Chapter VI: The Poem of One-Eyed Alexander (3)

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.]