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.