Week6_Xrays

Week6_Xrays - 3 Pet 100.000 households. Divorce is the most...

Info iconThis preview shows pages 1–11. Sign up to view the full content.

View Full Document Right Arrow Icon
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 2
Background image of page 3

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 4
Background image of page 5

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 6
Background image of page 7

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 8
Background image of page 9

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 10
Background image of page 11
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: 3 Pet 100.000 households. Divorce is the most unpopular . Brittany, Berri, the Pyrénéen, Savoy, and Auvergne. _ general natality for the whole of France is low—“2., ‘ .5 per 1000 inhabitants, and 3 births per marriage, the ‘ , mes being, in the Gers 146 per 1000, and 32 6 per 1000 ' mistere. In the south of France illegitimate births are awmnumber, whilst in the north (principallyin the Pas- ‘5 ', the Somme, the Seine Inférieure,dtheblEureCi f as, and as ially in Paris) they are oonsi era e an wwwnstant. p'ghus, in 1894 there were 778,937 legitimate J against 76.451 illegitimate births, the corresponding mum for 1893 being 808,110 find 76,662. The general amuty for 1894 was 21 per 1000, the extremes being the film, (15 per 1000) and the Bouches-du-thne (26-9 per ), Still-born children numbered 42,046 (24,543 males to 317503 females)—a fairly constant figure since 1881. :Ihe Lani} in the birth-rate leaves thinking Frenchmen as anxxous 1” over for the national future, and fully justifies the ecy that this great country will, say 100 years hence, E “I! egated to the position of a second- or third-rate Power. ,7 Health 4/ Paris. The appended table shows the deaths from infectious diseases that occurred in Paris from 1890 to the end of 1895. The deaths of inhabitants of the suburbs situated outside the fortifications who succumbed in the Paris hospitals are not 5' . l c , a. 5 ’ i t E. E - s —' “ a sa- 5. *6 s I 5 2 a; t: i s | = a s4 g t a i m ,_'__,___._. __ ,mmss 271 17 i 679 173 419 455 , ,, 1394 on 155 993 151 .255 1009 , ,, 1395 570 260 an m 508 1266 i , 1392 891 42 909 158 as: 1403 i ,, )891 416 39 983 202 332 1361 I 1890 656 76 1495 223 491 1668 5 .. wieWe-lr 1598 544 1133 . 236 433 1340 fie very marked decrease in the death-rate from infectious W in general cannot fail to strike the reader. London .ibelf cannot show such an improved record as regards typhoid fever. The diphtheria figures are also most reassuring, the Mil-rate having fallen from 1840 (average of ten years) to -485——less than a quarter. This speaks volumes for the dimcy of the new antitoxin treatment. Parisian Medical Journals. . 1n the course of a single twelvemonth no fewer than 82 periodicals having reference to the science and art of medicine have been added to the already ample supply pro- duced in Paris. In 1894 the number published was 177, but by the end of 1895 the portentous list had been lengthened to 199. Protection as applied to the Practice of Medicine in Fumes. " Hy remarks on the abov'e subject in last week‘s issue of ‘1'!!! LANCE}: are corroborated by the appended resolutions ‘ by the medical section of the Students’ Association 1! Paris. I quote from La Prone Médtoala, and refrain from supplying a translation. 7. “Indtudiantsen médecine. membres de l’AIsociation getter-ale des Menu de Paris, renni- pour discuter lee mesures A prendre in l'égard betudknts étrangerl,~ee sent uremi- aux dispositions suivanwa : “1. Les etudiants étnngen, event de prendre leur premiere latterly» mu. dsvrcnt prosenter u_n cortifimt d'études Iupérieures ohtenu .i enmen devnnt un Jury compoeé de profeueun d’une Faculté Au moment de s‘inscrire h in prefecture du département Oil ils “ l’intention d'exercer, lea docteurs en médecine devront disposer: v, .“ a) Lesdpieces étnbliuant leur qualite‘ do Franoais; 7‘“ Le lbms freneti- de docteur en m6decine: Tour es diplbmee exigés des étudlnntl frenetic an moment de in at ds leur premiere inscription. ‘Lnoune exception aux dispositions pm'cédentes no sen admise. “ Bur in question de l'entre'e dos eta-lingers dam lee Facultés - . nous avonl prnsé que l'équivalenoe accordee dam Ion ch~ “In ectueiies east one Lie losufllunte d'études Iupérieum et j d’autre M ii eel-alt engeré d'exlger des étrangers les diplémes ; , aux etudiants francs“. - 3"“ 8!!! ll question do l'exsmlce de la médecine. nous esiimom juste de .; lee eta-angers aux memes exigences que les dooteurs frencais. hunt, on moment do s'e'tabiir, Ivon- obtenu la naturalization 131111 F impossible de lenr imposer an moment oi: ils commencem. leum PAlils:—-—BERLIN. [Fan 1.1896. 331 «Etudes. etant données lee conditions exigéel par ll loi du fl juin 1889 sur- la naturaliution (in naturalisation pout Otto worries: (l) spree trol- ans de domicile autorisé; (4) aux etrnngen qui Justifient qu'lls resident en France depuie dix unnee- sans interruption). ” Nous avons reserve Is question den concours ui’relOVe uniquement de l'Aulstance publique de Paris, dos munici t6! ou d'admlnietrr tions dlverses." ., . BERLIN. ' (Fnou our: own Commrmm.) Tho Recent Diacovary in Photography. Prior-Essen Bowman's discovery continues to interest scientific circles and the general public in an extraordinary degree. Popular lectures and demonstrations on the subject are held here every evening in the overcrowded amphitheatre of the “ Urania,” a. society for promoting a general know- ledge of natural science, and all the tickets are already taken for the next meetings. Surgeons have begun to make prac- tical use of the discovery. In one of your correspondent’s cases. for instance. a finger which had sustained a compound fracture and from which a sequestrum had been removed was photographed by the new process, and the regeneration of the bone was thereby made visible. In another case the 'position of a piece of glass embedded in the tissues was ascertained by the same method. Similar reports come from other universities, as, for instance, from Berna, where Pro- fessor Kocher has photographed a needle in a woman’s hand; it had made its way under the skin some time ago and had not been found by any.other means. Professor Roentgen came to Berlin last week, at the invitation of the Emperor, in order to show his discovery, and he was expected to speak at a scientific meeting, but he left the city on the following day. The Antitazin Treatment of Diphtheria. The Imperial Health Office has issued a statistical report on the use of diphtheria antitoxin in the hospitals from April to June, 1895; 2130 cases were reported, of which 1812 (= 851 per cent.) recovered and 306 (= 143 per cent.) died; 23 of the latter died within' the first twelve hours; as they had come to the hospital in the final stage of the illness they are to be excluded from calculation, and the mortality is to be reckoned on the basis of 283 deaths (= 13-3 per cent). In the first quarter of the year the num- bers were 173 and 16-7 per cent. respectively; 710 cases are reported as being mild, and of these only 1 died; 293 cases are said to have been of moderate intensity and 1021 cases, of which no died, were severe. Of 106 patients with 13 deaths no iculars were given. As regards age, the report states 1: 41 patients were children under one year. of whom 17 died, giving a mortality of 4l‘5 per cent; 218 were from one to two years of age, with 80 deaths (= 36'? per cent.). The death-rate decreases as the age of the patients increases. ‘Those of three years have a mortality of 171 per cent, those of seven years one\of 8 2 per cent., and those of fifteen years one of 5-2 per cent. The injection of the serum was performed on the first two days of the illness in 752 patients, of whom only 48 died, giving a mortality of 64 per cent. This is a much smaller death-rate than in the first quarter of .the - year. The im- provement is due, according to the report, , to the greater strength of the“ pro ’on which is now in use (1000 units instead of 650). The injections performed on the third day were followed by a mortality of 10 per cent, those on the fourth day bye mortality ,of.17'3 per cent, those on the fifth day by a mortality of 235 per cent.. those from the sixth to the tenth day by a. mortality of 283 per cent, and those from the eleventh to the nineteenth day by a. mortality of 17 6 per cent. 841 patients entered from laryngeal diphtheria; 588 of them were operated on and 176 died (= a mortality of 29-9 per cent.). Some secondary effects of the antitoxin are reported, including skin erup- tions, pains in the joints, and suppuration at the place of injection. The result of collective investigation in the hos- pitals during the second quarter of the year is. therefore. that antitoxin has an obviously favourable influence on the disease, whilst the accidental efiects are of no importance. Treatment If Pmttatic Enlargement. Castration for hypertrophy of the prostate has been recommended and successfully performed by Dr. White of Philadelphia, who found that this operation was followed by a diminution of the gland and a decrease of pain. Dr. White’s method is less dangerous than the direct removal of the In. ,3, .1896] .GLI‘EICAL mmmmofis '1 ‘OF’ -TEII>NEW.T.HOTOGRAP1{Y. :J‘Il. Ill-rm , Mural. Jovuu. 3‘61 gigflosrffen'lirflh .APPLIEATION' 0r Tris rm 'Er‘. PHOTOGRAPHY Til-MEDICINE VAND‘ .. “ "’Iiifi-llBGERYv ., ' ' .5»,[Rsron-r r0 ruanmsn Msmcsn Jamar“) .ur: , :. We" have. commissioned municateiwithhus; Mr. Rowland writes to*us as’fo'll‘ows 2,‘ l interest in the subject.,has not. diminished, and’ numerous ‘ communicationshaveappeared; yet it is hard to find any. matter .of'importance as to this very difficult problem. ‘In England, Mr. Gifford, 'of Chard, has been working hard, and has produced many curious results, it is true, but none that are in anyway explanatory-of the new discovery. The chief dificulty in making ra id‘ headway consists in the scarcity of suitable tubes, the whole of the English stock having been bought up almost on the first receipt of the intelli ence from Germany,-and of these-but a small proportion ave been found to be of any use. Fresh arrivals are daily coming in, and some are being made in Germany. As many of our readers are probably already trying the new method, a de- scription. of' the actual appliances employed may be of use, together withsome hints as to the chorce of apparatus and good methods of working. THE CHOICE or A Corr. AND TRANSFORMER. First, as to the coil. This must be a fairly large one,'say 7-inch spark. It must be a really ood instrument, made: by a reliable maker; the cheaper Frenc i coils are of no use. It is important to have sufiicient battery power, for want of this is the most ire uent cause of failure in coil work. Dry cells are of no useat a l, and bichromate batteries fall ofl'so rapidly that they are unsuitable‘for the long exposures sometimes neces- sary. The best form of battery is undoubtedly Groves’s 'or Bunsen’s. A street supply from a company's mains, if avail- able, can be used with the least trouble. In using it, how- ever, care must be taken to transferm it to a suitable pressure, - ' ' Although results undoubtedly can be obtained by the use of acoil alone, yet .the best so im- have been obtained by using a small Tests transformer. These transformers can now be obtained from the instrument maker of suitable size for coils' from' 2-inch ‘spark and upwards. Their effect is to raise the frequency of alternation of the current to sn'exceedingly high pitch. The choice of the tube is the most'imImrtant matter. Too much care cannot be devoted to this. The vacuum must be exceedingly high; nothing else is of the slightest use. Before purchasing one it shoul be tried by-the instrument maker, and the character of the is- eharge noticed. If the tube lights up with an apparently uniformr whitish green glow, then the tube may be expected to give; ood results; if, however, the discharge is continuous in po 9. to pole the vacuum is a low one, and the tube use- _ ss for the ‘urposefin 'view.’ The character of the glow as noticed by t 9 eye can be’taken as‘a fairly good criterion as to fine possible performance of the tube. The glow should, I find, be eta-whitish purplish colour, quite-distinct from the green Buorescence of the‘glass. Great care must be taken of such a tubepand when in use it- must be most carefull insulated, for a frequent cause of destruction of good tubes is the‘break‘ Fag thrdugh of theldischarieéto someneighbouring good con- fihetor. The tubesmust . suspended by silk threads from t glass support, and-carefully cleaned on the outside. 2-3. 7' :‘Mn. Gns'ronn’s Resume: Tnnm EXPLARATIONr ’ - ‘ H:Mr:.Gifl’ord’s work has already been alluded to. He. has . blind, among other th' , that it ’ is possible to photograph ugh opaque bodies without-a. tube at all, using simply the I? hidischsrge from (meat the dischargers of a large coil. this way he has produced images of coins quite distinctly. WES-hm ‘ Mr. Sidney Rowland to investigate ; mo‘appl'ication of Roentgen—s discovery and to study prac- fighlflylits applications. .119 is'cmployed, now in’ doing so, v with some interesting results. .Any of our members who may have suitable cases‘of interest which they'desire to have v mwmgated'hy the' new iahmogmphy'hm Invited to com: ' resultssfrom"isochromatiéo-of-high’rapidity develo ed with - 'Not‘imuch further light'has been thrown on the nature of pypo'andceodu'wfllere with” no'lmupemble' d1 culwm the “new radiation since the discovery was announced. The. » :1 have repeated these ‘expcrinrents,~‘using;'insteaflmf'a coil disolmrgeytha-t from .19. Tests transformer,-witli' the result that g I have obtainednot only the shadowraf the coin to, - . but; perfect Jamm- of theengravingon theiooina-Mn': - argues.from 1 z of the nature of ‘light, but rather of anelcctricsl-efi'eot. But ord ese experiments thatRoenlgen .z- wareth this argument fails, Ithink, in thmlight cf thefotlowing ax- periment. . In: this case th'ngpenny maplacaibclziudthe plate, so as to avoid the .possnbihty, of any 31. ._:.efl’ect', and with exactly the same result-namely,:a'faitb1u village of the fine = Eression of. the coin. It is obvious, themforhythatwe have ereetodo :with an electriuil cont-actieflectrmndmot with ,ROentgen‘rays at all, - ~y - _- ~ I ---- '- ’ ’ - .As ,to' the best- plates-to" employ; 1-- ,. w .-. havbzfoundvthe'best Working the new process hit-only needs ear-cindotails and the careful selection of the tuber-The latestifocm iaof this shape, one electrode being an aluminium plateaird’th‘c other a ring. -_ The plate should be the cathode. - 2 - ’1 ' ' ' ' \\,\--"/ With an apparatus of this dcscriptién, which isno't very bulky, and on y requires care-in-workin‘ , 'it is quite. ssible for anyone to obtain negatives thatwifi'show all‘ atlas been shown up to-the present. Thecaccompanying~ hand (1). 363) was taken by me. with such an _zipparatus wrth an exposure of twenty minutes. Professor S. P. Thompson’s conclusions uptothcpresent are : - ' , . - . I. That success depends more on the degree. of exhaustion (of the tube) than'anlything else- Only the highest exhaustion 130 use. ' » I- ~ 2. Sharply defined shadows need as a- source alsmll bulb.» 3. The .1: rays do not enmnatc exclusively, ashes been sup- posed, from the phosphorescent patches on the: glass. 0n the contrary,.he has cases of double shadows cost by one tube, where the stronger shadow was shown as by ray'emanating straight from the cathode, while the weaker one was thrown as by re ys emanating at the phosphorescent patch; _ . 4.. Professor Thompson finds diamond to'be 'more opaque than black carbon. - _- ' 1 - v. 5. In wood (pine) the dark resinous streaksar-e more trans- parent than the lighter coloured tissue. . v — f . .--. ‘ fl 6. A specimen .of flies in ambershows no- shadow of the res. , a . . .. 7. There ap curs-to be no difi‘erence-in the-degree oi opacity of magnetisedjand non-magnetised iron; .g -. :~- -, Professor Thompson and Professor Lodge agreeinreprd- in: the rays as rather of- the nature ofsound Waves than of light. But they‘ differ as to the-lengtli,the one-considering them as excessively short, the other (probably) as longer than the rays of visible light. .; j, ' . _- And these embody all that can-.begdefinitely stated at present. It is __hoped-_that aiext weekphotogmpbs-of cases will be ready demonstrating the practical application of the new discovery. _ ' . , I. ,_ ' . ' - Some of the earliest endeavours to apply Professor Roentgen‘s discovery not only to-dia nesi's-biit tb treatnmnt are reported from Vienna. Profeésor osetig Wusthe first toutilise the new method. At the Medical Society-he reported two cases in which operative proceduréswetre carried-out underthe guid- ance of the exact knowledge of thaanatomical conditionsob- tained by the new radiation. The accompanying illustrations 362 are re roductionsl More“. Jon: r. l of photographs of the cases which were taken y Roentge ’s method in Professor Franz Exner’s Phy- sical Institute. distal phalanx of he first case is one of deformity the hallux, which appeared to be double. of the This diagnosis had already been made without the helpbf the new photography, but there was a difiiculty in distin— ishin which vgvlll'iich titre supern Professor Mosetig whole of the dou graphy showed, h lateral one) artic other was merel with the normal tinctly to be see comfort it afford the real condition his body removed normal phalanx. ‘ In the other case d to the of his abnormality before having a part of f the two bones was the normal one and merary would have had to resort to remove the As this could not be made out, Is distal phalanx. The Roentgen photo- wever, that only one of the two bones (the lated with the first phalanx, while the a supemumerary appendix, articulating distal phalanx by a sort of facette, dis- in the photograph. Besides the great patient to see with his own eyes , the surgeon was enabled to spare the the situation of a revolver bullet could be exactly made out after every other method had failed. The bullet had imbedded itself into the fourth interosseous space of the right hand, carpal bone. The the slight deformity caused by it in the metacarpal bone. surgeon’s hand was guided by the this case also the and become tightly fixed to the fifth meta- photograph shows clearly the bullet aiIid n photo- graph, and the bullet was easily removed. These photographs were taken b mine of a very large Ruhm-Korfl’ inductor, the exposure ein limb had to lie di sensitive plate. two hours, for which time the patient’s ectly (and quietly) on the box with the his seems a. great drawback of the method, but good photographs have since been obtained after a much shorter exposure. of the new discov graphs taken, outs Professor N cuss? calculus, the latter quite impenetrable stones were not quite opaque. was taken through The results were so soon to give the Herr E. Hasche experiments in th Franz Exner, of through which a p they were able to s osseous tissue had ceeded in of the bones of the vessels. This see was the first to attempt the application ry to medical diagnosis. He had photo- de the body, of gallstones and of a vesical consisting of phosphates, which proved to Roentgen’s rays, while the cholesterine The photograph of the latter a layer of calf’s liver 4 centimetres thick. promising that Professor Neusser intends l and Dr. 0. Th. Lindenthal have made Physico-Chemical Institute of Professor Vienna.l mEthod a trial on the living patient. In the finger of a colleague, stol bullet had passed many years before. ow the injured bone in which the loss of been made good by callus. They also suc- photogra hing the bones of a child’s arm, forearm and foot, but the; ’ failed in their attempts to get pictures skull and trunk. On a dead hand, how- s to open up a new possible application of ever, after injectio‘%, they were able to photograph the blood the method to the been successful in caching of anatomy. further modification, or rather extension, Professor AdolplEIand Dr. Lenz, of Elberfeld. seem to have of the Roentgen p able to photo ph than the handfsu further, that their only the bones but In France ex ri by Professor n Oudin. M. Gariel, Facult , doubts genera ly applied 1‘ was supposed. He the greater num body. In the tho otography. They announce that they are the bones of thicker parts of the body h, for instance, as the arm and wrist ; and, ethod enables them to photograph not the connective tissue. cuts are being made in the laboratories elongue and-MM. Perrin, Msscart, and Professor of Physics in the Paris Medical other the new photography can be so medicine and surgery as at first. sight it asks how this method can be applied to of the organs contained in the human , for instance, the organs placed behind the sternum and those in front of the vertebral column would equally to photo heart. M. Gui-is mation by this not by mode clefafL. transparency. but at present th hypothesis: even _ . method of photo examination must be The same dimoulty applies almost phy of the stomach. liver, kidney. and asserts that in orldertt‘o obtain ingu- grsp y s organs an or photographed by difl‘usian not by this step in advance will be realised, are. no indications which permit the are it so an “image” must be arm '2 CLINICAL APPLICATIONS OF THE NEW PHOTOGRAPHY. [Fm s, 1806. duced and not a “shadow” on the sensitive plate. There must be discovered reflecting and refractive methods of acting on the rays in the same way as concave mirrors. and lenses act on ordinary light rays. Research has shown that these rays are not submitted to refraction nor to re ular reflection in the conditions under which they have een studied. It would perhaps be rash to say that these effects will never be manifested under other conditions, but Pro- fessor Gariel considers it to be barely probable._ He acknow- ledges the importance of the results of the application of. the Roentgen method made by M. Lannelongue, already noticed in the BRITISH MEDICAL J OURNAL, but he pomts out ‘thst they in no way invalidate the conclusions summarised above. The cliché examined by- the Academicians present when M; Lannelongue made his communication showed that there are white patches in the midst of the shadow thrown by the bone, proving, as M. Lannelongue had previously affirmed, that the destruction of the osseous tissue operates from the centre to the periphery, not from the periphery to the centre. .All the three cases photographed were sim is. It is precisely in these that the method of photograp y by the new radiation will be of service. _ _ From Montpelier comes also testimony to the poem- bilities of the new photography. Three lecturers in that medical school have succeeded in photographing a 5-franc iece which was placed inside a purse. an had four folds of Feather between it and the apparatus. The form of the money came out distinctly on the photographic plate, as did also the shape and texture of the purse. THE NEW KIND OF RADIATION. Sin,~lt is known that cultures of the bacillus of tubercle are sterilised by direct sunlight. So far as I am aware, no differential experiments have been made to ascertain whether this result is produced by sunlight in its totality, or, if not, by what part of the spectrum. It is certainly posSible that the violet or ultra-violet rays may be the active agent. This suggests the desirability of determining by direct expel? ment whether the new radiant has or has not a sterilismg efl‘ect upon tubercle bacillus. I It is superfluous to point out that should this prove to be the case, it would place in our hands that which has been for some time our highest aspiration—namely, a means of sterilising the tubercle bacillus in situ within the bod . Even the lungs, though artially protected by impermea le ribs, would not be entire y withdrawn from this influence—I am. etc., Birmingham. Jan. 28th. WILLOUGHBY WADE, F.R.C.P. *3 This letter. received last week,was, in the pressure on our columns, inadvertently omitted from the last number 0‘ the JOURNAL. A HACTERIOLOGICAL department has been established 8‘ the Central London Throat, Nose, and Ear Hospital, Mr. St. George Reid has been appointed.to take charge 0f *‘ for twelve months. . , A MssriNo of the SouthJVestern Division of the Medlco' Psychological Association will be held at Barnwood £10053 Gloucester, on Tuesday, April i4th. After the election > new members the report of the Committee on Criminal sponsibility will be considered, to be followed by a. discuaslmz on the Nursing Staff in As lums. . Caonsm AND TYPKOID ma m INDIA.-—The next 3111! report of the Sani Commissioner with the Governméi“.fif1 of India will, the Moor Mail states, contain —sn interea'tmz summary of all the evidence regarding the 'comma baclu.. and its relation to cholera. The question of epidemic typh will also be dealt with in this report, which is to be 155 during the current month. Roux. Murmur? Cans. ran—The annual meetinfilof governors of this charity was. held on February 4t 8‘ - ociety’s house, 3i, Finsbury Square, under the resident}!" Dr. Robert Barnes. The math annual report w ich was by Mr. J. W. Long, the secretary, stated that last year chsrit nurses ministered to 4, 5 poor married worm?n their our of trial. That was the argost number of pa“ * relieved by the institution in any one year since i825. an was very satisfactory to state that out of the large u only four women died. 1832 THE LANCETJ in the deeper strata of our globe, and of their occurrence at the various oil wells in the world, which have given rise to an industry second in importance to none, especially when we consider that it is possible that our future methods of locomotion may largely depend on the world’s yield of hydro- carbon oils. There are several other minor discoveries in chemistry which it is beyond our province to record, but, as will be seen, the work of the year has been directed more to the questions of chemical evolution and to the constitu- tion of matter than to less occult fields. Contributions to our knowledge of the architecture of compounds which must obviously rest on a knowledge of the constitution of the element or the atom itself—the brick of the structure— should interest every true student of science, while they are of direct concern to the student of medicine,‘ since without a. knowledge of the constitution or structure of the molecules which go to make up the substances employed as remedies, therapeutics or the administration of these remedies can never be an exact science. Thus the research chemist may contribute, though indirectly, his share towards placing medicine upon a real and scientific basis. Roentgen Rays. By far the most important improvement which has been made during 1896 in the, whole domain of medicine and surgery is the discovery of the x rays. Many a time has the wish arisen during an attempteddiagnosis that we could see into the bodies of our patients, and indeed as long ago as 1868 the late Sir BENJAMIN W. RICHARDSON made attempts to look through the body by ordinary light. He tried various illuminants and the best results were obtained with the magnesium ribbon; he succeeded in seeing fairly clearly the shapes of, the bones of hand, but no practical use was made of the invention, and these experiments had been completely forgotten when in the beginning of January of this year the scientific world was startled by hearing that Professor ROENTGEN of Wiirzburg had discovered a new kind of light which could penetrate wood and the flesh of men and animals. The immense field of applicability in medicine and surgery of this dis- covery immediately struck everyone, but a very natural inoredulity prevailed until it was announced that the experiments had been repeated with success in London. In Tun Lucm' of Jan. 25th we published two skiagraphs (as they are now called), one of a part of a hand, and the other of the lower limbs of a frog: These were among the earliest which were published in London The nature of the light has not yet» been settled; the two suggestions that have rsccived. the most support are, first. that the rays are longitudinal vibrations of other while the ordinary light is due to transverse vibrations; and, secondly. that. they are rays beyond the compass ot the visible spectrum. Whatever may be their nature. their production iLa simple matter; The poles of a podenl. induction coll are connected with thostcrminals of. n Crookes’o tubs, whlohsis a highly! exhausted glass bulb contain- ing) two. electrodes, and. the rays. are developed during the disobargo between the terminals. We as not yet clear ssvto what arc the conditions which determinc the permeability of o substance-by the strays; but it may be aldfntrly definitely that the permeability varies inversely us THE ANNUS MEDICUS 1896. [DEC. 26, 1898. r the specific gravity—that is to say, that the greater the specific gravity the less permeable is the substance. Thus, aluminium allows the rays to pass freely, but the heavier metals, such as iron and lead, are quite opaque to them. Glass is impervious to the rays, and in a photograph a piece of glass embedded in the tissues gives a. clear and distinct shadow. A decided advance was made when Professor SALVINI of Perugia. devised a method by which the shadows formed by opaque objects could be seen. Professor ROENTGEN himself had shown that the x rays caused various salts to become incandescent. SALVINI applied this fact by spreading crystals of one of these salts on a screen and then put the screen on the side of the body opposite to the source of the rays. The salts which have been chiefly employed are the platinocyanides of barium and of potas- sium and calcium tungstate; of these the first named is probably the best. THE LANCM‘ at an early date set up the apparatus for the production of the rays, and many photo- graphs taken by its means were published; among these may be mentioned one of the trunk of a monkey in one o! the kidneys of which had been placed a uric acid calculus ; the shadow cast by the stone was well defined. As the thickness of the tissues increases the difliculty of obtaining clear photographs increases also, but very satis- factory results hnve been obtained in attempts to photo- graph throngh the whole human body. It the Crookes's tube is placed anteriorly, the vertebra are well defined, and the sternum is hardly to be recognised. but if the light is placed behind the reverse is the case. In photographs of the chest the heart can be seen as an opaque mass darker in the centre. By the use of the incandescent screen the movements of the heart may be witnessed. The lungs cast no shadow. The liver and diaphragm can be easily distinguished. This is a bold statement of the present position of Ronsrosn’s discovery as an adjuvant to medical diagnosis. As more ex- periments are made and as the apparatus is brought, as it will be, to greater perfection, we shall expect more delicate results. We have already been able to report a case W11" 0 a suspicion of aortic aneurysm was confirmed by the peculiar outline of the cardiac shadow. It is interesting to note that bone does not appear to 1" equally opaque in all experiments. Generally the bone! appear as dark structures. with well-defined outlines. and gaps are seen at the joints which correspond-to the trm‘ parent cartilages; but'fiin other cases the house seem ‘30 transmit no small amount of light, and then they appear 3‘ faint shadows. It is possible that all the x rays are not of the some nature, and at some time in the future we may I" able to use at will the rays most nibble for a partial” case. . ~ ~- Wo possess no power of refmcting- the x my! 30 “m we are utterly unable to obtain anything at tho W of a “true image,” the results are nothing mm m photographic prints of shadows. It is not unreasonle ‘9 hope that before long this dimculty may be overcome. 1‘ 3' .ls wished to define the depth of any substance can“!!! ’ .shsdow it is necessary to. make two observation 01' W 4 two photogrsphs from diflcrcnt points of view. . I As to the utility or the discovery there can be no don"- Foreign bodies. is main“. mineral in nature; can-1’“ readily observed. espodsfly when situated in the manna.- in: menu] THE ANNUS MEDICUB 1896. [ch. 28. 1898. 1833 W and it has become almost a routine practice to employ the method to locate needles and bullets before operating. The ease with which such bodies may now be found is a great contrast to the difficulty which every surgeon must have experienced formerly. The method has also been used to determine the situation of a " Murphy’s button," which had not come away. Another great application of the discovery is to injuries of the bones and joints; fractures and disloca- tions can be observed with ease, and the displacement of the bones recognised. In many cases of course it is not neces_ sary to use x rays, but many doubtful cases in which swelling has obscured the lesion are at once cleared up by their use, and when a fracture has been reduced and the limb put up in splints. the parts can be observed through the splints, so that the surgeon can be satisfied that the bones are in position. Growths in bones, erosion of bones, and new formations on bones are readily reco. gnised. Deformities, also, as in talipes, can be clearly seen. Renal and ve ical calculi in situ have in a few instances been diagnosed, an biliary calculi have also been seen; though these latter ofler but little resistance to the passage of the says. In medicine the method is at present of less value, but dilatation of the right side of the heart can be reco- gnised; atheroma of the aorta and aneurysms of the same vessel have also been obvious in photographs. Lastly, it may be mentioned that in a few cases an. pleasant res ts have followed the use of theix rays. In one case bal ese is said to have occurred, but the lesion most frequently noticed is an afiection cf the skin; in mild cases this has been nothing more than a. “sunburn,” butin one or two instances on extensive and troublesome dermatitis has resulted. During the year numerous photographs of the application 01 the Roentgen rays to surgery have been published in the columns of THE LANCET, illustrating the various points that we have touched upon. Public Health. en on the whole a healthy year. In thjee quarters for which the Registrar-General has issued re rts the general death-rate has been below the average, and c rtain diseases, such as “ fever,” diarrhoea, are, which are deemed to be true tests of healthiness, such as can be secured as the result of improved sanitary administration, have been less fatal than was the case as regards the mean of along group 0 preceding years. On the other hand, certain diseases whic ought to be kept under control have been in excess. This has been the case as regards small-pox. The city of Gloucester suflered exceptionally from this disease and received a terrible lesson as to the consequences of the rfailure to vaccinate its infantile population. Whilst the fear 1896 has each of the of death has , the influence of this lesson was potent for good, and it ansformed the town from one of the worst vaccinated es in this country to one of the best vaccinated. But the moment that immunity by vaccination was mar-ed, with consequent sudden abatement of the epidemic, the anti-vaccination agitation was renewed, and persons who at one moment hurriedly sought its protection for themselves and their families are now again either apathetic or in actual opposition to the practice. Amongst other places Attacked were Bristol, Aston Manor, High Wycombe, West Ham, and cases occurred in Monmouthshire, in South Wales, and in London. In this connexion we may recall the fact that the Royal Commission on Vaccination reported in August last the results of their sittings, which had extended over nearly seven years. We have dealt with that report in detail ; and we need here say no more than that the proof of the value of vaccination as a. preventive of small-pox was never more strongly put forward man it has been in that document. If the administrative courage of the Commis- sioners had equalled their power of exposition and of argu- ment in favour of vaccination and re-vaccination it would have been better for the public. Another disease which has been unusually fatal is measles, and it seems almost impracticable under existing circum- stances to control this malady, which causes some 12,000 deaths a year in England and Wales. The infectiousness of the disease in its earliest stages, the rapidity of its spread through school agency, the extreme youth of many of the sufierers, and the utter carelessness of many parents in regard to it. frustrate nearly every eflort to prevent its difiueion. Many authorities have temporarily added it to the list of notifiable diseases, but only a small proportion of them retain it after the lapse of four or five years. Diphtheria, too, shows no material sign of diminution. In London alone the deaths during the period September—November were very numerous, often amounting to between sixty and seventy per week; and notwithstanding all efiorts to prove the contrary there can be no doubt that the tenacity with which the infection clings to the school-going ages must be in large measure due to that which has been termed “school influence.” Diarrhoea was, happily, not a very fatal disease taking the year as a whole; but during six weeks of the months of July and August, when there was absence of rain and excess of tempe_rature,.the fatality increased in certain of our large towns and cities, and in the-metropolis it was by some persons assumed to have been exceptionally prevalent in districts where the water- supply was for a time materially diminished in amount. The contention was, however, not borne out; the disease was of much the same extent in localities of a similar character where there was no lack of water, and it had been of even greater extent under very similar meteorological conditions, when no question of water- supply could be raised. Such scarcity of water as did prevail was not of suficient duration to show itself in death-returns. ’ Following on the report which was made in 1895 by the first Royal Commission on Tuberculosis, a second one was appointed during the last Session of Parliament, with a view of ascertaining what administrative procedures are neces- sary and desirable with a view to such control of food- supplies as shall prevent them from serving as a means of conveying tuberculosis in its diflerent forms to the human subject. The principal questions involve our meat and our milk supplies, and in this way the interests of the butcher, the agriculturist, and the dairy farmer will have to be con- sidered as well as those of the public health. The Com- mission has commenced its sittings, and it is assumed that it will report during the forthcoming Session of Puliament. There has been but little legislation during the past year that has had direct concern with public health. But in one respect the limited action taken has been extremely satis- f ctory by reason of the fact that it has once-for all removed » JULY 21, 19cc. - mtence, and thzi - entiated from c of one or both shoulders, are also common. An arm may be jerked, a foot kicked, a halting movement or 8mm; other definite, usually simple act performed; some- times vocal utt ances are associated. The movements may, in one fog or other, persist for years, usually With mfiissions, occasionally With intermissions. They cease during sleep, and can be restrained temporarily by an efiort of the will. They‘ difier from the movements of chorea in their distribution, their character, their per- absence of seasonal relation. spasm, or mimic spasm, may be consid- of convulsive tic, and is to be differ- orea by its localization, involving one or several muscles on one or both sides of the face; its association with disease or paralysis of the facial -nerve, or the facial cortical center, and its occurrence in adults, rather than in children. The spasm may be clonic, or tonic, and is rel'eved by rest'and increased by emotion and activity. he disorder is irregular in course, and usually long in uration. The athetoid ovements that attend certain lesions of the brain somet' es closely simulate those of chores; but so far as the r ' ' , they are rather vermicular or serpentine, as compared with those .of cfprea, and less jerky, and rather pro- gressive than ab pt. They, too, are inco—ordinate and involuntary, but they are usually confined to the same member or meriiers; they persist indefinitely, and are Painless fucia ered as a variety ’U I 8 s: 3:" p '1 I; ‘4 o in t1 0" m m H ’U H 53 m m a. 0‘ «<1 3 5+ but little susce tible to therapeutic intervention; and they are, as a r e, although not always, associated with palsy and other pastic phenomena, and often with evi- dences of mental deficiency. They are excited or inten- sified by voluntai'y movement, and sometimes in associa- tion with other movements, and by excitement. So—called chronic or senile chorea, the disorder de- scribed by Huntington, is dependent on degenerative changes in the cerebral cortex, and occurs only in adult or late life. While the movements are much like those of chorea, they d not yield to treatment, and with them mental aberratio becomes associated The onset of the disease is gradual, the movements are less abrupt and jerky than those of chorea, the gait may be staggering, and other members or ancestors in the family may have been attacked. Hysteria may be attended with various disorders of movement, some of which may closely simulate chorea. These, however, are usually more abrupt in onset, more rapid,.more shoc -like, and more rhythmic than those of chorea, and theyli are, as a rule, associated with other hysterical stigma a. It should, however, not be forgotten that a hysterical atient may also be choreic or vice versa. So-called chores ajor is a manifestation of hysteria, as is probably also 3 —called electric chores. The fatal dis- order known as ubini’s disease, or electric chorea, is probably an inf ctious disorder, and is attended with muscular weakness and atrophy. Torticollis, or spasmodic wry-neck, in a child may simulate chores. Here the movement, however, is con- fined to a few muscles, and is always of the same char- acter. It may b tonic as well as clonic. The nodding, 1r rotatory spasm, observed in rachitic children, difiers from chores in its limitation to the head, in the exceedingly early period of life at which it occurs, in its association Eith other symptoms of rickets, and its disappearance wit improvement in the nutritional state. The character of the movements is sufficiently described by the name. menswear DIAGNOSIS. 147 Saltatoric spasm, jumpers, myriachit and latah, as well as other forms of myoclonus, are rare diseases, whose discrimination from chores is rarely necessary. 224 fiath Sixteenth Street. RECENT PROGRESS IN THE ROENTGEN-RAY METHODS OF DIAGNOSIS! B_Y CHARLES LESTER LEONARD, an, MD. PHILADELPHIA The operative technique of modern surgery is the re- sult of a process of evolution which is based upon the more accurate knowledge of the source of infection and the formation of pus. The employment of asepsis and antisepsis, as a consequence, has had the result of de- creasing the mortality in a field of operating that is ever widening, and narrOWing the horizon of the inoperable and hopeless. The value of operative intervention is limited only by the inability to recognize the pathologic process at a suficiently early period. It is impossible to restore to perfect functional activity organs seriousl injured by disease. Marked progress can not be look for in oper- ative technique. A high average result can be obtained by an ever-increasing number of operators. The innocuousness of surgical operations is leading to an increased employment of purely exploratory opera- tions and to operations that are not based upon a clear diagnosis of the pathologic process that is resent. V Progress in surgery 'can be expect when these methods are set aside and more accurate methods of surgical diagnosis are substituted. An early, accurate . diagnosis is now the sine qua non of a successful restora- tion of function. Progress in surgerywill keep pacewith the development of accurate methods of diagnosis and be proportionate to their advance. The new method of physical diagnosis which is the subject of this paper is but one line in which surgical diagnosis is progressing. Physiology, pathology, bac- teriology, and chemistry are all aiding. The phonendo— scope has increased the powers of perception and diifer- entiation in auscultation and percussion. Direct cystos- copy and the catheterization of the ureters have produced results in the clinical examination of the female that are approximated by analogous methods in the male. All these methods possess an increased amount of precision, which, like the clinicalthermometer, is the result of a basis on purely physical laws. The Roentgen-ray method of diagnosis owes its 801 curacy to these elements of physical precision. The physical phenomenon upon which this‘method is based is the production of a form of radiant energy, which emanates from a vacuum tube when a high potential cur- rent of electricity is passed through it. The best scien- tific opinion holds that this form of radiant energy is a light-wave which lies far beyond the ultraviolet in the spectrum. It is sufficient for its use to know it obeys the laws of rectilinear rays and can not be reflected or re- fracted. Its peculiar physical properties that make it valuable in physical diagnosis are the power to penetrate in varying degrees, substances that were formerly con- sidered opaque, and to register the amount of penetration on the fluorescent screen or the photographic plate. The pictures or skiagraphs produced are shadows, the va ' densities of which correspond to structures, each of which has a relatively constant resistance to the pene- tration of the Roentgen discharge. The more opaque W 'Read by Invitation at the annual meeting of the Modico: Chlrurglcal Faculty of Maryland. Baltimore, April 24. 1900. 148 presented by denser shadows, since they absorb or dispe the most rays; the less opaque permit more rays to p , while the least opaque or complete penetration are represented by absence of shadow. Although all substances constantly maintain their relative opacity, their shadowy representations vary with the shortness or length of the exposure and the quality of the Roentgea discharge. The discovery of the vary- substancesare mg effects pr duced by rays discharged from the . Roentgen tube uring difierent states of the vacuum led to their careful study. Professor Roentgen has termed these states “so t,” “medium” and “hard.” Various attempts have n : 11 made to secure accurate fluorometric measurements, ut with only partial success. A physical measurement at is fairly constant and directly ap- plicable to any t be while in action is the measure of the length of the uivalent spark-gap in air 'in a parallel circuit. This masure is very practical, as by it the self— regulating tube n be adjusted at any time.to produce any desired qual ty of Roentgen discharge. By this standrd the “soft” tube will have an equival- ent resistance ls than 11/2 inches of spark in air. The resulting negati e will show differential shadows of the less dense struct res, while the bones will be but slightly penetrated. Th “medium” tube has an equivalent re- sistance of from I 1/2 to 21/2 inches. It produces negatives of strong contrat, with some penetration of the bones. The “hard” tu has a resistance above 21/2 inches and produces a flat egative, without contrast, and is chiefly of value in dete ting foreign bodies more opaque than bone. The volume f Roentgen discharge is an important factor and is de - :ndent upon the volume of the secondary discharge that e ergizes the tube. It was a deficiency in volume that fo u erly made it impossible to penetrate the denser portions n the body with rays that would produce tissue differentition. This is the defect of the static- machine energy. The recognitio I of these varying qualities of Roentgen— rays and the adtation of them to the particular fields where they are nost useful is an essential of technique and marks the sures of the latest development in the adaptation of t ' method of surgical diagnosis. The improve u ent in the construction of apparatus, and the developent of the self-regulation tube are re- sponsible for the flexibility and adaptability which the rays now posses. With the self-regulating tube, it is possible to obta - and maintain any desired quality of Roentgen-rays fr any length of time. The power to maintain the tue atalow vacuum for any desired length of time is respo ible for the progress which has been made in tissu n Ii erentation. This is in turn respons- ible for much of he advance made in surgical diagnosis and will be the ther of future advances. THE X-RAY : AID IN THE STUDY OF ANATOMY. Before discuss ng the adaptation of this method to diagnosis,it is we 1 to point to its possibilities asamethod in anatomical stu 'es. The injection of opaque fluids in- to the veins, artries, sinuses, or cavities of the body renders their rela ion to each other and to the bones visi- ble. The relatio of the bones in difierent positions of the joints form‘s he basis of a comparison with patho- logic condtions. DETECTION ANI‘ LOCALIZATION OI" FOREIGN BODIES. A most. useful 3 well as most obvious application of this method was ound in the detection and localization of foreign bodies A great advance has been made in their localization. The early crude methods are replaced ROENTGE’N-RAY DIAGNOSIS. by simple processes which are remarkable for the .. .—~ matical accuracy of their results. The surgeon’s o. ' ,,_ directed by these calculations directly to the most .5"; fragments. These localizations are very valuable, ; .zi Cially, of foreign bodies of the eye. In all cases the o ;.;' f- tion must follow immediately upon thelocalization, ~.: cially in the case of the eye, since the electro : 3.7; is unable to overcome the resistance of the . adhesions that rapidly surround a minute fragment. these cases the negative value is almost as great as- positive. It prevents meddlesome interference where foreign body is present, or when it lies either in a.‘ u ,_ tion from which no further trouble can be expected“. where the surrounding vital structures make it v u. to remove it. - DIAGNOSIS AND TREATMENT OF FRACTURES. The value of this method in recognizing and ' the appropriate treatment for individual cases of trace; ture is not fully realized by the profession at large. It; is, however, fully recognized by many leading surgeon, who constantly employ it in their diagnosis and setting; of fractures. They control their results in setting by it; 3 use, and refrain from much interference with the dress. 5 ings which would otherwise be necessary. € The later developments in its employment and the in. creased definition in the skiagraph, enable the most minute fractures to be detected. The cancellated strno. tures of the bones can be distinctly shown, so that linear fractures without displacement, or impacted, fracturu can beshown with distinctness. The rapid swelling that follows fractures involving the joints adds greatly to the dificulty in detecting the fracture. Crepitus, that crude sign of fracture, is wanting on account of the exudate into the line of fracture. ‘ The progress in surgery which this method has made possible is very great. The pain and agony of fracture- examination can be entirely avoided. More definite and absolute knowledge can be obtained in a scientific man- ner, without causing the least discomfort. The time has arrived when the manipulation of a limb suspected of fracture should be considered meddlesome surgery. It causes the patient pain that is unnecessary, and inflicts serious injury on tissues already devitalized by trauma- tism, that may greatly retard or even prevent recovery. The knowledge gained by this methodof diagnosis should have as important an efiect upon the treatment of frac- tures as upon their diagnosis. It is a simple matter to show that many forms of apparatus now employed to produce immobility are failures. The individual fracture needs its own peculiar and appropriate dressing. The skiagraph has shown hOW great the variation in type is from the classic, empirical and schematic descriptions of the text-books: It is necessary to study carefully the mechanical elements involved in each fracture. The transverse, oblique, spiral and all other fractures each demand their appropriate treatment. The determination of the exact line of fracture directs attention to the mechanical dimculties that will be met with in reducing the fragments to their proper position and in retaining them there. It shows where the danger from exuberant callus is to be guarded against or the blocking of the joint by the protrusion of a fragment. Many simple fractures have been shown to be more dangerous to function than the compound fracture. The shape of the fragment can be seen in a compound frac- ture and the small fragments removed, while fixation methods can be employed if essential to repair. They should be employed in many cases of simple fracture. The amount of displacement, the involvement of joint JULY '31, 1900. ., surfaces, and t e extensive rupture of ligaments can be inferred from he altered relations of the bones that enter into the joint. The rarity of intercapsular fractures has been found to be due to the failure to detect them; this is also true of many other rare fractures. “Bad sprains” have frequently been shown to be unrecognized fractures. The progress made in this form of diagnosis has in— creased the power to recognize fractures until it is possi- ble to absolutely exclude fractures of the limbs. Frac- tures of the skull or of the vertebrae can be recognized only in particularly favorable cases and can not yet be excluded. It has been considered the duty of the surgeon to treat all cas of sus ected fracture as if the fracture existed, unless t could be absolutely excluded. This practice undoub edly resulted in procuring the greatest good for the ma ority of patients; and yet many of them have been depri d of much valuable time, 'and have been subjected to unnecessary confinement in bed and to need- less expense, where no fracture really existed. Since, as has been mentioned, the accuracy of the skiagraphic method of exa 'nation is now so great that fracture can be detected, or a solutely excluded in all suspected cases of fracture of the limbs, there is no longer any ground on which such a course of treatment can be justified. Absolute knowledge can be obtained in the majority of cases on. which a more rational line of treatment can be based. Much has been written and said regarding the inaccuracies and fallacies of the Roentgen rays. These so-called fallacies are not faults in the Roentgen-ray methodof diagnosis, but errors in the technique of its application. Such errors in technique are but human and the result of the faulty employment of this mecham ical method. It should not be judged by the errors intro- duced by the poor technique of the observer. If opera- tors would stud to find out and correct these errors, they would co r a greater benefit than they do by Charging their ignorance to the account of a method they do not understand. Another valuable use of the skis- graph in connection with fractures is the confirmation 0f the reduction, and the assurance, that the skiagra h can give, that the dressings are sufficient to retain t e fl‘agments in pro er position. Such a skiagraph is also 'Vel'y valuable evi ence in demonstrating the fact that the fracture was properly reduced and an appropriate dress- lng applied. _ CORRECTION our DEFORMITIES DUE TO NON-UNION. .The correction of the deformities resulting from VICious union is greatly facilitated by this method of findy' and the knowledge obtained by it aids the operator 111 correcting the condition which was responsible for the lTouble. _In cases of suspected non-union it is not always Possible to establish the fact, especially at an early _1'i0d, as the time when callus becomes opaque varies. months is probably a safe limit. The only method, h(Never, by Whit}? non-union can be proved is by the Nnction of a c ange in the relation of the fragments ,flgat can be detec ed by the skiagraph. {Asymmetry and functional disability do not always go .msether. Many old fractures that are not symmetrical .‘hen studied by the skiagraph have yet produced no «,Ri'nmnent disability. On the other hand perfect osseous gmetry may be present, and yet the injury have pro- 7‘ ‘ such serious lesions of the soft tissues, which can by the skiagraph, that a permanent g disabi ity results. 'ly inferred from this that skiagraphs FBQE’NTGE’N—RAY DIAGNOSIS. basis upon which damages can be 149 assessed in suits at law. They have, however, a distinct value, the bearing of which upon the facts in the case is gradually being determined. Although the question re- quires deep study and consideration, it is, perhaps, safe to say that they have been admitted as evidence and as such are capable of determining whether a fracture has taken place or not, provided the examination is made within a reasonable time after the injury; what the line of fracture was, and what its bearing upon the difficulties of treatment would be. In all cases in which skiagraphs are admitted as evidence, expert testimony should be called by both sides and the privilege demanded and used of examining the patient by this method. Skiagraphs under these conditions will demonstrate the absolute facts. Without expert explanation they are liable, by their erroneous visual impressions, to mislead the jurors. Skiagraphs taken with the fixation dressings in place are a safeguard to the practitioner and evidence that the result desired has been accomplished. They should never be given to patients except by the surgeon in charge or with his consent, as misinterpretations may result in serious trouble. IMPORTANCE OF X—BAY TO ORTHOPEDICS. Orthopedic surgery has already been greatly benefited by this new method. The predetermination of the exact osseous deformity facilitates treatment or points out the exact operative intervention that is demanded. The various pathologic conditions that simulate each other in outward appearances are readily differentiated by this method. This is particularly true of diseases of the hip. In spinal disease the extent of the deformity, amount of rotation or involvement of the bones by tubercular disease, is readily determined. Metatarsalgia was ac- curately described by Morton years ago; the proof af— forded by the skiagraph and the determination of the ex- act point for operation are invaluable additions. The result of osteoplastic operation and the efficiency of fixa- ltion diressings can be studied, and valuable lessons earne . The study of the malformations and regenerative pro~ cesses found in the bones is not the only value of this method. The fact, that in the majority of pathologic processes involving osseous tissues there is always an absorption or an increase in the amount of the bone salts, makes the study of these processes ssible by this method, since it is to these salts that the fines owe their opacity. Hypertrophy or atrophy can be readily de- tected and confined to a more area. The shape and size of exostoses and osteomata can be seen, and the needed intervention predetermined. DIAGNOSIS OF ANEUBYSMSL . y! In November of 1896, Dr. Pepper, in discussng the value of “Skiagraphy in the Diagnosis of Aortic Aneurysms,” in a paper read before the Pan-American Medical Association in Mexico, said: “In many cases the new agent serves only to confirm a diagnosis which has already been established with great confidence by auscul- tation and percussion. Even in these cases we may hope for greater precision as to location and size and form. In other cases, however, an intrathoracic aneurysm of such small size, or so situated as to cause but few symptoms, and not susceptible of diagnosis by ordinary methods, may be demonstrated by the X-rays. Lastly there are cases where symptoms strongly suggestive of aneurysm are present, and the gravest anxietv must be entertained, since clear diagnosis by exclusion may be impossible, and yet the employment of the X-rays may 150 be of positive value as failing to reveal an increase in the shaded form of the heart and aorta.” The progress which has been made since that time has more than reali ed the expectations expressed. The size and position oilz aneurysms that lie too deep to be de- tected with certainty by other methods can be shown by the skiagraph. Their pathognomonic expansile pulsa- tion can be seen upon the fluoroscopic screen, and the in~ crease or decrease in" their motion noted as indicated by a thickening bf their walls and as a progress toward in- crease 01‘ recovery. VALUE AND LIMITATIONS OF THE FLUOROSCOPE. It will be of- service to stop for a moment and con- sider the value— and limitations of these fluoroscopic ex- aminations. What value ought to be placed on the asser- tion based on these observations? It isbut a transient image that affects the eye of the observer. ' It can not be mechanically registered or reproduced. It is, there- fore, impossible to compare them with any fixed stand- ard or normal, or with any other case, or any other ob- server‘s impressions except through the senses of the in- dividual. How inaccurate these observations must be! The normal has hysiologic variations that are absolutely unknown in thil) relation. In appearance they may ap- proximate so closely to the pathologic in its incipiency as to make it impossible to differentiate between them. These fluoroscopic images can never be more than the personal observations of the individual; as such they may ap- proach in accuracy the results obtained by other methods of diagnosis, but they lack the element of mechanical accuracy based on physical laws, that would give them a greater value. As the opinion of the individual observer they should receive only that amount of credence which any similar personal opinion would receive, and must de- pend entirely upon the acuity of his perceptions for their value. vThey are chiefly valuable in detecting abnormal motion and in confirming observations made by other methods. Gross variations are readily detected. It is not possible to detect the lesser, incipient pathologic vari- ations from the physiologic normal or one pathologic condition from another. A great deal has already been claimed for the fluoro- scopic methods in the diagnosis of incipient tuberculosis. As confirmations of other methods they may have some value. They lack a purely mechanical process of produc- tion and a known fixed normal towhich they can be re- ferred. They undoubtedly aid the _observer in confirm- ing other impregions; but they are simply impressions and can not di erentiate between the incipient patho- logic and physiologic variations; they can only have a value as personal opinions secured by employing the sense of sightin a. new method; since they are limited by the observer’s acuity of perception, they can have no lother value. ‘ SKIAGRAPH MUST DISTINGUISH BETWEEN SOFT TISSUES OF DIFFERENT DENSITIES. Further developments, and results that have the ele- ment of mechanic 1 accuracy, can be obtained only by an improvement in LEis power to difl’erentiate, by the skis- graph, between t e less dense tissues. Some proaress has already been made in this direction. Areas of infiltra- tion and cavities with their surrounding wall of tuber- cular infiltrates ca be shown in the skiaszranh. while the progress of the didease can be recorded in a series of skias‘raphs. Thev are also valuable in mechanicallv con- firming the details of a diagnosis which has been made hr the other methods. ‘ ' The employment of this method in detecting consolida- ROENTGEN—RAY DIAGNOSIS. Joca. A. H. Al; tion of the apices and the incipient stage of tubercul would render the greatest service. lt is, however, ' possible, even where the skiagraph detects the incr :1; density due to consolidation, to prove that this opaci is due to a tubercular deposit, or that it is even path logic, except by employing, in conjunction, other met ods that are now in vogue. SURGERY OF THE KIDNEY. Within the past twenty years the surgery of the ney has been developed. The untiring efforts of clinician’s? and operators have already done much in systematizini the symptomatology, and in determining the vario pathologic processes that involve these organs. More; however, must be accomplished if the early recognition“ and differentiation of these conditions is to be suflicientlyf accurate to render operative intervention of the greatest service. The similarity of the symptoms is so great that they may readily be confused and the differential diag. nosis be impossible. The difficulty is increased when one or another symptom is masked or wanting. Fre. quently the symptoms become so severe and the condition of the patient so serious that operative intervention is indicated before a definite diagnosis has been reached, Here, where surgical diagnosis is often so deficient, this method has overcome the difficulties of diagnosis, and through it an absolute addition to knowledge can be secured. The absolute negative as well as the positive diagnosis of renal calculus can be made by this method, even when there are so few signs and symptoms that only a suspicion of its presence suggests the examination. Thus expectant or non-operative treatment is rendered rational where it otherwise would have been hazardous. RENAL CALCULI. Calculous nephritis is a pathologic condition in which delay in forming the diagnosis is most serious in its re- sults. 'The mortality from early operation when the calculus is small, is but 2 or 3 per cent; delay rapidly increases the danger until in the presence of suppuration it reaches 25 per cent. or more. Recovery after early operation practically restores the kidney to its primary and complete functional activity. The longer the patho- logic process is permitted to remain undisturbed, the greater is the injury and functional loss; while if it con- tinues undetected the entire kidney may be destroyed, or atrophy may set in and result in complete functional disability. Clinical experience and post-mortem findings have shown that the’danger from quiescent and unsuspected calculi is very great. Even where the symptoms unmis- takably point to calculus and operation is indicated. there is always grave danger that the other kidney may be in- volved in the calculous disease. The formation of cal- culi depends upon some systemic cause, so that the pos- sibility of the presence of a calculus in the other kidney should never be forgotten. Many operators even advo- cate double exploratory nephrotomy to guard against operation on the wrong kidney or when both kidneys are the seat of calculous disease. This is one of the problems that this method has solved. Quiescent or unsuspected calculi, that have either made their presence felt by one attack. where the symptoms have entirely subsided, or have never given rise to sufficient symptoms to cause more than a suspicion of their presence are a great dan- ger. since their presence threatens. sometimes the in- tegrity of one kidney. sometimes the life of the patient. These calculi. that are generallv minute. are dannnrnus. because they mayhecame impacted in the ureter and thus give rise to a partial unilateral anuria. or. if the other sigh; lib" JUNE ‘31. lQOO. xvi"- kidney has been prevously destroyed, to complete anuria and the death of the patient. Post-mortem examinations have frequently demon- strated that the total destruction of one [kidney has been . accomplished by this process, or the suppuration result- ing from the presence of one or more calculi, and that death has ensued when a calculus has formed in the other kidney and blocked its ureter. The process by which a kidney is thus destroyed is so insidious that destruction may simulate recovery. This pressure of the urine, dammed up in the ureter, soon equalizes the intra- nephritic blooderessure; the kidney ceases to act, and loss of functio is followed by atrophy and degenera- tion, until nothing may remain but a mass of fibrous tissue. The symptoms that ushered in the anuria sub- side completely and the patient has apparently recov- ered from the attack. There is in fact, such a complete simulation of r covery that undoubtedly many of the “cures” attribuled to internal medication would be shown by post-mortem examination to have been in reality the cessation of symptoms because the kidney has been destroyed; while many other cases never had a calculus. The patient who has sufiered from an attack of renal RO E.\"TCr’E.V-B.—l l' Dbl Cr'NOiSIS. colic, or in whoyn the possibility o of danger until symptoms are present that point to a calculus, can never be said to be out the absence or exact location of the calculus has been established. So long as the calculus remains in the patient’s kidney or ureter, there is always danger of partial or complete anuria. If the calculus exists, its presence should be detected, and it should be immediately removed; if there be no calculus, the patient should have that assurance, as a basis for the rational treatme nt of the condition that produced his symptoms. Quiescent and unsuspected'calculi are not the only ditficul of renal calculus. Within or outsid ties met with in forming a diagnosis pathologic processes, either e of the kidney, simulate it so closely that their symptoms differ only in some minute particu- lars or degree, and are often so nearly alike as to render v a differential diagnosis impossible by ordinary methods. 0 The classic symp always wanting the very smallnes ms are seldom found and are nearly 11 the incipiency of the disease, when a of the calculus makes it most danger- 0us and when operation is most favorable and the loss of function the slightest. - The conditions that simulate calculous nephritis and tender the differential diagnosis difficult are inflamma- tions of the kidriey, varying in degree from a simple _ ' itis to complete destruction of the ey by a suppurative process. The formation of a 'gnant tumor in the kidney may produce 3 are the counterpart of the early calcul- , 0‘18 .pyelitis and can not be distinguished from it in the eflrlier stages, or until the tumor has reached a palpable Tubercular disease of the kidney is most dificult diflerentiate. The similarity of symptoms is very ,,°‘{% and when it is impossible to detect the tubercle l"V‘Illlus in the urine. the differentiation is often im- gPOuible. in, The excessive secretion of oxalic or uric acid may give g“!!! to a symptom-complex that is difficult to separate afloat true calculous disease. In fact it is probable that conditions are often the nrorlromal stage of cal- §E§l9ns formation and the negative diagnosis established Nah cases can not guarantee that the patient will not .. o lfuli or gravel at a subsequent period. (- condition resmnsible for these er- s corrected. T’reteritis with or with- 1-31 out the fo‘rmation of a stricture may be very difficult to «lifierentiate from calculous disease. Uther conditions than those that are purely in- tranephritic and yet that involve the kidney may produce a resemblance in their symptomatology that is very close ' to that of calculus. Abnormal motion, either in the form of the floating kidney with a wide excursion from the normal position, or the movable kidney with a lesser, yet pathologic, displacement, may give rise to twists or sharp angles in the ureter or the renal artery and veins that will produce alterations in the flowi'of the blood or in the escape of the urine, thus altering the intranephric blood-pressure or the intrapelvic urinary pressure. These alterations may produce periodic congestions or an intermittent hydronephrosis. They are acute in type and have such crises of pain and are often attended by hemorrhage to such an extent as to make it impossible to exclude calculus. ‘ The continuance of these conditions or of an acute hydronephrosis may in time result in pathologic malformations, which have been variously described as valvular folds or twists of the ureter. Peri- renal abscesses and inflammations or cicatricial ad- hesions and contractions may also play their part. Besides these numerous conditions within and outside the kidney, other diseases in distant or neighboring or- gans may be readily confounded with calculous disease of the kidney. The ovaries, the appendix, and the gall-blad- der are all the seats of pathologic processes producing symptoms that may be readily referred to the kidney. Ulcerations or malignant disease in the stomach, in- testines, or other parts of the genito-urinary tract, may produce crises of pain that resemble very closely nephritic colic, since the pain is often referred to the kidney. Disease of the lumbar spine in its incipiency is frequently accompanied by pain that is laminating in type, and may be mistaken for nephritic pain occasioned by a calculus. This résumé of the conditions in which the symptom- atology is confused with that of calculus, shows how readily mistakes may arise, and how impossible it is to prevent them by the ordinary means of diagnosis at present at command. The list of operations performed for stone in which none were found would be very large if all were reported. Mr. Henry Morris, who is prob- ably the greatest authority on renal calculi. has reported forty-four cases in which he operated for- stone and found none. The patients in the majority of these cases were benefited, since the pathologic process present was deter- mined. and frequently complete recovery ensued. Many other operators of the highest diagnostic ability have made similar mistakes. In many of these cases explora- tory nephrotomy was indicated. Such operations are in- dicated. even where calculus has been excluded, when- ever the symptoms-point to a process the persistence of which would endanger the function or vitality of the kidney: they are. however, unjustifiable for suspected Palculus. since their absence or presence can be absolute 1y determined by the Roentgen-ray examination. burg- inal opinion has already reached the mint where it con- demns the incision of the kidney during an exploratory operation. unless some macroscopic lesion demands it, 0- n “1"uiius has been shown to be present by the skiagraph. Two cases have come within the author’s personal cxnerience in which the Roentgen-ray diagnosis was the only indication for incising the kidney. In each case-the r-a’ci""< was fcnnd and the na'icnt relieved befom seri- ous ininrv had been done to the kidney. In either of them may: the incision of "the kidney would have been 152 an unjustifiable procedure if the presence of'a calculus had not been predetermined, as there were no macro- scopic indications of its presenuce. These various simulations of calculous renal disease, and the benefits secured by the employment of the Roent- gen-ray method of diagnosis have been illustrated by the series of seventy-four cases in which an absolute neg- ative or positive diagnosis has been established. HYDBONEPHROSIS. - The benefits derived from this method of diagn are not confined to the detection or exclusion of calculi. In three cases a hydronephrotic condition was shown; in one instance accompanied by three calculi that were subsequently removed; in a second there was a pure pyonephrosis where the negative calculus diagnosis was subsequently proved by operation. The third case is of particular interest, as it illustrates the possibilities of this method and what may be expected from further de- velopments. Attacks that simulated a mild form of appendicitis had persisted for about three months, re- curring at intervals with an exacerbation of the symp— toms. The presence of a slight amount of blood in the urine after these attacks was the only symptom or sign that pointed to renal disease. It suggested calculus and the patient was referred for a Roentgen examination. The skiagraph showed the absence of calculi and in ad‘ dition an opacit *, greater than that of the rest of the kidney which c rresponded in form with the pelvis. The outline of the pelvis was not visible in the other kidney shadow, showing that some pathologic condition must have been present to produce the contrast. The clinical history afiade it highly probable that this shadow was due to the d stension of the pelvis by bloody urine, forming a condition of acute hydronephrosis. The sub- sequent history justified this conclusion. Another case similar in character in which a hydronephrosis was de- tected was shown by the catheterization of the ureter to be correct, as a large amount of pus was withdrawn. In another case which exhibited no renal symptoms and in which a true cystitis had been excluded, the skia- graph showed a minute calculus in the ureter just out- side the bladder. Its position was beautifully demon- strated by the shadow of the bladder wall. In another pelvic examination the shadow of the enlarged prostate was distinctly visible. No detail. was, however, added to the diagnosis that had been made by other means, except that calculi were excluded. ’ , The production of such detail and difierentiation in soft tissue shadows points out the way for further ad- vance in diagnosis. The value of the detection of abscess formation, as the result of tubercular disease in the kidney will be very great. A nephrectomy will, if the diagnosis can be made sufficiently early, completely eradicate the disease. THE EXACT LOCALIZATION OF THE CALCULUS. The exact localization of the calculus is one ofthe great advantages of this method. Not only is the operation rendered complete by the definite determination of the number of the calculi, and the question of the involve- ment of the other kidney decided, but the exact location also limits the operative intervention to a particular portion of the kidney. Thus a calculus weighing 42 grains was removed in a late case through an ' incision in the upper pole of the kidney which brought the operator directly upon the calculus. In another case the second calculus was found only because the exact localization led to the opening of a cyst in which it lay. In a third case three calculi were removed where one would have ACUTE TONSILLAR DISEASES. osis . Joua. A. M. i: d been considered the sole cause of the trouble. In u." cases calculi have been found in both kidneys. ‘ precise localization would be invaluable in a case partial or complete anuria from calculus. The h0- edge obtained would facilitate and limit the extent ~..3 severity of the operation. The greatest value of method lies in the mechanical method of its producti which arantees mathematical accuracy when it is p ‘ erly employed. If the calculus is suspected it can be .F‘? tected. The examination is harmless, painless, and.‘ comprehensive, detecting or absolutely excluding .J from all portions of the urinary tract. The completeness and accuracy of thesediagnoses, . .7 positive and negative, has been attested by the seven ‘ -cases,‘ out of the twenty-four that have been opera :. upon. A calculus weighing 9/10 of a grain has been . - tected, and a mass of crystals that were not org n... into a true calculus found and, removed. Calculi of . 5, chemical compositions are included in this number, fro the more opaque oxalate to the less opaque uric-sci stones. Calculi have been found in fourteen cases; ., negative diagnosis has been confirmed by seven opera" tions, and in only one case, through a fault in placing . ‘ plate, has a calculus escaped detection. .1 The technique essential to the production of negativ’ upon which these absolute diagnoses can be based ,1: 4 been already published.1 Where such mechanical .f sults are produced, absolute dignosis can be based upo them. All that is essential is that the negatives be perfu- in emulsion and show detail in shadows of tissues .. dense than the least dense calculus. , The same method applies with equal accuracy to ...‘ detection of vesical calculi. It is especially valuable " determining the size and number of calculi present; ‘ showing partially encysted calculi lying in a diverti ulum or in detecting calculi in the pocket behind an en' larged prostate gland. 1930 Chestnut Street. ~ : v... 4 n"? ACUTE TONSILLAR DISEASES AND THEIR E SEQUELAE.* JOSEPH H. ABRAHAM. M.D. msrnucron IN LARYNGOIDGY IN rm; NEW roux Ponrcuruo new roar: our. The tonsils belong to the hemopoietic system, and a ..~ germinating centers for the leucocytes. Their u’ of greatest activity is in childhood and youth, when : - the lymphatic organs are especially active, and when .~.." thymus gland is disappearing.1 Surrounding the tonsillar follicles are plexuses o lymphatics, and in the tissues of the tonsils there vz.‘ an intimate lymphatic network, composed of minu 2' channels from which the lymph is collected by large lymphatic vessels. These pass to the superior deep oer , vical glands, which frequently become enlarged in tonv sillar inflammations, and can be easily demonstrated in the upper part of the neck. Goodale2 proved that a > sorption exists normally in the tonsils and takes pl w through the mucous membrane of the crypts. Hoden ‘ pyl8 demonstrated that rarefaction of the epitheli n is of constant occurrence in the tonsils; as a result 0 this process, parts of the epithelium are considerabl‘ diminished in thickness. Therefore any in'itant to t ' cells increases desquamation, which may denude the ton sil in places of its epithelial covering and favor lym 1. Annals of Surgery, February. 1900. ‘Read before the Alabama Medlcal Association. at Montgomery‘ Ala.. April 17-20. 1900. , ...
View Full Document

Page1 / 11

Week6_Xrays - 3 Pet 100.000 households. Divorce is the most...

This preview shows document pages 1 - 11. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online