THE USE OF THE RÖNTGEN X RAYS IN SURGERY.
By W.W. Keen, M.D., LL.D.
The nineteenth century resembles the sixteenth in many ways. In or about the sixteenth we have the extensive use of the mariner's compass and of gunpowder, the discovery of printing, the discovery and exploration of America, and the acquisition of territory in the New World by various European states. In the nineteenth century we have the exploration of Africa and the acquisition of territory in its interior, in which the various nations of Europe vie with each other again as three centuries before; the discovery of steam, and its ever-growing application to the transportation of goods and passengers on sea and land; of the spectroscope, and through it of many new elements, including helium in the sun, and, later, on the earth; of argon in the earth's atmosphere; of anæsthetics and of the antiseptic methods in surgery, and, lastly, the enormous recent strides in electrical science.
Not only has electricity been applied to transportation and the development of light and power; but the latest discovery by Professor Röntgen of the X rays seems destined, possibly, not only to revolutionize our ideas of radiation in all its forms on the scientific side, but also on the practical side to be of use in the domain of medicine. It is, therefore, with great pleasure that I accede to the request of the editor of this Magazine to state briefly what has been achieved in the department of medicine up to the present time.
The method of investigating the body by means of the X rays is very simple, as is shown in Figure 1. The Crookes tube, actuated from a storage battery or other source of electricity through a Ruhmkorff coil, is placed on one side of the body. If need be, instead of using the entire tube, the rays from the most effective portion of it only are allowed to impinge upon the part of the body to be investigated, through an opening in a disk of lead interposed between the Crookes tube and the body. On the other side of the part to be investigated is placed a quick photographic plate shut up in its plate-holder, and is exposed to the rays emanating from the tube for a greater or less length of time. The parts of the plate not protected by the body are acted upon by the rays, through the lid of the plate-holder (to which the rays are pervious), while the tissues of the body act, feebly or strongly, as the case may be, as obstacles to the rays. Hence, the part of the plate thus protected is less acted upon than the rest, and a shadow is produced upon the plate. The soft tissues of the body form but a very slight obstacle to the passage of the rays, and, hence, throw very faint shadows on the plate. The more dense portions, presenting a greater obstacle to the passage of the rays, throw deeper shadows; hence the bones are seen as dark shadows, the soft parts as lighter ones. That the flesh or soft parts are not wholly permeable to the rays is well shown in the skiagraph—i.e., a "shadow picture"—of a foot. (Figure 2.) Where two toes overlap, it will be observed that there is a deeper shadow, like the section of a biconvex lens.
(From the "British Medical Journal.")
When we attempt to skiagraph the thicker portions of the body, for example, the shoulder, the thigh, or the trunk, even the parts consisting only of flesh obstruct the rays to such an extent, by reason of their thickness, that the shadows of the still more dense tissues, like the thigh bone, the arm bone, or the bones of the trunk, cannot be distinguished from the shadows of the thicker soft parts. Tesla ("Electrical Review," March 11, 1896) has to some extent overcome these difficulties by his improved apparatus, and has skiagraphed, though rather obscurely, the shoulder and trunk, and Rowland has been able to do the same. Doubtless when we are able to devise apparatus of greater penetration, and to control the effect of the rays, we shall be able to skiagraph clearly even through the entire thickness of the body.
It might be supposed that clothing or surgical dressings would prove an obstacle to this new photography, but all our preconceived notions derived from the ordinary photograph must be thrown aside. The bones of the forearm or the hand can be as readily skiagraphed through a voluminous surgical dressing or through the ordinary clothing, as when the parts are entirely divested of any covering. Even bed-ridden patients can be skiagraphed through the bed-clothes, and, therefore, without danger from exposure.
(From the "American Journal of the Medical Sciences," March, 1896.)
One of the principal difficulties of the method at present is the time ordinarily required to obtain a good picture. Usually this time may be stated at in the neighborhood of an hour, though many good skiagraphs have been taken in a half hour or twenty minutes. It is stated that Messrs. McLeennan, Wright, and Keele of Toronto have reduced the necessary time to one second, and that Mr. Edison has taken even instantaneous pictures; but I am not aware of the publication of any pictures showing how perfect these results are. Undoubtedly, as a result of the labors of so many scores of physicists and physicians as are now working at the problem, before long we shall be able to skiagraph at least the thinner parts of the body in a very brief interval. The brevity of the exposure will also better the pictures in another way. At present, if the attempt is made to skiagraph the shoulder or parts of the trunk, we have to deal with organs which cannot be kept motionless, since the movements incident to breathing produce a constant to and fro movement of the shoulder, the lungs, the heart, the stomach, the liver, and other organs which, hereafter, may be made accessible to this process. There is no serious discomfort excepting the somewhat irksome necessity of remaining absolutely still.
(From the "American Journal of the Medical Sciences," March, 1896.)
Another method of seeing the denser tissues of the body is by direct observation. A means of seeing through the thinner parts of the body, such as the fingers or the toes, has been devised simultaneously by Salvioni of Italy, and Professor Magie of Princeton. Their instruments are practically identical, consisting of a hollow cylinder a few inches long, one end of which is applied to the eye, the other end, instead of having a lens, being covered by a piece of paper smeared with a phosphorescent salt, the double cyanide of platinum and barium. When the hand is held before a Crookes tube, and is looked at through the cylinder, we can see the bones of the hand or foot almost as clearly as is shown in Figure 2. It has not yet, I believe, been applied to thicker parts of the body. Figures 3 and 4 show a baby's foot and knee as seen through this tube. The partial development of the bones accounts for the peculiar appearance. There is no bony knee-pan, or patella, at birth, and the bones of the toes consist only of cartilage, which is translucent, and therefore not seen. The name given by Professor Salvioni to this sort of "spy-glass"—if one may apply this term to an instrument which has no glass—is that of "cryptoscope" (seeing that which is hidden). The name suggested by Professor Magie is "skiascope" (seeing a shadow.)
This leads me to say a word in reference to the nomenclature. The very unfortunate name "shadowgraph" has been suggested and largely used in the newspapers, and even in medical journals. It has only the merit of clearness as to its meaning to English-speaking persons. It is, however, an abominable linguistic crime, being an unnatural compound of English and Greek. "Radiograph" and its derivatives are equally objectionable as compounds of Latin and Greek. The Greek word for shadow is "skia," and the proper rendering, therefore, of shadowgraph is "skiagraph," corresponding to photograph.
The first question that meets us in the use of the method in medicine is what normal constituents of the body are permeable or impermeable to the X rays. It may be stated, in a general way, that all of the fleshy parts of the body are partially permeable to the rays in a relatively short time; and if the exposure is long enough, they become entirely permeable, so that no shadow is cast. Even the bones, on prolonged exposure, do not present a sufficient obstacle to the passage of the rays, and the shadow originally cast becomes obliterated. Hence, skiagraphs of the same object exposed to the rays for varying times may be of value in showing the different tissues. The most permeable of the normal tissues are cartilage or gristle, and fat. A kidney (out of the body) is stated by Dr. Reid of Dundee to show the difference between the rind, or secreting portion, which is more transparent, and the central portion, consisting chiefly of conducting tubes, which is less transparent. On the contrary, in the brain the gray cortex, or rind, is less transparent than the white nerve tubules in the centre.
The denser fibrous tissues, such as the ligaments of joints and the tendons or sinews of muscles, cast very perceptible shadows, so that when we come to a thick tendon like the tendo Achillis, the shadow approaches even the density of the shadow cast by bone. I presume that it is for the same reason (the dense fibrous envelope, or sclerotic coat) that the eye-ball is not translucent to the rays, as is seen in Figure 5, of a bullock's eye.
(From the "American Journal of the Medical Sciences," March 1896.)
Mr. Arthur H. Lea has ingeniously suggested that the translucency of the soft parts of the living and of those of the dead body might show a difference, and that, if such were the case, it might be used as a definite test of death. Unfortunately Figure 6, of a dead hand, when contrasted with Figure 11, of a living hand, shows virtually no difference, and the method cannot be used as a positive proof of death.
That we are not able at present to skiagraph the soft parts of the body, does not imply that we shall not be able to do it hereafter; and should this be possible, especially with our increasing ability to penetrate thick masses of tissue, it is evident, without entering into details, that the use of the X rays may be of immense importance in obstetrics.
The bones, however, as is seen in nearly all of the skiagraphs illustrating this paper, cast well-defined shadows. This is at once an advantage and a hindrance. To illustrate the latter first, even one thickness of bone is difficult to penetrate, so that the attempt to skiagraph the opening which had been made in a skull of a living person by a trephine entirely failed, since the bone upon the opposite side of the skull formed so dense an obstacle that not the slightest indication of the trephine opening appeared. To take, therefore, a skiagraph of a brain through two thicknesses of skull, with our present methods, is an impossibility. Even should the difficulty be overcome, it is very doubtful whether there would be any possibility of discovering diseases of the brain, since diseased tissues, such as cancer, sarcoma, etc., are probably as permeable to the X rays as the normal tissues. Thus Reid ("British Medical Journal," February 15, 1896) states that a cancerous liver showed no difference in permeability to the rays through its cancerous and its normal portions.
Foreign bodies, such as bullets, etc., in the brain may be discovered when our processes have become perfected. Figure 7 shows two buck-shot skiagraphed inside of a baby's skull, and therefore through two thicknesses of bone. It must be remembered, however, that not only are the bones of a baby's skull much less thick than those of an adult's skull, but they are much less densely ossified, and so throw far less of a shadow.
The dense shadows cast by bone are, at least at present, an insuperable obstacle to skiagraphing the soft translucent organs of the body which are enclosed within a more or less complete bony case, as the rays will be intercepted by the bones. Efforts, therefore, to skiagraph the heart, the lungs, the liver, and stomach, and all the pelvic organs, probably will be fruitless to a greater or less extent until our methods are improved. While a stone in a bladder outside the body would undoubtedly be perceptible, in the body the bones of the pelvis prevent any successful picture being taken.
("American Journal of the Medical Sciences," March, 1896.)
To turn from the hindrances to the advantages of the application of the method to the bones, one of the most important uses will be in diseases and injuries of bones. In many cases it is very difficult to determine, even under ether, by the most careful manipulations, whether there is a fracture or a dislocation, or both combined. When any time has elapsed after the accident, the great swelling which often quickly follows such injuries still further obscures the diagnosis by manipulation. The X rays, however, are oblivious, or nearly so, of all swelling, and the bones can be skiagraphed in the thinner parts of the body at present, say up to the elbow and the ankle, with very great accuracy. Thus, Figure 8 shows the deformity from an old fracture of the ulna (one of the bones of the forearm) very clearly.
By this means we shall be able to distinguish between fracture and dislocation in obscure cases. Thus Mr. Gray ("British Medical Journal," March 7, 1896), in a case of injury to an elbow, was enabled to diagnosticate and successfully to replace a very rare dislocation, which could not be made out by manipulation, but was clearly shown by the X rays. We may also possibly be able to determine when the bones are properly adjusted after a fracture; and all the better, since the skiagraph can be taken through the dressings, even if wooden splints have been employed. If plaster of Paris is used (and it is often the best "splint") this is impermeable to the rays.
That this method will come into general use, however, is very unlikely, since the expense, the time, and the trouble will be so great that it will be impracticable to use it in every case, especially in hospitals or dispensaries, where crowds of patients have to be attended to in a relatively brief time. In the surgical dispensary alone of the Jefferson Medical College Hospital, about one hundred patients are in attendance between twelve and two o'clock every day, and all the time of a large number of assistants is occupied with dressing the cases. It would be manifestly an utter impossibility to skiagraph the many fractures which are seen there daily, considering that it would take from half an hour to an hour of the time of not less than two or three assistants skilled not only in surgery, but also in electricity, to skiagraph a single fracture. Now and then, in obscure cases, however, the method will be undoubtedly of great service, as in the case above described.
("American Journal of the Medical Sciences," March, 1896.)
Too hasty conclusions, especially in medico-legal cases, may easily be reached. We do not yet know, by skiagraphs of successful results after fracture, just how such bones look during the process of healing, and, therefore, we cannot yet be sure that the skiagraph of an unsuccessful case is an evidence of unskilfulness on the part of the surgeon.
In diseases of bone, which are obscure, it has already proved of great advantage, as in a case related by Mr. Abrahams ("British Medical Journal," February 22, 1896). A lad of nineteen, who had injured his little finger in catching a cricket ball, had the last joint of the finger bent at a slight angle, and he could neither flex nor extend it. Any attempt to do so caused great pain. The diagnosis was made of a fracture extending into the joint, and that the joint having become ossified, nothing short of amputation would give relief. Mr. Sydney Rowland skiagraphed the hand, and showed that there was only a bridge of bone uniting the last two joints of the finger. An anaesthetic was administered, and with very little force the bridge of bone was snapped, the finger saved, and the normal use of the hand restored.
Deformities of bone can be admirably shown. Thus Figure 9 ("British Medical Journal," February 15, 1896) shows the deformity of the last two toes of the foot, due to the wearing of tight shoes. (Owing to the accidental breaking of the plate, only a part of the foot is shown.) The lady whose foot was thus skiagraphed stated that she had suffered tortures from her boots, so that walking became a penance, and she even wanted the toes amputated. Relief was obtained by wearing broad-toed boots, which gave room for the deformed toes. Another admirable illustration of a similar use of the method is seen in Figure 2, from a case of Professor Mosetig in Vienna. The last joint of the great toe was double the ordinary size, and by touch it was recognized that there were two bones instead of one. The difficulty was to determine which was the normal bone, and which the extra bone that ought to be removed. The moment the skiagraph was taken, it was very clear which bone should be removed. Bony tumors elsewhere can also be diagnosticated and properly treated. Possibly, also, we may be able to determine the presence of dead bone, though I am not aware of any such skiagraphs having been taken.
(Taken at the State Physical Laboratory, Hamburg, and published in the "British Medical Journal.")
Diseases and injuries of the joints will be amenable to examination by this method. Figure 10 shows an elbow joint with tuberculous disease. The bones of the arm and forearm are clearly seen, and between them, is a light area due to granulation-tissue, or to fluid, probably of tuberculous nature, which is translucent to the rays. The picture confirms the prior diagnosis of tuberculous disease, and shows that the joint will have to be opened and treated for the disease. Deposits of uric acid in gouty diseases of the joints will undoubtedly be shown by these methods, but this will scarcely be of any help in the treatment. Whether light will be thrown on other diseases of the joints is a problem not yet solved.
Analogous to the bony tissues are the so-called ossified (really, calcified) arteries. In the dead body, arteries filled with substances opaque to the X rays, such as plaster of Paris or cinnabar mixtures, have already been skiagraphed successfully. It is not at all improbable that calcified arteries in the living subject may be equally well shown. So, too, when we are able to skiagraph through thick tissues, we may be able to show such deposits in the internal organs of the body. Stones in various organs, such as the kidney, will be accessible to examination so soon as our methods have improved sufficiently for us to skiagraph through the thicker parts of the trunk. The presence of such stones in the kidney is very often inferential, and it will be a great boon, both to the surgeon and the patient, if we shall be able to demonstrate positively their presence by skiagraphy. For the reason already given (the pelvic bones which surround the bladder), it is doubtful whether we can make use of it in stone in the bladder. Gall stones, being made not of lime and other similar salts, as are stones in the kidney and bladder, but of cholesterine, are, unfortunately, permeable to these rays; and it is, therefore, doubtful whether the X rays will be of any service to us in determining their presence.
The chief use of the method up to the present time, besides determining the diseases, injuries, and abnormities of bone, has been in determining with absolute accuracy the presence of foreign bodies, especially of needles, bullets, or shot and glass. It is often extremely difficult to decide whether a needle is actually present or not. There may be a little prick of the skin, and no further positive evidence, as the needle is often imperceptible to touch. The patient, when cross-questioned, is frequently doubtful whether the needle has not dropped on the floor; and it might be, in some cases, a serious question whether an exploratory operation to find a possible needle might not do more harm than the needle. Moreover, though certainly present, to locate it exactly is often very difficult; and even after an incision has been made, though it may be embedded in a hand or foot, it is no easy task to find it.
(Skiagraphed by Mr. Sydney Rowland, and published in the "British Medical Journal.")
The new method is a great step in advance in the line of precision of diagnosis, and, therefore, of correct treatment. About half a dozen cases have already been reported in the medical journals in which a needle was suspected to be in the hand or the foot, and, in some instances, had been sought for fruitlessly by a surgeon, in which the use of the X rays demonstrated absolutely, not only its presence, but its exact location, and it has then been an easy matter to extract it. So, too, in an equal number of cases, bullets and shot have been located, even after a prior fruitless search, and have been successfully extracted. Figure 6 is the skiagraph of the hand of a cadaver which shows a needle deeply embedded in the thumb, and also two buck-shot, which were inserted into the palm of the hand through two incisions. It will be noticed that their denser shadow is seen even through the bones of the hand themselves, for the hand was skiagraphed palm downward.
Professor von Bergmann of Berlin has uttered, however, a timely warning upon this very point. In many cases, after bullets or shot have been embedded in the tissues for any length of time, they become quite harmless. They are surrounded with a firm capsule of gristly substance which renders them inert. In 1863, soon after I graduated in medicine, I remember very well assisting the late Professor S.D. Gross in extracting a ball from the leg of a soldier who had been wounded at the Borodino, during Napoleon's campaign in Russia. It lay in the leg entirely harmless for almost fifty years, and then became a source of irritation, and was easily found and removed. There are many veterans of the Civil War now living with bullets embedded in their bodies which are doing no harm; and there is not a little danger that in the desire to find and remove them greater harm may be done by an operation than by letting them alone.
Glass is, fortunately, quite opaque to the Röntgen rays, and it will be of great service to the patient, if the surgeon shall be able, by skiagraphing the hand, to determine positively whether any fragment of glass still remains in a hand from which it is at least presumed all the fragments have been extracted. Even after the hand has been dressed, it is possible, through the dressing, to skiagraph it, and determine the presence or absence of any such fragments of glass.
("American Journal of the Medical Sciences," March, 1896.)
Possibly before long we shall be able to determine also the presence or absence of solid foreign bodies in the larynx or windpipe. Every now and then, patients, especially children, get into the windpipe jack-stones, small tin toys, nails, pins, needles, etc., foreign bodies which may menace life very seriously. To locate them exactly is very difficult. The X rays may here be a great help. An attempt has been made by Rowland and Waggett. to skiagraph such foreign bodies, with encouraging results. Improvements in our methods will, I think, undoubtedly lead to a favorable use of the method in these instances. Beans, peas, wooden toys, and similar foreign bodies, being easily permeable to the rays, will not probably be discovered.
If our methods improve so that we can skiagraph through the entire body, it will be very possible to determine the presence and location of foreign bodies in the stomach and intestines. A large number of cases are on record in which plates with artificial teeth, knives, forks, coins, and other such bodies have been swallowed; and the surgeon is often doubtful, especially if they are small, whether they have remained in the stomach, or have passed into the intestines, or entirely escaped from the body. In these cases, too, a caution should be uttered as to the occasional inadvisability of operating, even should they be located, for if small they will probably escape without doing any harm. But it may be possible to look at them from day to day and determine whether or not they are passing safely through the intestinal canal, or have been arrested, at any point, and, therefore, whether the surgeon should interfere. The man who had swallowed a fork which remained in his stomach (l'homme a la fourchette, as he was dubbed in Paris) was a noted patient, and would have proved an excellent subject for a skiagraph, had the method then existed.
As sunlight is known to be the foe of bacteria, the hope has been expressed that the new rays might be a means of destroying the microbes of consumption and other diseases in the living body. Delépine, Park, and others have investigated this with a good deal of care. A dozen different varieties of bacteria have been exposed to the Röntgen rays for over an hour, but cultures made from the tubes after this exposure have shown not only that they were not destroyed, but possibly they were more vigorous than before.
The facts above stated seem to warrant the following conclusions as to the present value of the method:
First.—That deformities, injuries, and diseases of bone can be readily and accurately diagnosticated by the Röntgen rays; but that the method at present is limited in its use to the thinner parts of the body, especially to the hands, forearms, and feet.
Second.—That foreign bodies which are opaque to the rays, such as needles, bullets, and glass, can be accurately located and their removal facilitated by this means; but that a zeal born of a new knowledge almost romantic in its character, should not lead us to do harm by attempting the indiscriminate removal of every such foreign body. Non nocere (to do no harm) is the first lesson a surgeon learns.
Third.—That at present the internal organs are not accessible to examination by the X rays for two reasons: First, because many of them are enclosed in more or less complete bony cases, which cut off the access of the rays; and, second, because even where not so enclosed, the thickness of the body, even though it consists only of soft parts, is such that the rays have not sufficient power of penetration to give us any information.
Fourth.—Even if the rays can be made to permeate the thicker parts of the body, it is doubtful whether tumors, such as cancers, sarcoma, fatty tumors, etc., which are as permeable to the rays as the normal soft parts, can be diagnosticated. Bony tumors, however, can be readily diagnosticated; and possibly fibrous tumors, by reason of their density, may cast shadows.
Fifth.—That stones in the kidney, bladder, and gall bladder cannot be diagnosticated, either (1) because they are embedded in such parts of the body as are too thick to be permeable by the rays, or (2) are surrounded by the bones of the pelvis, or (3) are, in the case of gall stones, themselves permeable to the Röntgen rays.
Sixth.—That with the improvements which will soon be made in our methods, and with a better knowledge of the nature of the rays, and greater ability to make them more effective, we shall be able to overcome many of the obstacles just stated, and that the method will then probably prove to be much more widely useful than at present.
From a photograph taken by Mr. Herbert B. Shallenberger, Rochester, Pennsylvania, and reproduced by his permission. This is a particularly interesting picture, because it not only shows the bones with unusual clearness, but also shows that the ulna (the small bone of the forearm) has been broken; a small projection at its lower end, which ought to appear, being absent from the bone as shown in the picture.
Footnote 1: [(return)]
The term "unpublished" is employed in this series of articles to cover documents that have never been published in any authoritative or permanent way. Most of the documents so designated have never, so far as we know, been published at all; but a few have been printed in local newspapers, though so long ago, and under such circumstances, as to be practically unpublished now.
Footnote 2: [(return)]
The original of this letter is owned by E.R. Oeltjen of Petersburg, Illinois.
Footnote 3: [(return)]
The originals of both the letters on this page addressed by Lincoln to Hardin are owned by the daughter of General Hardin, Mrs. Ellen Hardin Walworth of New York City.
Footnote 4: [(return)]
The swords referred to in this postscript are those used in the Shields-Lincoln duel. See MCCLURE'S MAGAZINE for April, 1896.
Footnote 5: [(return)]
Interview with Judge William Ewing of Chicago.
Footnote 6: [(return)]
Lincoln in Indiana in 1844. Unpublished MS. by Anna O'Flynn.
Footnote 7: [(return)]
This letter is dated October 3, 1845. It is now owned by the son of Williamson Durley, Mr. A.W. Durley of West Superior, Wisconsin. Mr. C.W. Durley of Princeton, Illinois, kindly secured the copy for us from his brother.
Footnote 8: [(return)]
This letter is still in the possession of Dr. Boal of Lacon, Illinois, and the right of publication was secured for the Magazine by W.B. Powell of that city.
Footnote 9: [(return)]
This letter, hitherto unpublished, is owned by E. R. Oeltjen of Petersburg, Illinois.
Footnote 10: [(return)]
From a letter published in the "Sangamo Journal" of February 26, 1846, and which is not found in any collection of Lincoln's letters and speeches.
Footnote 11: [(return)]
From an unpublished letter by Joseph Gillespie, owned by Mrs. Ellen Hardin Walworth of New York City.
Footnote 12: [(return)]
From an unpublished letter to Judge James Berdan of Jacksonville, Illinois, dated April 26, 1846. The original is now owned by Mrs. Mary Berdan Tiffany of Springfield, Illinois.
Footnote 13: [(return)]
"Personal Reminiscences and Recollections," by Samuel C. Busey, M.D., LL.D., Washington, D.C., 1895.
Footnote 14: [(return)]
At this meeting the secretary was Ezra Lincoln, also a descendant of Samuel Lincoln of Hingham.
Footnote 15: [(return)]
See MCCLURE'S MAGAZINE for September, 1895.