The American Journal Of Roentgenology Vol 1 No 7 May 1914 Che American Journal of Roent genology Edited by P.M.Hickey, M.D. Associate Editor, EC. Lapftte, M.D. ) COOOL. New Series The Direct Method of Diagnosis of Duodenal Ulcer by Means of the Roentgen Ray - - : By Arial W. George, M. D., Boston an a Isaac Gerber, M. D., Boston S| S ae I = m (s Roentgen Examinations for Head Injuries - - 294 me Nee By A. L. Gray, Richmond, Va. ae Ha Some Experiments in Standardization of Dosage for Roentgen Therapeutics - - - - - 298 By George W. Holmes, M. D., Boston Applicants for Membership Editorial - Announcement of Nail Meeting - AE £7 aly Xe rd ee Published by SEE ais Che American Roentgen Ray Society mee Application for entry as second-class matter at the Post Office at Detroit, Michigan, pending’ cccCcCC_iQ__‘rr“»#;nnnnitttiiitititiiititiiitititeiesiiiiiiiicKcciNMiNMQOniiit = a a TTTET[ttiiiii ‘PARAGON A SUCCESS THAT HAS BROKEN ALL PREVIOUS RECORDS AMONG X-RAY PLATES From a startin May, 1913, during the New York State Medical Meeting, to the FIRST PLACE AMONG X-RAY PLATES IN THE WORLD is our Astounding Record \ K ] FE, TELL you this, notin aspirit of self- adulation, butsimply that you may know how quickly a superior product is recognized among the progressive radiographers, to-day. Only sheer merit could have won for us this overwhelming preference in so short a time, and it is entirely due to the fact that the radiographers demanded something far better than the X-Ray plates then on the market. The immediate success of the PARAGON is proof that we have accomp'ished what we set out to do. To-day they are used by practically every well-known radiographer in the United States, and at two recent conventions over 90 per cent. of the plates exhibited were PARAGON. Can you wonder that the other manufacturers are rushing to bring out “new plates, now that we have shown that the old, slow plates were “behind the times.” : “Imitation is the sincerest flattery.” The best endorsement to-day, for other plates, is not that they are “better than” but “almost as good as” the PARAGON. Think that over. It means “WE LEAD” If you have not tried them, send in a trial order for the sizes you use most. We guarantee results. Our byword is “Develop until dense.” GEO. W. BRADY & CO., Sole Distributors 754 South Western Avenue, Chicago TM ite | eal It THE AMERICAN JOURNAL OF ROENTGENOLOGY Editor, P. M. Hickey, M. D., Detroit Associate Editor, F. C. Zapffe, M. D., Chicago VOL. I NEW SERIES, MAY, 1914 No. 7 THE DIRECT METHOD OF DIAGNOSIS OF DUODENAL ULCER BY MEANS OF THE ROENTGEN RAY By ARIAL W. GEORGE, M. D., Boston and ISAAC GERBER, M. D., Boston A paper entitled “Positive Diagnosis of Duodenal Ulcer by Means of the Roentgen Ray” was published by us in a recent Quar- terly* of this Society. We were led to publish this paper at this time and upon this subject for various rea- sons. First, because in the study of duo- denal lesions in our own private practice we were led to the conclusion that we could derive certain exact data, which were con- stantly confirmed at operation. Secondly, we thought that if we brought this matter to the attention of our members, prior to this meeting, it might stimulate interest and enliven discussion, so that this most import- ant subject could be thoroughly considered. Going over the literature on the subject, we were surprised at the lack of positive- ness, not only of our own colleagues, but of the foreign observers as well, and it seemed to us that the lack of exactness depended to a considerable extent upon the method used in the study; and the confusion that arose was because different investigators re- lied upon so-called “symptom-complexes”’ of hypermotility, exaggerated peristalsis, gas- tric stasis, relaxed pylorus, etc. The mass of evidence from the vast majority of in- vestigators, such as Holzknecht, Haudek, Pfahler and others added to the confusion, were inferential only, and by no means con- clusive. *Amer. Quarterly of Roentgenology, 1913, IV, 187. It is possible that we are obsessed with our own ideas, and fantastic in our con- clusions; but why make such a mystery of the study of the intestinal tract or make the difficulties paramount? Does the intestinal tract vary any more in its anatomical com- pleteness than the skeleton, lung or kidneys? Do we hesitate to recognize positively a frac- ture? Do we procrastinate between osteo- myelitis and scorbutus? Do we hesitate to pass a positive opinion regarding kidney- stone; why then should the intestinal tract be such a bugbear to the great majority of Roentgenologists? Possibly you will all with one exclamation say, “It is not.” But we can only judge from the writings of our colleagues both in this country and abroad. They seem to be united in the opinion that the Roentgen diagnosis of duodenal ulcer can only be suggestive, but not positive. For convenience and clearness in present- ing our ideas, as well as to limit the discus- sion of this matter to certain salient facts, which are material, I am offering you seven propositions. First: The ‘positive’ method (or pos- sibly it would better please our critics and we would be considered less radical if we used the words “‘direct method’’) consists in demonstrating adequately the anatomical condition of the first portion of the duode- num. This is opposed to the conception of symptom-complexes, which we have stated 288 The American Journal of Roentgenology are only inferential in their evidence and are not conclusive as compared with this method in which we actually try to demon- strate the lesion. Second: Ninety-five per cent. of duo- denal ulcers occur in the first portion of the duodenum. Third: Anatomically the first portion of the duodenum is a constant entity. Fourth: If normal, the first portion of the duodenum can always be demonstrated on a plate, with characteristic shape and smooth outline. There is no exception to this rule. Apparent exceptions are due to improper technique. Fifth: A constant defect in this duodenal cap means a pathological condition. This may be ulcer, adhesions, cholecystitis, or anatomical or accidental variations, such as pressure of adjacent organs, etc. Sixth: Any duodenal ulcer, which is more than a simple mucous membrane erosion, will deform the outline of the bismuth mass. To this statement there is no exception. Fic. 1. Normal duodenum, taken prone. Patient weighed 125 pounds. A—First portion of duodenum. Note the smooth contour, and absence of valvulae conniventes. B—Second or descending portion. C—Third or transverse portion. Fic. 2. Normal lateral view in a patient weighing 220 pounds. Note the resemblance to the prone view shown in Fig. 1. Seventh: A normal “bulbus duodeni” or duodenal cap on the plates rules out indur- ated or surgical duodenal ulcer. To these seven propositions I shall limit my discussion, and I trust you gentlemen will do the same. I do not wish to take this opportunity to recapitulate what was stated in our former paper. I will take up then, the first proposition, which I have stated in part. As I have said we try to show on a plate the anatomical condition of the first portion of the duodenum. No set rule can be made as to how this can be accomplished. We have used the serial method throughout our 600 bismuth cases. No criticism di- rected towards the serial method can deny the one most important advantage of this method and that is thoroughness; and it is because of this thoroughness that we are able to adequately demonstrate the first por- tion of the duodenum. The second proposition that ninety-five per cent. of duodenal ulcers occur in the first portion of the duodenum needs no further discussion here. Third: Upon this proposition, that the first portion of the duodenum is anatomic- ally a constant entity, the whole value of the Dvurect Method of Diagnosis of Duodenal Ulcer 289 application of the Roentgen Ray depends. Upon the truth or falseness of this statement the entire problem of exactness in demon- strating duodenal ulcers will stand or fall. Our conclusion is based upon the generally accepted anatomical opinion, and especially upon the researches made by Prof. Germain of the Tufts College Medical School. From the examination of the duodenum in four hundred cadavers, he came to the conclusion that the first portion of the duodenum is con- stant in shape, contour and general char- acter, unless there is real disease present. Fourth: If you will admit this proposi- tion that it is possible with the serial method to show a normal duodenal cap when it is normal, then you have practically admitted half, if not more, of the matter under dis- cussion. This is where the method of serial plates has a distinct advantage over the fluoroscopic method used alone or with occa- sional plates. It is probably true that the great majority of investigators either do not recognize or can not demonstrate a normal duodenal cap in every normal case. ‘This is entirely a matter of insufficient or improper technique. With the fluoroscope, and in the upright position, it 1s sometimes a physical impossi- bility with certain bismuth meals to show a perfectly well filled cap. The same fre- quently holds true of the prone position with any bismuth meal. We ourselves use a meal consisting of 90 grammes of bismuth sub- carbonate in 500 c. c. of artificially prepared buttermilk and water. With this meal we are positive in stating that in some one of the three positions (prone, standing or lat- eral) by using a series of plates, we will be able to demonstrate in any given case a nor- mal cap, if a normal cap exists. To this we claim there are no exceptions. If you will admit, as above stated, that a normal cap can be demonstrated whenever the duo- denum is normal, then if the cap shows a constant defect upon the plates, the first por- tion of the duodenum must be pathological. By defect we mean a break in the outline, a deformity or any variation from the normal picture of a cap. We have thus narrowed our discussion down to one and really only one important problem, and that is, will all duodenal ulcers show in the Roentgen plates? This brings us to the sixth proposition that any duodenal ulcer more than a simple muc- ous membrane erosion will deform the out- line of the bismuth mass. Dr. W. Mayo has recently published a pathological study of a number of ulcers excised from the anterior. wall of the first portion of the duodenum.* ‘These ulcers seemed to have a different general char- acter from the classical callous gastric ulcers *Annals of Surgery, 1913, LVII, p. 691. Fic. 3. Reproduction from article by Dr. Wm. Mayo. This shows the very small mucosal defect of the duodenal ulcer, with the relatively large cicatrix extend- ing through to the serous coat. 290 The American Journal of Roentgenology with which we have all been familiar. The gastric ulcers usually show a relatively broad, punched-out, callous defect in the mu- cosa with induration around and _ below. These dtiodenal ulcers, however, showed often merely a pin-point defect on the mu- cosal surface with mucous membrane heaped up around it. However, the amount of cal- lus in the sub-mucosal, muscular, and peri- toneal coats bears absolutely no relation to the minute size of the ulcer itself. Now it is not this pin-point mucosal defect that we try to demonstrate, but it is the effect on the bismuth contour produced by the extensive callus in the sub-mucosa and other layers. (See Fig: 3.) This deviation from the normal bismuth outline is usually exaggerated ; that is to say, if the callus is in itself only slight, it will still produce a bismuth deformity that is un- mistakable. I believe it is fair to state that because of this exaggeration more can often be demonstrated on the Roentgen plates than can be seen by the average operator at the time of operation. In no part of the gastro- intestinal tract is the deforming effect of scar tissue upon the bismuth mass so appar- ent as in the duodenal cap. Fic. 4. Classical ulcer of first portion of duode- num, superior surface. The cicatrix ex- tended anteriorly and posteriorly. Note incisura on inferior surface. i L | | Fic. 5. A—Ulcer of duodenum. Incisura is present on opposite border. The duodenal ulcers that consist of merely a mucous membrane erosion, of course, will not show any effect upon the bismuth, but these are an almost negligible portion of the cases and they probably give only slight and transient clinical symptoms. These are the cases, which are of no surgical consequenice. I believe, gentlemen, I have demonstrated to you the basis upon which this sixth prop- osition is founded. The most severe criticism that has been made of our former paper was that it was quite impossible by our method to differen- tiate between adhesions due to duodenal ul- cer and those due to gall-bladder disease. In some very exceptional cases it is true the differentiation may be impossible. Asa rule, however, the case where adhesions are due to duodenal ulcer alone will show not only the fixity of the duodenal cap in the sub-hepatic region, but also a constant de- fect in some part of the duodenum due to the callus of the duodenal ulcer itself. As a rule, gall-bladder adhesions will merely show general deformity with fixation under the liver, but there will not be any one con- stant irregularity. As for the differential diagnosis between adhesions due to duodenal ulcer and duo- denal ulcer itself, in those cases where the { Direct Method of Diagnosis of Duodenal Ulcer 291 duodenum is not fixed to the right, I must confess that this differentiation can very often not be made. But as far as prognosis and surgical indications are concerned, this differentiation is not at all necessary. The real point of importance in this matter is whether or not we have a lesion involving the duodenum and produced by ulcer. This brings us to the seventh and last proposition regarding the negative value of our Roentgen examinations. In many of the cases in which we have demonstrated a nor- mal complete duodenal cap we have passed a negative opinion upon the possibility of duodenal disease, and the case subsequently at operation has never to my knowledge been proved wrong. Even though we do not go so far as to make the statement that a nor- mal cap means no duodenal ulcer of any kind, I think that we have at least established the authority to say positively that these cases do not warrant surgical interference so far as possibility of duodenal ulcer is con- cerned. I believe that a big half of the value of Roentgen evidence is in the negative as- pect, and this negative evidence has even greater value in the duodenum than in the stomach. From what I have said, gentlemen, it is evident that this whole subject depends prac- Fic. 6. More extensive cicatrix, causing a greater deformity of the duodenal cap. . - Fic. 7. Extensive ulcer of first portion of duode- num. Plate taken with patient lying prone. tically upon two important points; first, the ability to demonstrate completeness of the first portion of the duodenum and secondly, the demonstration either of a normal cap or of a constant defect. There is no better de- fence for serial radiography than the fact that we can bring out just these points. We know that the fluoroscope has not accom- plished it and we know that some men are doing this work by means of repeated plates. I believe that I have sufficiently represented my attitude upon this problem and I there- fore leave these propositions in your hands for further discussion. Since the above paper was read before the American Roentgen Ray Society by Dr. George, we have had 18 more operated cases of duodenal ulcer. This number, added to the previously reported 59 cases, makes a total of 77 operatively proved cases of duodenal ulcer. We have already re- ported three minor errors of diagnosis, no one of which was a serious error. In the entire series we have had but one real fail- ure of diagnosis. This was a case in which a large series of plates showed a persist- ently deformed duodenal cap in the prone position. However, one lateral view showed a definitely normal cap. During 292 The American Journal of Roentgenology Fic. 8. Same patient as Fig. 7. Lateral view. the discussion of the diagnosis with the surgeon, this lateral view was entirely ig- nored, and a positive diagnosis of ulcer was made. At operation the duodenum was found normal, but there was a chronically inflamed appendix. ‘This had probably pro- duced a pyloric or duodenal spasm resulting in the incomplete filling of the duodenum. This was a case in which the mistaken diag- nosis was. due, not to any deficiency in the Roentgen method, but to careless interpre- tation. The plates themselves did not he. Sufficient attention should have been paid to the normal appearance of the duodenum in the lateral view. At this point we feel that it 1s proper to reiterate our ideas on the importance of the lateral view in bringing out the anatomy of the duodenum. This position has a dis- tinct indication in two types of cases. The first group is where there is an ir- regular, incomplete filling of the duodenal cap.. Here the possibility of spasm is al- ways present. The one means at our com- | mand to rule out this condition is the lateral view. This method of examination of the duodenum requires a very careful attention to the technique. Unless care is taken the plates will be blurred, indistinct, and worth- less. The patient lies on his right side upon aplate; asually-or' the 10” x 12” size... It is advisable to use the smallest diaphragm and cone obtainable. The writers use a dia- phragm 11% inches in diameter, and a cone 6 inches long ‘This is brought practically in contact with the left side. The exposure must be slightly longer than is required to give a satisfactory plate with the same patient in the prone position. If this tech- nique is carefully followed out, a satisfac- tory lateral view can be obtained in prac- tically every case. Asa rule, in stout people the lateral view is easier to obtain than with thin subjects. By means of this method the antrum of the stomach and the first por- tion of the duodenum are in the most de- pendent position. We thus get the effect, not only of the peristaltic force of the stomach muscles, but of the force of gravity as well. These two forces acting together will usually relax the spastic pylorus and duodenum, so that the normal contour of the duodenum can be demonstrated. Some- times it may be necessary for the patient to lie upon his right side for a considerable length of time before the spasm is released. This explains why a normal cap was fin- ally shown 1n the case above described where Fic. 9. Same as Fig. 8. Plate taken 20 minutes later. Note the almost exact reduplica- tion of the deformity in the duodenal Cap: } Direct Method of Diagnosis of Duodenal Ulcer 293 Fic. 10. Very extensive ulcer causing almost an en- tire obliteration of the first portion of the duodenum. the incorrect diagnosis of duodenal ulcer was made. The second class of cases in which the lateral view has a distinct application is that group where the pyloro-duodenal region cannot be properly demonstrated in either the prone or standing positions. To this group belong practically all stout patients. In these people the increased intra-abdom- ‘inal pressure causes the so-called “steer horn” stomach with the right-sided position of the antrum and duodenum. In such stomachs, it 1s usually impossible to demon- strate the pylorus and duodenal cap in the prone position. When standing the bismuth will usually precipitate in the duodenal cap so as to make the complete filling of the duodenum likewise impossible. In such cases, the lateral view is very satisfactory. Figure 2 shows a lateral view of a very stout man in which all three portions of the duodenum are very definitely and beau- tifully demonstrated. We believe that the lateral view should be used as a routine in every stout person, for in no other way can the duodenum be so adequately shown. 259 Beacon Street. Fic. 11. Extensive duodenal ulcer with secondary dilatation of the stomach. Note the sacculation produced by some of the ad- hesions. 294 The American Journal of Roentgenology ROENTGEN EXAMINATIONS FOR HEAD INJURIES By A. L. GRAY, RICHMOND, VA. To no exposed part of the human anat- omy is traumatism followed by results so uncertain, as to the cranium. Injuries ap- parently trivial often produce the gravest consequences while the converse is also not infrequently true. The opinion of the Roentgenologist 1s more relied upon by the surgeon in cranial examinations than in almost any other of the diagnostic fields of Roentgenology, and the necessity for accuracy in technique and conclusions is plainly evident. The import- ance of examining the skull after injuries of only moderate severity has so often been impressed by the Roentgen findings that it needs no comment in advocacy thereof. Per- mit me to say, however, that in infants and very young children the thinness of the cranial vault renders injury to the intra- cranial structures far more liable than in adults, and the damage often escapes detec- tion until some serious manifestations ap- pear in later life. It seems entirely reason- able to conclude that permanent injury often results from the carelessness of a nurse, who, on her daily trips to the park, having for- gotten her charge by reason of the atten- tions of the ever present suitor, is awak- ened from her dreams by the cry of the little one who has tumbled from the bench or has pitched head first from its carriage to the pavement beneath. Such injuries as these are usually never reported to the parents, and the abrasion or contusion, if noticeable, is explained in some other plausible way. The convulsions and palses that come on later are called idiopathic or are attributed to birth trauma and the true cause remains forever unknown. In injuries of greater severity it 1s very common for the patient to be rendered 1m- mediately unconscious, and perhaps, in a few hours the mind clears and the attending physician dismisses the case as one of ‘“con- cussion of the brain.” The real nature of the injury may or may not be revealed later. Unfortunately fracture of the skull usually does not give rise to focal signs that can be detected, and inspection, palpation, and per- cussion are very imperfect guides. The presence of haematomata is usually a most valuable sign, but may be misleading and often in extensive fractures this sign is en- tirely wanting. The value of the Roentgen examination should be not alone in ascer- taining whether or not a fracture be present, but, in the absence of other determining fac- tors, in enabling the surgeon to decide whether or not an operation is indicated and the site and nature of the operation if it is deemed advisable. If craniotomy be considered unnecessary, the permanent rec- ord of the Roentgen plate will be a guide for a future operation, should the subse- quent history of the case demand it. For accuracy in the diagnosis the sharp- est possible detail is demanded. Unless this_ be obtained, a definite exclusion of fracture can not be made. To exclude fracture the plates should show plainly the bone struc- ture, sutures, and fine grooves for the smaller branches of the epi-dural and diploic ves- sels. In the very young, where the grooves are too faintly marked, the outline of the skull should be sharply cut throughout, and all the sutures clearly visible. The difficulty of obtaining detail in plates of supposed head fractures is familiar to all of us who are connected with emergency hospitals. The patient is usually not only unable to give intelligent assistance, but oftener than otherwise, resists all efforts to keep his head still. The ingenuity of the operator and his assistants is sorely taxed. Roentgen Examinations for Head Injuries 295 It is especially difficult to obtain sharp stereo- scopic plates, since the time required in ex- posures and shifting must be from 2 to 8 seconds, and all the usual braces and weights must be discarded. The motion of respira- tion and even the cardiac impulses must be overcome. Of the methods devised for surmounting these obstacles I wish to mention the use of sand bags against the chin or chin and nucha, padded clamps, and a modified lateroprone position with the upper shoulder supported so as to allow free antero-posterior move- ment of the chest in respiration. In children it is often possible to make a quick single exposure at the end of expira- tion, and in adults I have taken advantage of the long pause in the Cheyne-Stokes type of respiration that is not infrequent when the injury is grave. I have employed recently a very simple and effective method of holding the head still without the use of clamps, weights, or other apparatus that might tend to interfere with the interpretation of the plates. I use two or more lengths of gauze bandage 214 or 3 inches wide, and loop the middle of one of them around the patient’s head, fas- tening the free ends to some suitable fixed portion of one side of the table. The sec- ond bandage is correspondingly placed with the free ends toward the opposite side. The head is thus pulled from two opposite direc- tions and when the tension is sufficient to stop all movement, the free ends of the second bandage are securely tied to the table. If these two are found insufficient without exerting too great force, a third bandage is looped under the chin and fixed at the head of the table. Should the table be so con- Illustrating Dr. Gray’s Method for Stereoscopic Examination of Skull ee 296 The American Journal of Roentgenology Roentgen Examinations for Head Injuries 297 structed as not to furnish convenient fixed points for the attachment of the bandages, I employ heavy sand bags to which the free ends of the bandages are tied. There is thus afforded support from all sides and percep- tible motion is usually entirely abolished. The transparency of the bandages permits _ the making of head plates unmarred by ex- traneous objects. In some of my sharpest plates I have given an exposure of as much as ten seconds while the patient’s respira- tion proceeded normally. Since the extent of a cranial injury can be determined far more accurately by the stereoscope, whenever possible this method should be pursued, but 1f detail 1s not prac- ticable it is necessary to make single plates from several directions. The position of the head for the Roentgen examination is usually suggested by the presence of contusions or other marks of violence, but these are by no means always present. This is often true of fractures about the base where the injury has been produced by indirect violence. The usual bleeding from the ears, nose or eyes is not a constant accompaniment. By far the greatest amount of informa- tion may be obtained from a stereoscopic examination made with the head placed on one side with its mesial plane parallel with the plate. The target should be in a ver- tical line through the bregma, and the tube should shift transversely with this line as a center and at a distance not greater than 22 inches from the plate. This position not only shows the vault clearly but also admits of a better view of the base. In the absence of guiding factors, an examination thus made will prove most advantageous. The best position for plates of definite portions of the skull will suggest itself read- ily to the experienced Roentgenographer. A general rule, however, that may be applied is, attempt not only to throw the part in such a position on the plate that the overlying ' structures will not confuse the picture, but so place the head and direct the rays that the region sought will stand out as conspicu- ously as possible. For a correct interpretation of the plates it is clearly necessary that the Roentgenolo- gist should be thoroughly familiar with the normal grooves and depressions in the skull. The presence of exaggerated Pacchionian depressions has occasionally caused a con- siderable degree of perplexity in injuries supposed to have been produced by punctur- ing bodies. The development of the skull and the presence of Wormian bones and the sutures surrounding them should be held in mind especially in the young, lest they lead to a misinterpretation. Perhaps the most difficult fracture of the vault to recognize is one occurring in the groove for the trunk of the middle meningeal artery. If a linear fracture is confined to this groove, it 1s ques- tionable whether it can be recognized. Dip- loic veins especially the anterior and pos- terior temporal often produce very marked thinning of the bones along their courses and may be mistaken for fractures. In one case in my experience a linear frac- ture followed the course of an abnormally large diploic vein. Upon operation it was found that the outer table only was in- volved. It may be generally stated that, if the plate throughout shows no blurring, a fracture line will appear sharply cut and with characteristic angles and irregularities, while a vessel groove or canal shades from its center to the edges and disappears into the adjacent bone. Having determined the presence and ex- tent of a fracture, the Roentgenologist is frequently called upon by a surgeon for ad- vice as to the course to be pursued by him. The special points to be considered are: 1. The Location. This should be con- sidered both as regards probable damage to vital portions of the intra-cranial contents by the causative injury and also the degree of traumatism entailed by an operation at the site involved. The location should also be considered in relation to extra-cranial structures especially the nasal, pharyngeal, and auditory cavities in regard to the prob- ability of infection through compound wounds. 2. Shape. Whether linear, circular, stellate or of a jagged and irregular course. These points will, to a great degree, aid in determining probable localized pressure from depressed fragments. 3. Size of the fissure, or the amount of separation of the edges of the fragments, which also gives an idea of the probable damage to the soft tissues as well as the possibility of hernia or excessive scar tissue at the side of the wound. 4. Course, as to the probability of dam- age to blood vessels, nerves or other im- portant structures. 5. Whether the margins are overlapped ot are dodging each other. From consid- eration of these points we may obtain valu- able information in estimating the extent of the fracture, the injury to soft structures and the degree of compression. 6. Age. By reason of the thinness and pliant condition of the skull of an infant, it is probable that a marked degree of ac- commodation may take place resulting in perfect compensation or complete return to the normal. A blow that would cause a de- pressed fracture in the adult will often pro- duce an indentation without fracture in the very young child. In such cases, intra-cran- ial pressure alone may obliterate the depres- sion. The possible interference with cere- bral development at the site of the injury, however, should be carefully weighed. The patency of the fontanelles is to be consid- ered in operations for general decompres- sion. Nature’s method of relieving the sit- uation may leave less scar tissue and close in the cranial orifice far more perfectly than the most skilful surgeon. : Finally it is very important that the Roent- genologist should follow his patient to the operating table taking with him the plate or an accurate diagram of the conditions. He should, if possible, remain throughout the operation to see that the impressions he has received are also in the mind of the operator. 312 E. Franklin St. SLIDES 1. Showing detail. Jones. Hematoma. 2. Same. Headon. Fracture Mastoid. o. atid bag against chin only. Thompson child. Fracture extensive and dodging. 4. Padded sand bags. Bigger. Fracture Occi- pital bone. 5. Padded clamps. Malcom. Multiple cracks. Aeroplane case. 6. Shoulder supported. No other fixation. Moorefield. f. Quick exposure at end of expiration. Nash child, crying. Dent in frontal bone. 8. Interval of Cheyne-Stokes respiration. Hoagland. Extensive gaping fracture of parietal. 9. Illustrating also separation of margins. Sack. Fracture of parieto-temporal region to parieto-occipital suture. 10. Illustrating head held in position. 11. Same showing centering rod over bregma. 12. Radiograph of same head immediately after last photo. (One of stereoscopic pair.) 13. Same case as No. 1. Stereoscopic with head fixed by bandages. 14. Exposure of 8 seconds. One of stereoscopic pair, head fixed by bandages Dr. Clark. 298 The American Journal of Roentgenology SOME EXPERIMENTS IN STANDARDIZATION OF DOSAGE FOR ROENTGEN THERAPEUTICS By GEORGE W. HOLMES, M. D., Boston, Mass. Ever since the discovery of the therapeu- tic action of the Roentgen ray upon certain pathological processes, attempts have been made to accurately measure the amount of rays required to produce best and quickest, the desired changes. Advance of work in this field has been greatly delayed by the lack of efficient apparatus. Fortunately during the past few years, considerable improvement in machines for the production of the rays has been made. It was to take advantage of these recent improvements, especially those of the type of apparatus now in use in the Massachusetts General Hospi- tal, that this work has been undertaken. Efforts toward the measurement of X-ray dosage have in the past been directed along two lines: First, attempts to measure the amount of electrical energy delivered from the Roentgen tube during the time of ex- posure which produced the desired effect. Second, by placing between the tissues being treated and the excited tube certain chemi- cal substances which undergo changes when exposed to x-light, and from the amount of change in these substances, to judge the amount of dose to the tissues being treated. It is evident that the first method is almost entirely dependent on the degree of perfec- tion of the apparatus used, while the second is independent of apparatus—accuracy de- pending upon the ability of the operator to judge slight chemical or color changes. In comparing these methods, two ques- tions arise which must be answered before the relative value of either method can be determined. First, is the amount of change produced in living tissues in direct propor- tion to the amount of electrical energy dis- sipated? Second, does the amount of change taking place in certain substances when exposed to x-light always maintain the same proportion to the degree of change taking place in living tissues? In an attempt to answer these questions, the following experiments were undertaken: The apparatus used to excite the tube was a type of transformer capable of generating a non-fluctuating voltage with a current of from one to one hundred and fifty milliam- peres, with a voltage on the tube terminal of from ten to eighty kilovolts, and equipped with instruments for measuring these varia- tions in milliamperes and volts. We first made a series of exposures upon photographic plates to determine whether or not the amount of chemical action as recorded was or was not in direct propor- tion to the electric energy delivered through the tube measured in watts. Plates were exposed in the following manner: An 8x10 plate was divided into two equal parts, each one of these parts was further divided into five equal parts. All divisions, except the one being exposed, were then covered with lead sufficient to prevent the passage of any rays. Five exposures were made over one-half of the plate starting with forty kilovolts, and increasing with each exposure up to eighty kilovolts (the am- perage and distance being constant). The other half of the plate was then given five exposures, keeping the voltage and distance constant, but increasing the amperage at each exposure. The plate was then de- veloped and the amount of chemical change taking place with each exposure as shown by variation in color of the different divisions compared. It was found that where the wattage was the same, the colors matched. This experiment was repeated many times, varying the amount of energy used for the series—so that plates were obtained of different photographic values, Some Experiments in. Standardization of Dosage 299 also with different tubes of the same make and with tubes of different makes—tubes having tungsten, platinum and silver tar- gets. The result was always the same. It was also noted during these experiments that the amount of photographic action could be doubled either by doubling the voltage or the amperage, and that the amount of heat generated in the tube was apparently directly dependent upon the wat- tage, i. e., tubes of high voltage became hot sooner than tubes of low voltage passing ' the same amount of amperage. I have stated that the results of the exper- iments were the same no matter what type of tube was used. This is true in so far as areas receiving the same wattage with the same type of tube always showed the same degree of color change, but when plates taken with tube having tungsten target were compared with plates taken with tubes hav- ing silver target, a distinct difference was noted in the amount of color change pro- duced by the same wattage in a given period of time. This was expected, as it is well known that the character of the rays changes somewhat with the character of the metal composing the target—metals of low atomic weight giving rays of less penetrat- ing qualities than those given off from the metals with higher atomic weight. In the remaining work, tubes with tungsten targets only were used. We then began to make careful records of the voltage, amperage, distance and time of exposure used in all treatments given— as far as possible the same voltage was used for each case throughout, it being varied with different cases. A standard distance of ten inches was used. When an erythema was obtained the total amount of wattage and time were computed. After a sufficient number of these record charts had been obtained, it was possible to arrange a com- paratively accurate table of doses, showing the number of milliamperes, kilovolts and time of exposure necessary to produce an erythema of the skin with a tungsten tube at a distance of ten inches. These doses were then given at a single sitting in selected cases and the results noted. From the study of the results in these cases, 1t was possible to correct the table so as to eliminate any errors due to long dura- tion of treatment. A study of the completed table showed that the following factors must be consid- ered in giving an erythema dose: time, am- perage, voltage and distance—all of which are in accord with past experience—but it was also found that the higher the voltage used, the shorter the time required to pro- duce a reaction. We had up to this time believed the opposite to be true, i. e., that low tubes were more dangerous than high ones. TABLE OF DOSAGE. Kilovolts Milliamperes Minutes Inches 40 5 15 10 50 5 12 10 60 s 10 10 70 5 8 ? 10 80 5 vi 10 If the results from this table are compared with the results made from the photographic plates they will be found to be the same, namely, the amount of change taking place on the photographic plate and the amount of change taking place in the skin were both in direct proportion to the amount of electrical energy delivered through the Roentgen tube measured in watt seconds. In order to compare these results with those of previous workers and to test the value of the pastille as a means of measuring dosage, a series of experiments were under- taken using the Sabouraud pastille, the Hampson radiometer and the Holznecht radiometer. Treatments were given accord- ing to the table previously described. The pastille was placed in position enclosed in black paper and exposed throughout the treatment. Only cases where a full erythe- ma dose was to be given were used. At the end of the sitting, the pastille was examined and the dose as recorded by it charted. It was soon seen that the dose recorded by the 300 The American Journal of Roentgenology e é Some Experiments in Standardization of Dosage 301 pastille was too little with low voltage and We were unable to complete these experi- Se == too much where a high voltage was used. ments on account of the large amount of | 5 wo | 8 a: Piethiee work showed. that to -lave the material required and the inability of our , Peaae he Es B 3 two methods agree, the dose had to be given apparatus to deliver rays at Xe, high volt- § : 3 ES 3 : at about sixty kilovolts, i. e., with the tube age. We hope, however, with improved ee a| 3 = |32| 3. [8 reading between 6 or 7 Benoist—the only apparatus to make some definite statements ere ae a5 ae | re ecliae degree of hardness where the dose *, along this line of treatment in the future. : ‘ ie crates 3 ey accurately measured by any of these instru- During the past year we have given at the 2 = 3 o5 28 ae ae ments. The same results were obtained Massachusetts General Hospital and in pri- y 2 3 ae pie ee ge with the three types of pastilles used. vate work, thirteen hundred and eighty-one ere 2 Tea ee ee ol ead 2S) eee ae The necessity for using a tube of certain treatments, in which as far as possible ie MAS ara He ante fae a degree of hardness when using the pastille method of dosage described in this article Mr. B E ea in and) 2/28 ds. | 50) 25) 50)... .|[mproved. as a measure of dosage has been observed was used. The average number of treat- ae nerve De by previous writers. ments per case were seven, and the number . Se PaCey oa iidta Slop mos OONA12 |. a shan s Cured. Te deuisesoccbles tat: i he. prckelit of cases treated, one hundred and ninety- Biss Bo iwiee as Care rests 6.4 5. 14] 6 mo.| 60) 25)....|... Did not return. technique where large doses of very har q seven. Of these, seventy-four showed a ANB} cuckoo oe te Giant cell sarcoma filtered rays are given (measured by the distinct reaction, and ten of the reactions | [plat eee ee gee 14| 8 mo.) 70)'50)....{.-- Improved. pastille) that the dose is actually less than followed single massive doses. In no case Bis tsa eed? Care Breast ...... 21.2 a6.) GOB). 2.4) 4 Re Did not return. where the soft unfiltered rays are used, and was there any bad effect due to over-dosage. 6) Miter, 5-8 Care. Breast A072. 21) 5 mod.) 60) 25)... 2). ..|Did: not ‘return, that the good results obtained by this Appended is a tabulated list of the cases UAT SoC sa 2 oe Gare .Breasts ic 4. 9} 2 mo.} 60) 25) 192)... |Improved. technique are due not to the supposed treated, with the results obtained. 8)Mrs. D....... Care Rectum....) 2) 3 ds. | 60) 25)....)...|Improved. . larger dose but to the special action on or COncLUSIONG 2 Ei eahes atnount of OAS, lis ar ae Epithelioma, back adaptation to the case being treated of the (hemical or biolo gical action produced by GOPiGat Po vee cia: De eet: 60) 25]... .|.. . Improved. high voltage ray? Furthermore, is it not 4p, x-ray is in direct proportion to the LO irs Baten Care. Breast. ss: 15| 4 mo.| 60) 25)....)...|Improved. Still treating. eee et een eee anes amount of electrical energy supplied to the TUN rSy iste ase epi Breast. .... di oe Raa: 60) 25]....|.../Did not return. Peer = ites ee seein see ee one tube which produces the ray. Second: : es = were y Care JAW sr one. 418 ds.-| 70} 25)... <|,..(Did not return. high voltages, to give much larger doses With modern apparatus, it 1s possible to yi eee .|Malig lymphoma.| 29} 1 yr. | 65) 25)....).../Cured. than are now being given, without danger measure this energy with sufficient accuracy fest Uses yee 2 2 de. Roland ode. 3\14 ds. | 70) 25} = 75).. .| Improved. ened to use it as a basis for a table of doses. = are eee eros Sas nee ee 18] 7 mo.| 70} 25|....) RiImproved. Still treating. | se . Third: The results obtained with this CSA os aiued umor side of face). 2)-7 dsu| 15) 25). 2.4)... Much improved. Still treatin ants eae a kno Rada it 19 method seem more accurate and are more 17\Mrs. F........ Rpitn, Paces. i3 oot. 4) 2 mo.| 50) 30} 65)... /Cured. ' : of different voltage in the t ent er dtr. easily applied than any other. Fourth: The Teas. Pe faa Carc Breast shee 1G) Or mn6;) BO)" 25). 2 |S. Improved. ferent pathological Sencione possibility of giving accurate dosage with LO Mir: Fag. coke eee ee ES Okita cess « 7| 4 mo.| 60} 30) 185]...|Very little improvement. ti ds- of course eoident to ony neo rays of widely varying degrees of penetra- 20 Mr. (7s. dee (Gare Breast. .¢.. 18] 3 mo.| 60} 25]....| RINo improvement. by viliar “with the, lageotl abeOnDErOnieGr tion and of testing their value in different DT Miss. Cre. 28 Care Breast gies i ee eee BOBO] 5 awl saves odie tate ote Te eee eee x-light that the distance to which Ai pathological conditions is made possible. | ree As eee Leukoplakia..... De, at cee GOI DAD| o.oo Did not return. Sere ide beloweihe subice OF At nen Fifth: The high voltage or hard ray may \ Zo: ELAS Ss as Gane. Janson LALO 07500) 120) « a. clove 5 No improvement. Siiated: must determine-to a consideranl: be more dangerous than low voltage or soft ) 24/Mrs. is Rae eer Malig Rectum...| 14) 1 mo.| 60} 25]....)... No improvement. extent the voltage of the rays used, regard- ray. : Zo Wiese Ey « s.02 ..|Tubereulosis.~.:.). 2) -7 ds..| 60) 25). ...|...|No improvement: less of the nature of the disease being In closing, I wish to thank Dr. Walter J. Dol Wits” H.. 23 ese 4 Carc Breast. .:.. tl 6 M0;) 65)" 25). 2c Sheba Improved. Operation advised. treated. Dodd for his constant help and advice. Lig ae On a PIG hy Mars 3632.5 14: 5 mo.) 60-25)... .\ RI No improvement. 25\ Wins: EL: oss. Epith left side face) .5| 4 mo.| 60) 25) ...| 70)/Improvement. 29 \ Miss Diet. T. B. Glands, neck} 15) 6 mo.| 60) 25) 300) 65|Much improvement. OUI Ga Sy Psoriasis of Leg. .} 20/14 mo.| 40}...]....]... Alllesionshealed promptly, but returned. Treatm’t repeated. DLINI Sy 2alee le: Rodent Ulcer ticht.-eyelid:: i. .| -8)a.i0:) 60)2 2) a2. 65|Lesion cured. 302 The American Journal of Roentgenology GOAL Suen sa ak aes Carcinoma....... 2 = hs NAME DIAGNOSIS E bs & S| og [88 Z B) 2 | 88 a] 8 13g Z ees SOU cp scaree tas Epith, eyelid.....| 5) 2 mo.| 50 Sei IC eke. a oh Adenocarcinoma..| 38} 6 mo.| 80 Salis. Et .. os. 4|\ Care Breast... ... 6| 1 wk.! 60 Sa Wiics oes ae Care’ Uterus...... 4| 1 mo.| 60 36|Miss McD..../Carc Breast..... 8) 1 mo.| 50 ST Wire, Wistwa xc. P. O. Breast. .... do TL vite |)50 38/Miss M....... Intest Sarcoma...} 18/10 mo.| 50 SO NL. Ok Seen. Lupus Vulg..... 4/10 ds. | 50 AGW eae 164 PSORIASIS? ish ay 4 4| 1 mo.| 30 ANE) eee ae SV COSS 2. wis + ess 7| 6 mo.| 50 21011 6 ag Lee ge oe Epithelioma..... 5) 3 mo.) 60 7 ae et ee Painful Sear..:.: 3] 3 wk.| 60 BA GE ee ete Leukemia....... 18] 2 mo.| 60 715 a Ser rr Epithelioma..... 2) 1 wk.| 45 AG Reece sta Sa ee Epithelioma..... 4| 2 mo.| 70 AUS nce altos wae ee Delayedresolution| 2) 3 ds. | 50 Lh a ee ee Keratosis of hands} 4} 1 wk.| 50 AQUI eI aaa d esata pycosis) vule.. i: Dern s 55 DUR ict4 geese Epithelioma..... 2) 2 ds. | 35 Bl eck eae Hodgkins -Dis:...|~ 6) 1 mio:/-50 Bae ft eer PSOne sate 2| 3 ds. 65 Doles. tae Pruritis? ¢se0c53 Lee 60 1S ae Chay itis: a .ecneac Lee aes 50 DOM Oks cc vse sycosis vulg:..:..; 3| 1 mo.| 50 DOs eetisea wen Erythema indur..} 12} 1 mo.| 50 DA. Oe hawe nea. Herpes zoster....| 2) 1 wk.| 50 OSS Bn 5 Ate ne VES sce t B\ = amnOs.00 BOIS Stig. Sees Erythema indur..| 3) 2 wk.| 45 GUNG Si eesesos Epithelioma.....| 4| 2 wk.) 50 Ey, ia dew B oaretet Cacaine Buri; . «|: 4) b me...60 G2D. Buk sak oe PRUBISICN ho kee Eat ee. 80 sl ae ee ee are Hodgkins Dis....| 54/11 mo./?60 O4IC. Bc aide wes Hyperhydrosis...| 6) 1 mo.| 60 9) 5 mo.| 60 (min) given at each sitting Average number of milliamperes Total dosage received in milli- Dose received before a reaction Fy REMARKS 333 7) a BO Sa aiees! Improved. PO) inal oo Improved. ZO ia ta elterete fates Wobent o. £0 ta ata tt a ee bes ee ee Did not return. i a? ee Improved. 7/3) rr ees Improved. 9 a ee Improved. 30) 140).../Did not return. 20} 140}.../Did not return. 60) 415}110/Cured. ey) © 155|105|Much improved. 105). ; .; Did: not return. 425). ..|Still treating. (0).2.)Did-not return: WW Ww Cr. 25; 100)... (Still treating. 30; 60/.../Result not obtained. 30) 120).../Did not return. 65| 65} 65|Def. reaction. One month complete. Epilation over exposed area. 25| 55)...|Lesion entirely healed. 30} 250} R/Did not return. 40} 85} 85)Decided improvement. 15} 15}.../Did not return. 60) 60}...|/Did not return. 30} 115) 55)/Lesions practically cured. 50) 318). . .| Improved. 30| 70} 70\Improved. 30} 100}. . ./ Improved. 20) 55)...|/Lesions practically cured. PV EMU DE dia tia odin b areuie 8 he wes whe Pal oc 25| 130} 60/Still treating. 40} 40]...)Did not return. 15)1044|240|Skin tanned. Spleen still large. Otherwise well. 25| 155}. . .| Improved. 30} 191]/131)/Improved. Some Experiments in Standardization of Dosage 303 al & NAME DIAGNOSIS o & 3 GH : Sol age o 2 Bet GOED ve ee Merce e SVCOSIS 7s... F.0hs 25 i pre Gilles Vw se oarewee Adenoma .622. 22. 2| 1 wk. SIV) po taanaee eee Lup vulv (sebac).| 3] 1 wk. GOlle- Wiens eats KWeloid.:.es% 223 5| 1 mo. POLES, WV scat bigs he Hezemas. 3 s4 ot 3) 2 wk. Tiles. WY ea ees Epithelioma..... 4| 7 mo. To ee ee Hodgkins Dis....| 2/ 1 da. vis || ae © eee ee eee Epithelioma..... 10} 3 mo. iC. a ee Ie VEROEES 48 5 53% OF Se ee Tite Maus ore aon IRC IOIG:) aa oa Mea we 7| 3 m0 The? loess pene ak Eczema......... 6; 1 mo C1 | Wx. baa ee Tuberculosis..... Boot oa ole TO) | cslitass cane dae: ALCO IAs.4 4% 10) 3 mo. TOE: J cee Chr eczema..... 12} 7 mo. SOIR. Liceeaes Lichenplanus....| 12} 5 mo. rol Rea eerie rts Hodgkins Dis....| 55/10 mo. Soy Liga ae Ay US ans ea 3/11 ds. na || aa © eens ervie METAS 5 inca 9 «50.3 3)11 ds 64) Po IVEY cates Recur Gare... « 3/12 ds S| Oe eee a POUT Sy oa xatas if nea: SG Te: IVE go ciate peoee Psoriasis lich....| 6) 2 wk. STR. Wlh..25 eae Trehtae Dis 2.341 4| 4 ds. Ssil. Be Maes DarCOMIG {544 yeti < 5| 6 wk. 89. McC..... o.: Purunculus. os; ... i: alee! OUI, WICC. sates Epithelioma..... 5| 6 wk. OlibieG, NM. <5 Epith (?neck)...| 14) 4 mo OF Mel’. s.s32. jeg big 1s | er ieee Oo) |. IWMLGGr Sos glee Ulcer, right eye..| 3] 3 wk. 941M. McL...... Beoph gore...) Lievens 95I. McN......../Epithelioma..... 4| 2 mo. JOG. Mois beet Scrofuloderma....! 4) 5 :wk. Ta INA So gece Epithelioma..... 2| 8 ds. OS) | ule, eae eee Folliculitis....... 5| 4 mo OO Ko Wah as Epithelioma..... 4| 2 mo. LOOLA, IM 5. bo eee Tuberculosis... .. 7| 2 wk. 101|M. M........|Epithelioma..... kilovolts Average number of milliamperes Average voltage used in REMARKS (min) given at each sitting amperes (min) Dose received before a reaction obtained Total dosage received in milli- 45| 45} 45|Improved. 15| 45)...|Did not return. 20| 70) 70\Improved. 50} 215)125\Improved. Still treating. 30} 80]...|Did not return. 30) 125]125|Did not return. 25} 50].../Did not return. 20) 210) 90/Very much improved. 50} 50}...)/Did not return. 30) 148]. ..|No improvement. 30) 149|149|Improved.. 24| 24]...|Did not return. 30} 320/140\Improved. No evident tumor present. 25) 230|105|Improved. 30) 235)190/Slightly improved. 25)1221|140\Slightly improved. 30| 145]...|Did not return. 25) 85)...|Did not return. 30| 115]. ..)/Did not return. 15) - 15|,.2|\Did- not return. 30) 205)185|/Improved. _,.{Did not return. 20| 155}...|Did not return. .|Did not return. 45| 45 Did not return 25| ‘70|...\Still treating DO eA wigtem Still treating 30) 150} 90|Doing well. Did not return. 25| 125|...|Did not return. 35| 70) 70\Lesion apparently cured. 30) 195) 50\Improved. 30| 160)130|Healed. 20) 145]. . .|Improved. 100)/100/Wound healed. 304 The American Journal of Roentgenology Yl @ Some Experiments in Standardization of Dosage 305 ge | 8 o~ | $18 18 a | Bel | 3 22) 8 18 | : . la Bele |e Q . le (le |E NAME DIAGNOSIS E & E EP BE a REMARKS NAME DIAGNOSIS E fH E Bs aa - REMARKS | eee see bey tS | ee 3] 3 |S) 88) #3 |B 7 So} gg) 6] Pe] ee Bs | ee ‘ i ‘ g josla,| 8 |e 2 2/ 8 |@3\ a9) "ales 2 4) 8 |#8/28|—8) eg : BE} § /S3/58| 88 | a2 : 5} B |e) 85) 88 |B mae Z| Ae let tee ee I, ee ee ee ey a Go ale eee eis aie gt | ie dl, od oe VO 2A AV iw yee et BAUS & utes wreteie 4} 1 mo.| 40) 25) 157|...|/Result excellent. 187|L. K......... Pruritis......... Te... 40| 30} 30)...|Did not return. TOS Nas sea ears Melanotic sarc...) 33} 9 mo.| 60} 30) 835/306|Superfic _ blister, practically LSS We Benes eects LAipus -vule.s vss 4) 1 mo.| 50; 25) 100] 50)Very much improved. cured. - 189K. Bowe gas 34 Prupitic sas, ooes-.3 ee GO) 10). eds es Did not return. 10200 Bete iene ores ee Dermatitis..... 10| 4 mo.} 40} 30} 290). . ./Improved. IAQ. Ae nace Bes Lupus...........| 5] 5 wk.| 60} 20} 102/102|)Rather severe reaction. es Dae ?Thymus........ ieee eee Chen ke hoe ae re 141J. Avs... 2... Tuberculosis... . . 4) 4 ds. | 60) 20) 140)... .|Did not return. LOGY. Pe.e ooo TRIMS 44 ons’. 3] 5 wk.) 20} 20) 65) 65|Marked improvement. 0) a eee eae G. C. sarcoma...| 6/17 ds. | 70} 50} 220/170|)Improved while under treat- Le ee hea Ce high oye a oe iN ere 30; 50} 50) 50\Epilation complete. en LOG AY « En ie se Epithelioma..... 2) 1 wk.|...|/ 30) 60]...!Did not return. 1430OoC. B.. 2.0. Marconia... 2.5.4.) 8)4ds.-|-(5) 25] 75)... Did not return, | 1H) 2 (a 0) Mh aera rey Sarcoma.........{ 11] 6 wk.| 50) 25] 275!...|No improvement. A OY TB see Epithelioma..... 10; 5 wk.| 70; 20) 215|190)/Marked improvement. i ICUs oe leas er M lymphangioma| 1]...... 60! 20) 20]...|Did not return. PA ly. 2s ocean ooh Epithelioma..... 6) 5 wk.} 50 au 195).../Toreportin Sept. Improved. i END a a ee Mycosis fung....| 23} 4 mo.| 60} 25} 619/619|/Improved. MGIB: Backend Derm -Vetl.:..c.0: 4) 1 wk.) 45} 20} 100/100|/Improved, but not more than i 112)A. F..........)?Enlarged glands.| 18) 1 mo.| 50] 20] 435). . ./Improved | lesion (not treated). ESE es ee to Enlarged thymus.| 2! 1 wk.| 60! 20) 45!/.. ./Still treating. 147\]. Bw... ea ee sarc testes...... 4| 1 mo.} ? | 36} 168/168|Improved. b5 | Game c ayaree eee Epithelioma..... 19] 5 mo.| 60} 20] 363}. . .|Improved. 1O6(C. Ba wets os cach LE RUGUEIS, 2c. 251 2} 1 wk.| 60} 20} 42) 42)Improved. 2: ee Prints... 2} 1 da.| 40] 35) 75!.../Did not return. 157|A. B........../Malig parotid....| 8] 5 wk.| 70} 25] 215|.../Some improvement. | Late Gist aes atone iinet 6 aes 2} 2 ds. | 60] 20) 35!...|Did not return. LOO as a. ate Drtieatia i296 i 7| 1 mo.} 50} 30) 185)120|Almost complete relief. | 126|M. H......... Eepith, Of faces, y= 109) mio. 50) 20) 185| |e ccs es eevee ede ede duds 159)P. J. B....... Malig Lymph- | 1h Oran o re re Wel Gane <5 532°. 2| 2 ds. | 60} 20) 40]...|/Did not return. omata..........{ 5) 3 mo.} 50) 30) 174). . .|Relief. US ig dee wiaua, Hie 455 Epithelioma..... 2| 9-ds: |" 70) 35). 75|...|Did not’ return. TOO ey VB cena Cates Mak . cats _ 8| 6 wk.} 60} 50} 310/310/Still redness, mass much re- 1) ass Oe Persist thymus...| 3} 2 wk.| 60} 25) 75|.../No reaction. Gland smaller. | duced. Did not return. Still treating. PODS ee caneacaue Ketat seni) i. 2. 5| 5 wk.| 65} 40} 180} 45)Improved. TOO sd tape uk Carcinoma....... 11} 5 mo.} 60} 30} 310).../|No improvement. 162/E. B.......... Epithelioma. .. .. 5} 5 wk.) 50) 30) 151)... .|[mproved. Dee Nel pie tahoe PsOnagie.. «4 axes 5] 1 mo.| 50} 25] 120)...|Did not return. 163)W. C......... Acne rosacea....| 3) 2 wh.| 60) 20) 45) 45/Improved. UBZ) VV oleae > eatin actss CIOVCOSISS . 28 boils 2) 3 wk.| 50) 55} 125/125/Slt erythema. No epilation. 164M. E. C...... T. B. adenitis....}| 7) 3 wk.| 70) 15} 140). . .|Improved. We be Vee oes Med tumor...... D1. Ode. 70|2 201 401. “| Did not return: : bs) 1B ae Omer saree PRCA 2 eae 2) 2 wk.| 40) 15; 30|...|No improvement. LOSI Toca anaes. Prititicy 2% e 2% Like ceee 40} 15) 15].../Did not return. LOG eC isaied mieh red, wake LNCS ine a 3) 3 ds. | 60) 20) 75)...|/Did not return. 1 aa a ee Enlarged thymus.| 1]...... AQ 15) 15). .< Did: not veturn. 1GOfiMrs. Coit g cs Carcinoma.......| 15) 5 mo.} 70} 30) 412/412|Slightly improved. 136M. K.........|Hyper thymus. . ca 60! 20! 40!.. .|Still treating. MOGs Gy ae 2k + ek Hodgkins Dis....} 6) 1 mo.j 50) 15) 155)100 Improved. I eee 306 The American Journal of Roentgenology @ Some Experiments in Standardization of Dosage 307 | NAME DIAGNOSIS E z E ee Re = REMARKS | 3 A) 8 | #8) wal Wa | eg 169|IM. A. D...... Epithelioma..... Neate. 3 60) 6O]....]... (Filter). Did not return. | | POM Deaseites: PCGibiSs peta tec 5| 5 wk.| 50} 15) 90)...|Noimprovement. Stop treat- | ments. a | 17 Se ic hat oon ee IVE yes rine: 5: 6; 1 mo.| 50} 20} 122) 70/Lesion healed rapidly. | oN Be De see% [od DN ee, oe 7| 2 wk.| 50} 20} 150} 65|Improved. Fille hae ® Paes cee Epithelioma..... 3} 1 mo.| 40) 30) 120)120/Much improved. Did not re- vurn. 174 Wires TD. Po WieGs Care's nea see D\° Lmos bOi 25 laa ae Did not return. | 175|Mrs. T. McM. .|R cheek.........| 4) 1 wk.} 50) 25} 100). . ./Improved. Total sitet Ot eases: treated sos 4 asccate by a edie d waes sens hghwnn woo werden 197 PP OIRVIIS SOI, INL enOOPOs ea s,s < a cei: 27\ FM. = 6025 heel ae Improved. | ET E/ a) = ele | oer Thyimis: sie 3) 2 Wiel’ OOl Zales sls Improved. Total number of cases treated in which reddening of skin appeared............. 74 | 178|Miss E. M..../T. B. Glands....| 9] 3 mo.| 50| 25)....|... Well. 17GB; Be IN ats Care. Ear o.cc. | 22 Simo. 25025 R/| Well Total aimmiiberm Or treatinents ovens ac .5o.4640e sees ee ee re re eer h 1381 | 180|Miss M. O..:.|Care Face: os 22 o: 22 ds4\468)225)) 60)... .|\Did not return. | 1511B. OF yea) ah biyanterae eee Lee. BO ess tes. Did not return. Awerage number of treatments given each case...6 425 ieee eae nee eye eee ji | TS2 iy. ce. Pee Leukemia... 255% Dl a-GSe | OOler.\. <1... |L oosick for further treatment. | 183 Miss. Es P..<. Carcinomas... nce 20/14 mo.| 60}.?.|....|...|Improved. 184|Mr. A. B. P...|Asthma......... DO] 2 Wk.) SO/.? |... foe fe cece eee ee eee eee, Shortest duration of treatment where cure was obtained............0.. ee eeuee- 1 dose 185(Mrs. S.A. R...\Epithelioma’ l3/Pimois60) 40)... ) 6. - Well. } 186\Mrs, FF, Ro... |\Garcinoma. 3.212 sb) deine) 5020 atl sc Improved. Longest duration of treatment where cure was obtained.........-...-2+-s0sue- 1 year | 187|Mrsi A. S.-S.-\Carcinoma.. <0... (215 s6ames|e50\-25), =|, :. Improved. 18S Mics Onde Goren ee eos. 2 ye e502 25).5. 2. |... Improved. LSO Mrs, |. Fico... Wielesect1.5- 4| 1 mo.) 50) 25} 135} 90/Improved. : I90}E. G. S......./T. B. ule cheek... .| 3)-1mo.} 45) 50|....|...|Improved. Still treating. | LOU Whiss eae Carcinomas... well eee GO eel s,s ...|Did not return. | 1O2\ Mrs. FT es Epith Nose.:..../° 5); 1 mo.) 50). 25) 125):. . Improved. | | 193\Mrs.. T. R. W.:|Carcinoma.. 222. <.\20|-9mor*60)25)......|. . . Improved. | i 194 Wise K.-W... 0 PSB: Glandsy 7.4 TTA 2smese 50|s25). os4).. Improved. \ POD os See e ed Epith NOS6 . 7.1: “SB somo: WoO 2B |... Improved. | | 196|Mrs. C. E. W..|Epithelioma..... LS ames a0 PG F.0 |... Improved. | LOTR. Ee W 2... pith sbip.. oh. QL wee) S25) 52 |. ss Improved. | Some of the areas treated were too large to be covered at a single sitting. In these cases, the total amount of dosage received does not correspond to the amount received by a single area of skin surface. The cases are not numbered in the order in which they were treated. | 308 The American Journal of Roentgenology APPLICANTS FOR ACTIVE MEMBERSHIP IN A. R. R. S. Following is a list of the applicants for membership in the A. R. R. S. which will be published in the Journal twice before the annual meeting in accordance with the By-Laws. With the approval of the other members of the Executive Committee I have deter- mined to present the names of all applicants whether complete or incomplete indicating the deficiency in case of those who have not fully conformed to the By-Laws. It is probable that where the application has been turned in within the specified time and no scientific paper presented or where a letter of recommendation was not pre- sented within the time limit the Executive Committee will consider the applicant eligible if these are presented before the annual meeting. THE FOLLOWING Have CoOMPLIED IN ALL Respects WITH THE By-Laws: Dr. M. J. Hupeny, 31 N. State St., Chicago, Ill. Recommended by Drs. A. Hartung and Hollis E. Potter. Dr. JAcop Wo. Frank, 114 N. 17th St., Philadelphia, Pa. Recommended by Dr. A. J. Quimby and H. Clyde Snook. Dr. ERNEST GARDE Epwarps, La Junta, Colorado. Recommended by Drs. Rus- sell H. Boggs and George C. Johnston. Dr. ALFRED LuGER, Peter Bent Brigham Hospital, Boston, Mass. Recommended by Drs. Jas. T. Case and Walter J. Dodd. Dr. J. 5. DERR, 335 Candler Annex, Atlanta, Georgia. Kecommended by Drs. J. W. Hunter, Jr., and Howard E. Ashbury. Dr. SAM’L BERESFORD CHILDs, 342 Metro- politan Bldg., Denver, Col. Recom- mended by Drs. G. E. Stover and Hol- lis E. Potter. Dr. Wo. B. Bowman, 818 Brockman Bldg., Los Angeles, California. Recommended by Drs. Albert Soiland and Edward H. Skinner. APPLICANT FOR CORRESPONDING MEMBERSHIP. Dr. F. Howarp Humpuris, 8 W. Chappel St., Mayfair, London W., England. Recommended by Drs. George E. Pfahler and Edward C. Titus. APPLICATIONS FOR ACTIVE MEMBERSHIP WHICH ARE DEFICIENT IN SOME PARTICULAR. Dr. Harotp B. THompson, Seattle, Wash. Recommended by Drs. Hollis E. Potter and R. D. Carman. Complete, but appli- cation was not received complete until March 21, 1914. Dr. L. Marsu Dotioway, 120 Nasby Bldg., Toledo, Ohio. Recommended by Dr. P. M. Hickey and H. W. Dachtler. Application received March 20, 1914. No scientific paper presented yet. Dr. Max KAHN, 667 Columbia Ave., Balti- more, Md. Recommended by Dr. Albertus Cotton. Only.one signature and no let- ters of recommendation. Dr. Ear Kine, 75 Caroline St., Saratoga, N. Y. Recommended by Drs. Thurman A. Hull and Jas. P. Marsh. No letters of recommendation and no scientific paper. Dr. FRED B. HALt, 618 Metropolitan Bldg., St. Louis, Mo. Recommended by Drs. Be Hi “Skinner and R: D. Carman. No scientific paper yet presented. Dr. Wn. ALBERT Evans, 32 Adams Ave. W., Detroit, Mich. Recommended by Drs. jas. 1. Case and P. M. Hickey. Scientific article not yet submitted. Dr Aj ko Tarr, Charleston, S. C.. Appli- cation not signed by members of the Soci- ety but a letter from Dr. Robt. W. Gibbes endorses. o Applications for Membership 309 Dr. E. S. Biatne, Cook County Hospital, Chicago, Ill. Recommended by Drs. Hol- lis E. Potter and Jas. T. Case. Lacks let- ter of endorsement from Dr. Potter. Dr. W. T. S. Grecec, Calumet, Mich. Recommended by Drs. A. W. Crane and Geo. C. Chene. No letter of endorsement from local physician. Letters from the signers not received until March 23, 1914. Dr. Rost. EMMETT AusTIN. Recommended by H. Clyde Snook and Dr. Albert So1- land. No letters of endorsement and no scientific paper. Dr. Jos. FrrEDMAN, 73 W. 116th St., N. Y. Recommended by Dr. Leopold Jaches. Application not signed by two members. Dr. ANTHONY BASSLER, 21 W. 74th St., N. -¥.- Recommended by Drs... Wi Cald- well and G. W. Pfahler. Application received April 9, 1914. No letter of endorsement from local physician or surgeon. Dr. PuHititrip Howarp CookeE, 771 Main St., Worcester, Mass. Recommended by Drs. Percy Brown and H. W. Van Allen. Application dated 10/3/13, received 4/22/14. No letter of endorsement either from signers or local physician. In every instance the applicant or his signer has been promptly notified of the deficiency where one existed. ALFRED L. GRaAy, Chairman Exec. Com. 310 The American Journal of Roentgenology The American Journal of Roentgenology Published by The American Roentgen Ray Society Issued Monthly. Subscription, $5.00 per year. Advertising rates submitted on application. Office of publication, 32 Adams Avenue West, Detroit, Mich. President DR. SIDNEY LANGE, Cincinnati, Ohio Vice-Presidents DR. D. D. TALLEY, Richmond, Va. DR. ALBERT SOILAND, Los Angeles, Cal. Secretary DR. W. F. MANGES, Philadelphia, Pa. Treasurer DR. LEONARD REU, Buffalo, N. Y. Librarian H. W. DACHTLER, Toledo, Ohio Executive Committee DR. ALFRED L. GRAY, Richmond, Va. DR. GEO. C. JOHNSTON, Pittsburg, Pa. DR. ROLAND HAMMOND, Providence, R. I. Publication Committee DR. DAVID R. BOWEN, Philadelphia, Pa. DR. J. T. CASE, Battle Creek, Mich. DR. GEO. H. MACKEE, New York, N. Y. Editor Associate Editor P. M. HICKEY, Detroit F.C. ZAPPFE, Chicago EDITORIAL The education of the future Roentgenolo- gist is of considerable importance. If he is to be regarded as helping more than a photographer and to be placed on a higher plane than the technician in the laboratory, he must devote considerable time and study and money to attain the knowledge and experience which will ‘give his opinions value. Heretofore this training has been obtained principally by longer or shorter visits to Europe where greater or less infor- mation was obtained according to the familiarity of the student with the German language and his willingness to expend money for courses with the private tutors In many of the medical colleges of this country, the course in Roentgenology is sim- ply an advertisement for the one giving the lectures. This personal aggrandizement may not be intentional but in reality it 1s what the course often amounts to. The Roent- gen specialist must have first of all a good knowledge of pathology. Unless there is this basic foundation of the principles of pathology, as applies to medicine and sur- gery, the interpreter of the different plates is most sadly handicapped, in fact, without this he never can rise to anything but medi- ocre attainments. Pathology is the most im- portant knowledge for a Roentgenologist. In one medical college the course of in- struction presented is as follows: At the close of the lectures on embryology in the first year, the professor of Roentgenology gives a series of lectures showing the applh- cation of Roentgenology and taking up the development of the skeleton of the embryo and of the growing child from the Roentgen standpoint. At the close of the lectures on anatomy in the second year, are given a number of lec- tures on normal Roentgen anatomy demon- strating to the student the appearance of the normal bones and joints which he has studied as depicted by the Roentgen plate. The student is required to study these nor- mal plates and to pass an examination on their interpretation. In the third year after a student has fin- ished his studies in surgical pathology, he is Shown the Roentgen pathology of bones and joints. In the fourth year in connec- tion with his clinics, he is instructed in the interpretation of plates of medical pathol- ogy. While it is perhaps hardly desirable to disassociate surgical and medical pathol- ogy, still from a practical standpoint, the teaching of surgical Roentgen-pathology in the third year and medical Roentgen-pathol- ogy in the fourth year has practical advan- Q € —— | € é Editorial tages. While such a course as this does not give the student any more than a general idea of the subject, he receives his diploma with more of the knowledge than would be gained by simply listening to a few lec- tures in one semester. However, if he takes up the specialty of Roentgenology, what he has so far learned is to be regarded as sim- ply a general smattering. We are glad to notice that in various parts of the country, courses are being offered for the education of the Roentgen diagnostician. While some of the post-graduate schools have perfunc- torily added on certain lectures to their post- graduate curriculum, these have not been dll usually of much value to students. The best way at present is to enter as a) 0 tary assistant some large laboratory w he will be given the daily Opportunity of the interpretation of plates, checking up if possible, with the other laboratory find- ings and operative procedure will help very much. If the people throughout our country are to have the benefit of Roentgen diag- nosis, there must be a number of educated Roentgenologists who can lend their help. It will take much time and thought to properly develop educational facilities and the future Roentgen course will only gradually be evolved. lun- here @ 312 The American Journal of Roentgenology e | ANNOUNCEMENT OF ANNUAL MEETING | | HE American Roentgen Ray | Society will meet in Cleveland r at the Hore/ Hollenden, September | 9th to 12th inclusive, 1914. The program promises to be of unusual interest and value, and includes a paper by Dessauer of Frankfort, on the subject of artificial | production of gamma rays; Coolidge, | the inventor of the Coolidge tube, | Schearer and Duanne will also read papers. Thesubject of deep therapy | and the production of the hard rays will be fully presented and discussed. The rest of the program will be taken by a large number of papers on gen- eral subjects. The medical profession is cordially invited to attend these meetings. Very truly, W. F. MANGES, Secretary. eo ®@ Built for SERVICE! In equipping an X-Ray Laboratory for practical work the Roentgenologist must select practical, serviceable equipment. Proven ability to meet day-by-day needs is a safer guide than startling advertising claims. SNOOK X-RAY APPARATUS meet every condition necessary to continuous, satisfactory ser- vice. First introduced in 1907 and progressively improved since that time—the experimental stage has long since been passed. This type of X-Ray Apparatus possesses the strongest possible proof of merit—it is accepted as standard equipment in the majority of X-Ray Laboratories, both in this country and abroad. BULLETIN 102 (sent free) describes and illustrates SNOOK APPARATUS. Ask about the BOWEN DEVELOPING TANK A thoroughly practical device that will immediately prove its usefulness in any busy laboratory. | SNOOK-ROENTGEN MEG. Co. 1206 Race Street, Philadelphia, Pa.

The American Journal of Roentgenology

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Turn Of The Century Electrotherapy Museum

The American Journal of Roentgenology

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