance 
and a few crackling rales, especially after cough; dulness over right 
back, becoming flat 3 inches above angle of scapula; over the upper 
portion of the lung numerous line rales; spoken and whispered sounds 
increased; over the flat area breathing is diminished and nearly absent 
at base, with diminished vocal and tactile fremitus; dulness in right 
axilla below fourth rib, with diminished breathing; good resonance and 
respiration over right front. 
Examination with fluorescope: Right side dark, ribs only faintly indi- ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
37 
eated throughout right chest; outline of diaphragm not seen on right 
side. Left side clear, heart not displaced, the left border and apex 
clearly marked. 
13. G. M., 23 years. Pleurisy with effusion. Good resonance and 
respiration over left chest; dulness over whole of right chest, with flat- 
ness below the third rib in front and 1 inch below spine of scapula in 
back; right side, at apex, breathing is bronchial, with crackling and a 
few moist rales; below, breathing becomes distant, and is nearly absent 
at the base; a few line rubbing sounds are heard over the right chest. 
Examination with fluorescope, November 5: Left chest normal; right 
chest, first and second ribs seen faintly ; no outline of diaphragm seen ; 
below fourth l’ib, chest about as dark as the hepatic area; liver not dis- 
placed downward; heart not displaced to left. November 12, left chest 
normal; right chest, outlines of first, second, and fourth ribs seen ; out- 
line of diaphragm not seen. 
14. G. J.,43 years. Pleurisy with effusion. Dulness, right side be- 
low third interspace in front, soon running into flatness ; behind dulness 
begins about mid-scapula; left side negative. 
Examination with fluorescope : Right side, first and second ribs seen, 
but not very distinctly, and no outline of diaphragm ; heart not displaced 
to left; left side normal; ribs and spleen and heart seen well. 
15. E. C. Pleurisy with effusion. Dulness from spine of scapula 
on right and below fifth space in front; visible respiration almost en- 
tirely on left side ; heart not displaced. 
Examination with fluorescope: Whole of right side darker than left 
side; border of the diaphragm on the right side is not so well marked 
as on the left side, where it is clearly defined ; ribs on right side do not 
stand out so distinctly as on left side. 
16. H. E. M. Pleurisy with effusion. The day before the X-ray 
examination was made the chest was tapped and about one quart of 
fluid was drawn off from right side. 
Examination with fluorescope: Right side darker than left side, 
but not uniform in character. The area above an imaginary line 
running from the point where the cartilage of the sixth rib joins the 
sternum to the outer end of the clavicle, although darker than the left 
side, was lighter than the area below this line. Percussion showed less 
dulness above this line than below it. The outline of the diaphragm on 
the right side was indistinctly seen. No record as to heart. 
17. D. D. Dry pleurisy on left side. 
Examination with fluorescope : Both sides of chest equally clear. The 
diaphragm moves well in respiration. 
Two thoracic aneurisms are represented in the figures 8, 
8', 9 and 9' bylines on the skin which follow the outlines as Fig. 8.— Aneurism — front of chest. 
Fig. 8 . — Aneurism — back. 
38 Fig. 9. — Aneurism — front. 
Fig. 9'.—Aneurism — back. 
39 40 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
seen in the fluorescope. The heart in three of the thoracic 
cases given below is much displaced. Aneurisms of the 
arch of the aorta are most clearly outlined when their 
borders are nearest the fluorescope; those on the left when 
examined from the back, those on the right when examined 
from the front. It is obvious that aneurisms of the tho- 
racic aorta can sometimes be detected earlier by X-ray ex- 
amination than in any other way. In obscure thoracic cases 
where an aneurism of certain portions of the aorta is sus- 
pected, but does not exist, it may probably lie excluded by 
an X-ray examination. 
M. J., 59 years. Aneurism. About four years ago the patient sud- 
denly became unconscious for about one minute without warning; 
recovery was immediate. About one year ago he began to be hoarse, 
and this hoarseness grew rapidly worse; about the same time, while 
running, he had marked dyspnoea; this symptom has increased; can 
walk some distance if careful. About three months ago he first l'aised a 
little rather dark blood, and has continued to raise a little blood since 
then, especially after talking. Within the past months has had short and 
sharp attacks of pain, starting in the pit of the stomach, radiating to 
left shoulder, and down left arm to elbow. There is numbness of left 
arm associated with this pain; voice is shrill and husky; left vocal 
chord is paralyzed and fixed in the median line; arteries somewhat 
tortuous and resistant; heart’s area decidedly diminished (emphysema) ; 
action regular and fairly strong; apex beat in nipple line; first sound 
in aortic area is rough ; second sound is ringing and valvular; resonance 
of lungs somewhat exaggerated; over upper half of left chest there is 
respiratory murmur; vocal fremitus and voice-sounds are diminished, 
especially in front; percussion not modified; faint pulsation to be felt 
by pressing the chest between the two hands; seems most marked at 
junction of second rib with sternum. 
Examination with fluorescope: The curved lines in the upper part 
of patient’s left chest (see Figs. 8 and 8'), both front and back, and 
the curved line on his right chest, indicate the outline of the aneurism 
as seen in the fluorescope. The lower curved lines on his left chest, 
front and back, mark the outline of the heart; the lowest curve on the 
left back and the right front, part of the outline of the diaphragm; the 
dotted line, the cardiac area as determined by percussion. This shows 
how a large aneurism may exist in the chest without giving rise to 
physical signs. Some weeks after the return home of the patient he 
took a twenty-mile drive, contrary to the direction of his physician, 
immediately after which the aneurism burst, and lie died in a moment. 
F. K. Aneurism. The illustration of this aneurism is not given ; its 
character was similar to that of M. J. 41 
ADAPTATION OF X-RAYS TO MEPICAL PRACTICE. 
C. S. T. Aneurism: Four months previous to entrance to hospital 
the patient complained of pain in the right shoulder and elbow, which 
was followed a week or two later by pain in the chest over a pulsating 
area on the right side in front. 
Examination with fluoreseope: The aneurism in front on the right 
side was easily recognized by percussion, but on the left side in front 
there was no dulness to pei'cussion over this area of the aneurism, but it 
was seen in the fluoreseope. The presence of the aneurism was obvious, 
but its extent could only be determined by the fluoreseope. 
Iv. B., 44 years. (A patient of Dr. F. C. Cobb, kindly referred to 
me by Dr. E. C. Codman.) Aneurism. Lost his voice very suddenly 
about two weeks before he was examined; has pain in left shoulder 
for two or three seconds at a time. 
Examination with fluoreseope (see Figs. 9 and 9') : The upper 
curved line, front and back, marks the outlines of the aneurism as seen 
through the fluoreseope, and were drawn by me on the patient’s chest. 
In the view of the back (Fig. 9') the arrow marked P indicates the 
point where pulsation was most marked; the right and left border of 
the heart are also marked on the chest (Fig. 9), and the left border in 
the back (Fig. 9') ; the parallel lines drawn on the chest in front are the 
outlines of the diaphragm in full inspiration and complete expiration. 
C. A., 40 years. Aneurism. Pulsation seen and felt in the lower part 
of the neck above and behind the inner end of the right clavicle. There 
was evidently an aneurism of the subclavian artery. An operation was 
advised, but before this was done an X-ray examination was made in 
order to determine the lower limit of the aneurism and ascertain if it 
extended to the larger arteries below ; in which case an operation would 
be more serious, or it might be necessary to abandon it altogether. 
Examination with the fluoreseope: No indication of any aneurism 
extending below the lower border of the clavicle. A radiograph showed 
the outline of the aneurism in the neck, but also gave no indication of 
any below the clavicle. Both sides of the chest were equally clear, thus 
showing there was no aneurism there. Operation for ligaturing the 
innominate artery confirmed the observations made by X-ray ex- 
amination. 
The position and size of the heart are not always indicated 
correctly by percussion, and the apex beat cannot always 
be felt, and even where this is readily felt X-ray examina- 
tions show that it does not correspond in all cases to the 
apex of the heart as seen in the tiuorescope. The lower 
border of the heart cannot be obtained by percussion, 
but can be seen in the tiuorescope during deep inspiration ; 
in some patients nearly the whole outline of the ventricles 
can be seen. The right and left border of the heart may 42 
AD APT AT I OK OF X-RAYS TO MEDICAL PRACTICE. 
usually be more correctly determined by the fluorescope 
than by other means. 
In some eases of emphysema the outline of the heart is 
not found by the ordinary examination, but is seen with more 
than normal clearness by the X-ray examination. It in 
some cases we are unable to establish the position of the 
heart exactly by auscultation and percussion, it is obvious 
that we may be still less able to determine its size. In 
studying diseases of the heart, the fluorescope is of assist- 
ance in determining its size and position, also in determining 
increase in density of the lungs due to oedema or marked 
congestion, the result of cardiac or other diseases. The 
fluorescope may show that the lungs of a patient suffering 
from cardiac disease or dyspnoea on exertion are less clear 
than normal, and after suitable treatment the dyspnoea dis- 
appears and the lungs become clear, thus confirming the in- 
formation obtained by the fluorescope. 
The Roentgen rays enable us, then, to gain a better knowl- 
edge of the size and position of the heart, and to under- 
stand better not only the condition of the heart, but that of 
the patient also; in other words, they add to our knowl- 
edge of diseases of the heart and some oi the conditions 
that accompany them. In passing let me say that there are 
a number of other diseases or conditions that may bring 
about changes in the thoracic cavity, the information oi 
which obtained by means of the fluorescope may enable 
us to form a much better estimate of the patient’s con- 
dition than would otherwise be possible. 
I should be glad to take up examinations of the heart 
more fully, were it not that the importance of the subject 
demands more space than is now at my disposal. 
In emphysema the lungs are unusually clear and their 
volume is increased. The heart is seen in the fluorescope 
more’ clearly than normal, although by percussion the out- 
line cannot be determined. The diaphragm is seen to be 
lower than normal, and the excursion which it performs 
between deep inspiration and expiration to be less than 
normal. The heart also may lie lower than in health, and 
in the later stages in a more vertical direction. 1 lie lower 
position and the more limited excursion ot the diaphragm ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
43 
giye a means of making a diagnosis of this condition prob- 
ably earlier than has hitherto been possible, or in some 
cases the lack of these signs enables us to exclude it. Case 
B. F. suggests that there was no emphysema, although this 
was the diagnosis made from physical signs. 
1. G. P., 55 y ears. Diagnosis: Pleurisy with chronic bronchitis ; sub- 
ject to asthmatic attacks and cougli for years; caught cold two weeks 
before entrance to hospital. Physical examination : Severe cough witli 
Fig. 10. —Emphysema. Diaphragm lines lower and nearer together than normal. Dotted 
line indicates cardiac area by percussion. Broken line under inner end of left clavicle shows 
arch of aorta. 
pain in left chest, with marked dyspnoea; lungs hyper-resonant 
throughout; respiration everywhere harsh, with many rales, fine, 
squeaking, sibilant, and coarse; expiration somewhat prolonged; 
friction rub in left axilla below fifth rib ; respiration slightly diminished ; 
heart negative; outline not found percussion ; no apex beat. 
Examination with fluorescope: Diaphragm lower down in the chest 
than normal and the excursion inches only. Outline of heart shown 
distinctly. The position and limited excursion of the diaphragm and 
the fact that the outline, of the heart could not be obtained by per- 
cussion indicate emphysema. 
2. G. J., 33 years. Emphysema and aortic regurgitation. Heart: 
dulness from left sternal border to just inside nipple line. Good reso- 
nance throughout the lungs ; sibilant and sonorous rales. 
Examination with fluorescope: The full line (see Fig. 10) indicates 44 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
a part of the cardiac area as seen in the fluorescope, the Crookes tube 
being 20 inches distant therefrom; the dotted line, the cardiac area as 
found by percussion. A comparison of these two lines shows that the 
fluorescope revealed more in regard to the size and position ot the heart 
than was obtained by percussion. 
3. M. A. J. Emphysema. Lungs hyper-resonant over all on percus- 
sion. Inspiration and expiration prolonged. Fine and coarse bubbling 
rales. Heart’s area obscured by hyper-resonance of chest. 
Examination with fluorescope: The diaphragm on both sides reaches 
the highest point at the sixth rib in the mammary line. Heart lower 
down in the chest than normal, but clearly seen ; left border % inch inside 
mammary line ; right border II inches to right of sternum on level with 
nipple. Apex in fifth space. 
4. B. F. Diagnosis : Emphysema with asthma. Examination with 
fluoi’escope: Diaphragm moved on the right side two and one-half 
inches, and on the left side three inches. This excursion of the dia- 
phragm being normal suggests that there is no emphysema present. 
In pneumothorax, hydro-thorax, and oedema of the lungs 
the fluoreseope is of service; some partial oedema of the 
lungs is, I am inclined to believe, a more frequent condition 
than I had supposed. On first examining a patient of this 
latter class, his condition being unknown, I was surprised to 
find how difficult was the passage of the rays. I was at a 
loss when I found the picture of the patient’s thorax in the 
fluoreseope was unusually dark, and supposed something 
was wrong with my Crookes tube, but after trying another 
I realized that the patient’s chest was denser than normal ; 
the tube was not in fault. I give the following cases to 
illustrate the aid the fluoreseope renders in oedema of the 
lungs ; the fluoreseope showed this condition when it was 
not made out by physical signs : 
C. E., 47 years. Diagnosis: Chronic diffuse nephritis and cardiac. 
Three months previous to entrance to hospital patient complained of 
increased dyspnoea, fluttering of heart, and faintness ; later, feet swelled 
in morning. Physical examination on entrance : atheromatous arteries ; 
heart extended from one and one-half inches to right of median line to 
eight inches to left of line; apex beat in eighth space; no murmurs. 
Lungs: Dull in both backs below angle of scapula; over these areas 
breathing is diminished and accompanied by numerous fine r;tles. Ten 
days after entrance, feels less well and complains of dyspnoea. Eleventh 
day after entrance, Roentgen ray was tried on patient, but was not thrown 
through the chest, and the cause was thought, by Dr. Williams, to be ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
45 
marked oedema of the lungs, but examination shows only a few moist 
rales at bases. Heart: At apex a rough systolic murmur is heard. 
Nineteenth day after entrance, eight days later, patient suffers a great 
deal from dyspnoea, sits up in bed nearly all the time, night and day. 
Pulse on twentieth day very weak ; marked cyanosis; dyspnoea; death 
at 3.30 P.M. 
Examination with fluorescope, eleventh day after entrance : First and 
second ribs can be fairly well made out on both sides. No outline of 
any ribs except the upper ones can be distinguished; lungs below the 
third rib are much darker than normal; no outline of diaphragm on 
either side to be seen ; heart not seen. This examination, in connection 
with the physical signs, indicates oedema of the lungs, with, perhaps, 
some hydro-thorax. 
C. J. J. Diagnosis: Chronic diffuse nephritis; cardiac dilatation. 
Dyspnoea on exertion; swelling of the feet; orthopnoea. Lungs: No 
dulness ; moist rales heard over both bases, front and back ; bronchitis 
and dyspnoea; improved under treatment. 
Examinations with fluorescope: Ribs seen, but less distinctly than is 
normal; outlines of diaphragm and heart not sharply defined; heart 
considerably enlarged to the left. This examination, together with 
physical signs, indicates oedema of the lungs sufficient to increase their 
density and make the outline of the ribs and neighboring organs ill- 
defined. 
It will prove instructive to study by means of the flu- 
orescope cases of dyspnoea on exertion, and note the 
amount of congestion or oedema of the lungs accompanying 
them. 
In some cases of bronchitis the lungs appear less bright 
in the fluorescope than in health, but in others this is not the 
case. 
It not infrequently happens that the physician or patient 
fears the latter has some serious or obscure disease of the 
chest. In such cases, of the various methods of examining 
the lungs there is no one which gives such good evidence 
that they are free from serious disease as the examination 
with the fluorescope. 
The foregoing observations and cases show that by X-ray 
examinations of the chest we gain assistance in recognizing 
a density greater than normal, in tuberculosis, pneumonia, 
infarction, oedema, congestion of the lungs, in aneurism, 
and in new growths ; they likewise assist us to recognize 
fluid in the pericardial and pleural sacs. The distribution, 
location, and amount of this increase in density which the 46 
ADAPTATION OF X-ltAYS TO MEDICAL PRACTICE. 
fluorescope shows assist us in some cases to differentiate 
these diseases and conditions. Diminution of the normal 
density, which is the result of emphysema and pneumo- 
thorax, is indicated by the position and movement of the 
diaphragm; a certain curve of the diaphragm is character- 
istic of this latter condition. The excursion and position 
of tlie diaphragm arc of assistance in determining the condi- 
tion of a lung or lungs in tuberculosis, pneumonia, and 
other diseases. As is the case with all other observations 
on which a diagnosis is founded, the conditions which are 
revealed by the fluorescope are only to be properly inter- 
preted after experience in making X-ray examinations has 
enabled the physician to give these observations their due 
weight. 
I have already referred in a previous article to the ex- 
periments made at the Massachusetts Institute of Tech- 
nology on the action of the X-rays upon several forms of 
bacilli. flic rays in those experiments had no effect on the 
bacilli. 
I shall preface the following surgical cases by a few brief 
suggestions only, which may be of assistance to those who 
are beginning to use the X-rays in surgical cases. 
rflie character of the radiograph depends, to a consid- 
erable extent, upon the length of the exposure. Too long 
an exposure will show an excellent picture of the bones, 
but not the soft parts; a shorter exposure may give bones, 
muscle, fat, etc. 
A more satisfactory examination of the leg and forearm 
can be made with the fluorescope than of the thigh, for 
example, because in the former the bones lying closer to 
the surface are nearer to the fluorescope, and therefore their 
outlines are more sharply defined than those of the femur 
or hip-joint. These latter are better seen with a strong light 
at some distance from the patient. In passing it may 
be of interest to note that in the examination of the hip- 
joint it is an advantage to have the patient lying on his 
face. 
Fractures with displacement of the bone can be readily 
made out by means of the fluorescope; when, however, there 
is fracture with onlv slight change in the outline if is 47 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
not readily detected by this means, but may be found more 
certainly by a radiograph. The tluorescope sometimes gives 
a better appreciation of the conditions in fractures with suf- 
ficient displacement, because by turning the part it may 
be seen from more than one side. The tluorescope also 
enables the practitioner to use both eyes and hands; that is, 
the part may be examined by the hand while observing 
it through the fluoreseope. This enables him to deter- 
mine, for instance, that a given induration is not bony, 
although it feels as if it were. 
In examining the extremities it is well to compare the 
diseased with the healthy one ; for example, the outlines of 
tuberculous joints, and especially the ends of the bones near 
them, are obscured instead of being sharp in outline; the 
diseased bones seem larger, but not so dark as the healthy 
bone. There appears to be less of inorganic salts in the 
diseased than in the normal bones, and more inorganic salts 
in the tissues surrounding the diseased bones than in the 
corresponding parts on the normal side. Whenever possi- 
ble it is advisable to place both the healthy and the affected 
extremity side by side under a large fluoreseope. 
A radiograph of a cancer of the breast, taken after re- 
moval, showed the diseased portions were more resistant 
to the rays than the healthy tissues. 
NEEDLES, BULLETS, AND GLASS. 
1. Piece of needle in ulnar side of hand. 
Fluoreseope and radiograph showed needle, which was removed by 
surgeon. 
2. Two bullet wounds, one about 2 inches posterior to large tro- 
chanter of right femur, second over last lumbar vertebra, about 1 inch 
to left of median line. 
By tluorescope, one bullet located on inner side of right thigh, 2 
inches below pubes; removed b}r surgeon. Second, just above the left 
sacro-iliac synchondrosis. [Allowed to remain.] 
3. Bullet wound of right shoulder. 
Bullet located by tluorescope and removed by surgeon. 
4. Piece of needle in left knee. 
Located by tluorescope over inner tuberosity of tibia; removed by 
surgeon. 48 
ADAPTATION' OF X—PAYS TO MEDICAL PRACTICE. 
5. Piece of needle in hand four weeks ago. 
Located by iluoreseope and radiograph; removed by surgeon. 
Fig. 11. — Radiograph of hand, showing that the enlargement of the ends of lingers was 
not due to changes in the bone. 
G. Bullet in thigh. 
Located by iluoreseope; removed by surgeon. Ilad been searched 
for unsuccessfully outside the hospital. ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
49 
7. Piece of needle in thenar region. 
Located by ihiorescope ; removed by surgeon. 
8. Piece of needle in toe. 
Seen in lluorescope; not found by surgeon. 
9. Bullet wound in groin. 
Fluorescope located bullet in thigh; removed by surgeon. Previous 
unsuccessful search before entrance to hospital. 
Fig. 12. — Epiphyses of femur and tibia. 
10. Small wound in calf of right leg, probably from piece of car- 
tridge exploded on car track. 
Small piece of metal (copper) located in leg; removed by surgeon. 
11. Piece of needle in foot. 
Located by fluorescope; removed by surgeon. 
12. Bullet in left thigh. 
Located by fluoi’eseope and radiograph ; removed by surgeon. 
13. Piece of needle in right hand. 
Located by fluorescope ; removed by surgeon. 50 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
14. Small bit of glass in linger. 
Fluorescope showed nothing; radiograph showed triangular pieee of 
glass about h inch the longest way. See Fig. 18. 
15. Bullet wound of baek. 
Shot in left back over scapula. Bullet located by fluorescope and 
found in right back under scapula. 
With the fluorescope held against the back, the patient lying on his 
face, considerable movement of the Crookes tube from side to side 
gave very slight movement of shadow of bullet, thus showing that it 
was near the surface of the back. 
Removed by surgeon. 
16. Congenital malformation of toes. 
Radiographed. 
17. Necrosis of ileum. 
Radiograph showed roughened outline of ileum. 
18. Necrosis of tibia. 
Fluorescope shows lighter area in tibia about 3 inches long, beginning 
about 1 inch above ankle, at the upper end of this a light area 3 inch 
in diameter. Radiograph also shows the same. Appearances confirmed 
at operation. 
19. Tubercular knee. 
Fluorescope: outline of left knee-joint not defined. Head of tibia 
larger. Radiograph shows the same. Appearances confirmed at 
operation. 
20. Osteo-sarcoma of humerus. 
Fluorescope and radiograph show distinctly great enlargement of 
humerus and shaggy outline. See Fig. 16. 
21. Osteo-myelitis of right humerus. 
Fluorescope shows whole humerus thickened and roughened, head of 
bone involved. 
22. Tuberculosis of femur. 
Fluorescope and radiograph show thickened femur. 
23. Fracture of patella after wire suture. 
Radiographed. 
24. Fracture one year old of both bones of leg. 
Sinus into which crayons of iodoform had been inserted. Fluorescope 
shows fracture and also iodoform which is as well marked as a piece of 
lead. 
Radiographed. See Fig. 14. ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
51 
25. Tuberculous knee. Left knee considerably swollen, quite 
uniformly, surface moderately tense, knee held at moderate flexion. 
By fluorescope : no outline of knee-joint seen ; head of tibia and fibula 
Fig. 13.— Old fracture of radius. 
and patella not seen; all of these clearly seen in other knee. The 
radiograph gave the same result. The appearances suggested the 
presence around the joint of some deposit through which the rays 
passed less readily than through normal tissues. 52 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
26. Fracture of tibia in stout woman. 
Seen clearly in lluorcscope; seemed in perfect position when examined 
antero-posteriorly, but the lateral view showed some overlapping. 
Fig. 14. — Fracture of both bones of leg which has been dressed with iodoform. This 
latter obscures the fracture of the tibia. The dark foreign bodies resembling pieces of metal 
are pieces of iodoform. This radiograph was taken with bromide paper which was then 
coated with oil, and silver prints were made therefrom. 
27. Necrosis of hand. 
Fluorescope shows about the third metatarso-phalaugeal joint enlarge- 
ment and bending of first phalanx. 
28. Old injury to elbow. 
Radiographed. 
✓ 
29. Necrosis of feet after frost-bite. 
Radiographed. ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
53 
30. Exostosis of inferior surface and distal end of third and fourth 
metatarsal bones about the size of a large pea Removed by operation. 
This enlargement was not seen in the lluoreseope ; but the patient 
was a child five years old, and therefore it was less marked than in an 
adult. 
No radiograph taken. 
Fig. 15.— Rickets in colored child three years old 
31. Hard, perhaps bony, tumor in popliteal space, marked tender- 
ness to slight pressure; hard swelling, not pulsating. 54 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
Fluorescope showed bones and knee-joint normal; examining finger 
when touching hard and tender point was seen to be at least two inches 
from bone. 
[At operation proved to be vascular tumor about the size of a walnut.] 
32. Fracture forearm two years before. 
Fluorescope and radiograph showed fracture clearly. 
33. Congenital deformity of hand. 
Radiograph showed clearly the malformation of bones. 
34. Osteo-sarcoma of right femur. 
Suppurative periostitis of left fibula. 
Fluorescope shows right femur clearly defined, no enlargement Left 
fibula thickened and not sharp in outline. 
35. Fracture of vertebrae. 
Radiograph unsuccessful, as plate proved to be a poor one. [Did not 
fix after development.] 
EKACTUKE SUSPECTED, BUT NOT FOUND BY TI1F, X-KAY EXAMINATION. 
36. Fracture of the radius three inches above carpus, found to be 
perfectly straight and normal in fluorescope. 
37. Fracture of ulna nine weeks old. 
Fluorescope showed dislocation of carpal end of radius. 
38. Injury of foot; question of fracture of external malleolus or dis- 
location of bones of foot. 
Fluorescope showed nothing abnormal. 
39. Child eight years old swallowed a silver twenty-five-cent piece, 
some years previously ; some bronchial irritations since. 
Radiograph of whole of upper half of body showed a perfectly 
normal thorax, and no coin present. 
40. Fracture of os ealcis. Tenderness and swelling below external 
malleolus. 
Fluorescope did not show any fracture. 
41. Needle in palm of hand on previous day. 
No needle found by fluorescope or radiograph. 
42. Needle in foot two years previously. 
Fluorescope and radiograph showed no needle. 
43. Suspected injury to elbow-joint. 
No fracture found by fluorescope. 
44. Colies fracture. 
No evidence of fracture in fluorescope. ADAPTATION’ OF X-1IAYS TO MEDICAL PRACTICE. 
55 
Fig. 16.— Osteo-sarcoma of the humerus. 
45. Recent fracture close to base of fii’st metacarpal, crepitus 
distinct. 
No evidence of fracture found in fluoreseope. 56 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
46. Fracture of os ealcis. 
I compared this heel bone with the normal foot under the fluorescope 
and as a further means of testing the condition of the bone I tried to 
Fig. 17. — Bullet in the tibia; just below the bullet small dark spots are seen, which are 
bits of lead scraped off the bullet in its passage through the hone. This indicates that the 
bullet was fired from a point below the level of the knee. (The patient dropped his revolver 
on to the floor, when it went off.) Evidence of this sort might prove serviceable in a medico- 
legal case. 
move the supposed fractured os ealcis, while at the same time looking 
at it with the fluorescope. No fracture was detected. ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
57 
47. Fracture of metatarsus. 
Intense pain, tenderness, arch of foot seems flattened out. 
Radiograph showed nothing abnormal. 
48. Baby said to have needle in side of abdomen. 
No needle seen in fluorescope. 
Fig. 18. — Small piece of 
glass in inner side of little 
finger. 
Fig. 19. — Needle in hand. 
49. Sprain of ankle (?) 
Fluorescope shows no deformity of ankle compared with uninjured 
one. 
50. Fracture of cervical vertebrae. 
Four cervical vertebrae seen in fluorescope; nothing abnormal made 
out. 
51. Fractures of condyles of humerus; question of good position of 
parts; considerable swelling. 
Fluorescope shows jjosition at elbow good. 
52. Compound fracture of femur; long suppuration ; extreme sensi- 
tiveness of femur for several weeks; considerable thickening of femur; 
question of osteo-myelitis. 58 
ADAPTATION OF X-RAYS TO MEDICAL PRACTICE. 
Fluorescope shows outline of left femur clearly defined; thickening 
felt by finger while looking through fluorescope evidently not bony. 
53. Question of foreign body in finger. 
Nothing shown by radiograph. 
54. Question of piece of needle in finger. 
Nothing shown by radiograph. 
55. Question of injury to bones of hand. 
Fluorescope shows no bony injury. 
56. Question of renal calculus. 
Nothing seen in radiograph. 
57. Question of needle in thumb. 
Fluorescope and radiograph show no needle in thumb. 
58. Question of fracture of shoulder. 
No in jury seen by fluorescope. 
No harmful effects have been received in any way by the 
patients, more than two hundred and fifty in number, whom 
I have thus far examined by the X-rays at this hospital, and 
there need not be the slighest anxiety on the part of the 
patient if the examinations are made by some one who has 
had experience and has suitable apparatus. I have seen, 
however, several persons who have suffered a more or less 
severe inflammation of the skin, the nails also being some- 
times involved, but they were all individuals whose occupa- 
tion brought their hands into close proximity to the Crookes 
tube, or who, for purposes of testing its possibilities for 
harm, had exposed some part of the body to its action at a 
short distance for a considerable period. But there are 
simple ways of obviating these effects. 
Interesting, not to say magical, as are the physical 
phenomena connected with the X-rays, we should not be led 
to assume for them an exaggerated importance in practical 
medicine. They do unquestionably afford us valuable aid, 
and through them an advance in our methods of examining 
patients is obtained. I have thus far found them of es- 
pecial service in diseases of the chest. 
I have had the privilege of studying the physics of the 
X-rays in the Rogers Laboratory of the Massachusetts In- 
stitute of Technology, and I am under obligation to Pro- ADAPTATION' OF X-RAYS TO MEDICAL PRACTICE. 
59 
lessor Charles R. Cross and two of his assistants, Mr. C. L. 
Norton and Mr. R. R. Lawrence, for their cooperation. I 
also desire to express my appreciation of the active interest 
taken by the trustees of the Boston City Hospital in my 
work, and the kindness of my colleagues on the staff for 
affording me an opportunity of examining many of their 
patients. 
SUMMARY. 
Apparatus and methods described. 
Respective uses of fluorescope and radiograph considered. 
Causes of the difference in permeability which the tissues 
and organs of the body offer to the passage of the X-rays. 
Calculi and instrument for radiographing them in the 
bladder. 
Normal thorax described as seen in the fluorescope. 
Importance of the position and movement of the diaphragm 
in estimating or excluding abnormal conditions of the lungs. 
Uses of fluorescope in tuberculosis, pneumonia, pleurisy, 
aneurism, emphysema and oedema of the lungs considered 
and illustrative cases given : 
The fluorescope gives us earlier evidence of disease in 
some cases of tuberculosis, and in pneumonia more accurate 
information, than can be obtained by the usual physical 
examination. 
The fluorescope gives us the means of making an earlier 
diagnosis of certain cases of thoracic aneurism than anv 
other method. 
The fluorescope enables us to recognize or exclude em- 
physema. 
The fluorescope assists us to recognize oedema of the 
lungs, pneumo-thorax and hydro-thorax. 
The fluorescope shows a displacement of the heart in 
pleurisy, which is sometimes not recognized by other means. 
The fluorescope assists in the recognition of fluid in the 
pleural cavity. 
The fluorescope enables us to outline the heart more accu- 
rately and more completely than has hitherto been possible, 
and assists us to recognize certain changes in the heart. 
Examples of surgical uses.