AN OUTLINE 
OF 
SOME OF THE MEDICAL USES 
OF THE 
RONTGEN LIGHT. 
BY 
FRANCIS H. WILLIAMS, M.D., 
BOSTON. 
From the Transactions of the 
AMERICAN CLIMATOLOGICAL ASSOCIATION. 
1898. AN OUTLINE OF SOME OF THE MEDICAL USES 
OF THE RONTGEN LIGHT. 
By FRANCIS H. WILLIAMS, M.D., 
BOSTON. 
Mr. President and Gentlemen : In accepting the cordial 
invitation of your President to read at this meeting, I intended 
to limit my paper to one disease—pulmonary tuberculosis—but 
at the very kind suggestion of the President I shall present, 
instead, a general statement of the medical applications of the 
x-rays, as being of more interest at this time, and give the 
results of the clinical observations made in some of my patients, 
in order to suggest ways in which an x-ray examination may 
corroborate other evidence or assist us to an earlier or to a 
more correct diagnosis. 
In a general way, x-ray examinations may be said to have 
thus far been most used to detect foreign bodies, or changes in 
shape and composition of bones, as in fractures, dislocations, 
necrosis, tuberculosis, osteosarcoma, deformed pelvis, rickets, 
and osteomalacia. 
Gouty deposits about the joints, as shown by Dr. Arthur L. 
Fisk, are distinguished from rheumatoid arthritis by means of 
an x-ray photograph. 
In the abdomen the outline of the spleen, the left kidney 
and the liver may, under favorable conditions, be seen in the 
fluoroscope. 
The stomach may be examined by giving the patient a large 
dose of subnitrate of bismuth (which the x-rays do not easily 
traverse) with food, and then looking at the shadow of its con- 
tents by means of the fluoroscope (Fig. 1). I have also taken 
in this way an x-ray photograph of the stomach contents. 
Carcinoma. In all the cases of carcinoma of the stomach that 
I have examined with the fluoroscope, if the growth could be 2 
FRANCIS H. WILLIAMS, 
seen with this instrument it could be felt. I have taken one 
x-ray photograph of a carcinoma in the stomach, and its thick- 
est portion, as shown at the operation, corresponded to a dark 
area shown in the photograph and seen in the fluoroscope. 
In ascites the surface of the ascitic fluid may be seen in the 
fluoroscope if the patient is examined lying on his back and 
the physician is looking through the body transversely. In the 
abdominal cavity new growths may sometimes be seen from 
this same point of view. 
Renal or vesical calculi of fair size containing phosphate or 
oxalate of calcium have been detected by an x-ray photograph. 
X-ray examinations may be used in other diseases or conditions 
of the abdomen and pelvis, but I will not discuss them here. 
One of their most useful applications is for diseases in or 
contiguous to the thoracic cavity. I shall consider this subject 
largely from the stand-point of a practitioner whose special in- 
terest is diseases of the chest, for it was the confidence which 
I had in the possibilities of the fluoroscope to assist in the 
diagnosis of diseases of the lungs and heart that led me to 
begin and develop this method of examination. 
I think the subject can be most clearly presented by the 
following cuts (Figs. 2 to 15), that are reduced copies of dia- 
grams which were made by transferring outlines, that I drew 
on the skin of patients while looking through the fluoroscope, 
to a skeleton outline copied from one of Luschka’s plates. 
These patients were examined lying down, except the one 
suffering from pneumohydrothorax. 
Since it is in part the movement of the heart and lungs 
which we wish to observe, an x-ray photograph does not answer 
as well as the fluoroscope or fluorescent screen. Examination 
with this instrument has also the advantage of being made more 
quickly; the photograph takes time to develop, but gives more 
details in parts that are at rest. 
The positions of the diaphragm and heart are shown as in full 
inspiration in the diagrams Figs. 2 to 15, and the broken lines 
indicate the position in expiration. The dark lines at the sides 
represent the level of the nipples. MEDICAL USES OF RONTGEN LIGHT. 
3 
In health (Fig. 2) you will see that the diaphragm has a 
wide excursion between the extremes of respiration, and that 
the heart also changes its place. In order that you may ap- 
preciate what nice distinctions the fluoroscope is capable of 
making, let me state that the difference in the brightness of 
the lung-area between expiration and full inspiration may be 
perceived in the fluoroscope. In health the lungs are seen to 
be lighter about full inspiration and darker in expiration, as 
they then contain more blood per cubic inch. This shows how 
conditions involving congestion, as in early tuberculosis or in 
some forms of cardiac disease, may alter the appearances in the 
fluoroscope. 
The diagram of health (Fig. 2) is the key to the others, and 
I shall ask you to use it as a starting-point in studying them. 
Please compare individually the diagram of each of the diseases 
as I take them up with the diagram of health, especially the 
amplitude of the excursion of the diaphragm and its position in 
the thorax in certain of them. Usually the excursion of the 
diaphragm on the left side is about two and one-half inches, 
and generally rather more on the right side; but the excursion 
varies with the size of the individual and the shape of the chest. 
Likewise conditions present in the abdominal cavity may some- 
times change the extent and shape of the outline. 
We will begin with thoracic aneurism. 
Many thoracic aneurisms (Fig. 3) which were formerly 
beyond our reach for diagnosis may now be recognized with 
certainty, and, further, symptoms due to aneurism are some- 
times ascribed to other diseases, and an x-ray examination is 
required to establish the diagnosis. This, diagram represents 
the condition found in a patient sent to me in consultation who 
had a stricture of the oesophagus, and into whose throat an 
oesophageal bougie had been passed every third day for months. 
Another patient, who had a similar aneurism, was thought to 
have intercostal neuralgia, and had been operated on for this 
previous to coming to me. In one of my own patients with 
cardiac disease I was about to give digitalis, but an x-ray ex- 
amination showed the presence of a thoracic aneurism in an 4 
FRANCIS H. WILLIAMS, 
early stage, and I was thus spared from doing him harm. In 
no other way than by an x-ray examination could these aneu- 
risms have been detected in this early stage. 
In emphysema (Fig. 4) you will observe that the excursion 
of the diaphragm is less than in health, and that it is lower in 
the chest. The heart is in a more vertical position than in 
health, and moves less between full inspiration and expiration. 
In marked cases the right side of the heart, both auricle and 
ventricle, is larger than normal, and in some cases both sides 
are enlarged. 
In pleurisy with large effusion (Fig. 5) the heart is much 
displaced, as indicated by the diagram. I removed a gallon 
of fluid from this patient’s chest. The heart was then seen to 
be nearer its normal position, and the excursion of the dia- 
phragm on the left side was greater in amplitude and went higher 
up in the chest—that is, was nearer the normal. 
In pleurisy with slight effusion (Fig. 6) the appearances in 
another patient are shown. By auscultation and percussion 
there was some doubt about the presence of fluid in this 
patient’s chest. 
In pneumonia (Fig. 7) the dark area of the pneumonic 
process is seen, and, further, the excursion of the diaphragm is 
less than normal. The appearances in pneumonia are very 
conspicuous; so much so that I have not chosen a patient in 
the most active stage of the disease, but rather during its sub- 
sidence. This diagram was made from the appearances on the 
seventeenth day of the disease. Ho signs were found by aus- 
cultation and percussion on this day. This shows that there 
may be conditions in the chest which are readily seen in the 
fluoroscope, but which are not patent to auscultation and per- 
cussion. On the thirty-second day signs of disease were still 
seen by the fluoroscope, but the patient Avas then discharged; 
otherwise, an abnormal condition of the lungs might have been 
followed by means of this instrument for some time longer. In 
cases that I have examined after their discharge from the hos- 
pital the lungs attained their normal brightness before the 
excursion of the diaphragm Avas normal. MEDICAL USES OF EONTGEN LIGHT. 
Central Pneumonia. I have recognized the presence of cen- 
tral pneumonia with the fluoroscope before there were any 
signs by auscultation and percussion. 
Pulmonary Tuberculosis. It seems hardly necessary to 
state that the diagnosis of pulmonary tuberculosis is not made 
by an x-ray examination alone, but the fluoroscope may show 
that the lung is in an abnormal condition in two ways: the 
diseased portion appears darker than in health, and the excur- 
sion of the diaphragm in quiet breathing and in full inspiration 
is restricted, usually on one side in early tuberculosis, and this 
muscle often goes higher up in the thorax than normal on this 
side. (The average movement of the diaphragm in the nipple line 
in health is 2J to 3 inches in men; it usually goes up higher in 
the chest, and its excursion is generally greater on the right than 
on the left side.) These signs lead us to suspect tuberculosis. 
It is well to make a second examination after an interval of 
a few days, for both of these signs may sometimes be found 
temporarily in other conditions, as in anaemia and debility; 
whether they may then indicate a soil favorable to the develop- 
ment of tubercle bacilli I will not now discuss. Also a dimin- 
ished excursion of the diaphragm may occur in emphysema; 
but in this case the muscle goes lower down in the thorax, not 
higher. Again, we sometimes find a perfectly healthy indi- 
vidual with a chest so unusually deep—that is, with a long 
antero-posterior diameter—that he has naturally a shorter dia- 
phragmatic excursion than the average. 
But when we find by an x-ray examination a shortened 
excursion of the diaphragm on one side and see that the mus- 
cle goes higher up in the chest than normal, accompanied by 
increase of density of that side, as shown by the diminished 
brightness of the lung, especially at the apex, we should look 
for pulmonary tuberculosis. The daily temperature should then 
be noted and the tuberculin test used. By means of the flu- 
oroscope and the tuberculin test an early diagnosis may be 
made without waiting for well-defined physical signs, the ap- 
pearance of cough or the finding of tubercle bacilli; and this 
is of importance, for delay may deprive the patient of his best 6 
FRANCIS H. WILLIAMS, 
opportunity for recovery. The x-ray examination may give 
the first warning of tuberculosis, or, if this disease has been 
already suspected for other reasons, it may add strong supporting 
evidence. I have taken every opportunity to examine patients 
with tuberculosis in the early stage, and have usually found the 
evidences of disease more marked in the fluoroscope than by 
auscultation and percussion. (When the disease has made some 
progress the appearances in the fluoroscope are, of course, very 
conspicuous.) 
Further, I have found suggestion of tuberculosis in several 
patients when auscultation and percussion had not revealed it, 
whom I examined by the fluoroscope with reference to some 
other disease. This diagnosis was confirmed by the subsequent 
development of the case, the presence of bacilli, or by reaction 
to the tuberculin test. 
The dark areas which are found in the lungs in pulmonary 
tuberculosis are not wholly due, I think, to a consolidation, for 
a marked congestion may give rise to similar appearances. In 
some patients, whom I have examined at intervals of a week or 
two, I have seen these dark areas extend rapidly, and in others 
diminish in the same way, and as it does not seem probable 
that other changes in the lung would take place so quickly as 
the increase and decrease of these dark areas would suggest, a 
congestion seems to be the natural interpretation of this rela- 
tively rapid alteration in the brightness of the lung. Further, 
in passive congestion or oedema of the lungs in mitral disease 
the lower portions of these organs may be darker than normal 
without corresponding physical signs, and, after rest and the 
administration of digitalis, the lungs soon become clear.1 Also 
in patients apparently suffering from debility, and who do not 
react to tuberculin, we may find a dark area in the lung that 
1 I examined normal lungs, after they were taken from the body, with the fiuoro- 
scope, and found they were penetrated by the x-rays with the greatest ease; there 
was no marked difference in brightness between a fully and a partially distended 
lung. In life the lungs are brighter during full inspiration than expiration. This 
greater brightness is due to a diminished amount of blood in an equal volume of 
lung at this time. These observations, together with others bearing on this subject, 
are referred to in my article entitled “A Study of the Adaptation of X-rays to Medi- 
cal Practice,” Med and Surg. Report, Boston City Hospital, January, 1897. MEDICAL USES OF EONT6EN LIGHT. 
7 
clears up after a rest of a week or two. But the recognition 
of a congestion, especially at the apex, may be valuable in 
some cases, as an early warning of the beginning of tubercu- 
losis, and it should certainly cause us to make a careful in- 
vestigation with this diagnosis in mind. And in those cases 
in which our suspicions are excited by a first examination a 
second should be made to confirm or disprove the first. 
In pulmonary tuberculosis the x-ray examination may assist 
us, first, to make an early diagnosis; second, to estimate the 
extent of the disease ; third, to determine whether it is dissemi- 
nated or localized; fourth, to recognize a cavity; and in all 
these cases helps us to decide on the wisest course for the 
patient to pursue. I wish to emphasize the importance of its 
first use, for if pulmonary tuberculosis is promptly recognized 
a considerable proportion of cases can be cured, and cured 
without change of climate if the patient is able to follow out 
hygienic treatment intelligently in suitable surroundings. In 
more advanced cases the knowledge gained by means of an 
x-ray examination may prevent the patient from being sent on 
a fruitless and expensive journey in search of health when he 
should remain at or near his home. I have seen patients who 
were sent away when a journey was distinctly contraindicated 
by an x-ray examination, and the result proved the correctness 
of the indication. 
As the x-ray examinations in pulmonary tuberculosis come 
more into use I am convinced we shall sometimes recognize its 
presence earlier, and be less apt to overlook the disease in its 
beginning. 
The following cases are chosen to illustrate some of the ways 
in which x-ray examinations may be useful in pulmonary tuber- 
culosis. 
In the first patient the signs in the fluoroscope were more 
marked than were the physical signs. 
Case I.—Lawrence C., twenty-eight years of age, entered 
the Boston City Hospital, April 14, 1898. Mother died of 
phthisis; history of several hsemoptyses. On March 31st, 
coughed up blood several times; says he lost about a pint. 8 
FRANCIS H. WILLIAMS, 
April 14. Physical examination: Harsh respiration over 
both fronts, otherwise no physical signs. 
X-ray examination: Marked darkness over upper two- 
thirds of left chest. Excursion of diaphragm one and one- 
half inches on left side ; two inches on right side. The normal 
excursion, as already stated, is about to 3 inches, the right 
side usually moves rather more than the left. 
Ylth. Physical examination: Respiratory sounds less pro- 
nounced than normal on both sides, otherwise no physical signs. 
19th. No change in signs by auscultation and percussion. 
Second x-ray examination: Similar to that made on April 14th, 
but more marked. 
The patient was given one-half milligramme of tuberculin, 
and reacted to it, the temperature rising to 102.4° in eighteen 
hours. 
Case II.—George S. B., teacher, thirty-two years of age. 
Lost his mother and one brother by tuberculosis. Haemop- 
tysis, June 5, 1897. In Dr. Folsom’s service in Boston City 
Hospital for ten days. Nothing found in his chest. Subse- 
quently, to June, had several slight hemorrhages. In July, 
Dr. Smithwick found a few small rales above the right 
clavicle. 
September 17. Dr. Smithwick found no rales at right apex, 
but thought he found a few in the right axilla ; otherwise, there 
were no physical signs. Said “ the patient might be examined 
to-day without any signs of tuberculosis being detected; ” no 
rise in temperature; no tubercle bacilli found, though the 
sputa have been examined several times. Dr. Smithwick 
brought the patient to see me on September 17th. 
17i£/i. X-ray examination: Right apex to lower border of 
second rib was darker than the left apex. Excursion of the 
diaphragm on right side one and three-eighths inches; on left 
side, two and three-eighths inches. This, together with what 
had gone before, led me to state that I had little doubt the 
patient had tuberculosis. 
October 3. Dr. Smithwick found tubercle bacilli. 
Bacilli had been found in the following patient (Case III.) MEDICAL USES OF RONTGEN LIGHT. 
9 
just before the x-ray examination was made, but it is of interest 
to compare the signs found in the fluoroscope with those by 
auscultation and percussion. This patient had been at the 
Boston City Hospital, under the careful observation of Drs. 
Buckingham, Withington, or Jackson for some months. 
Case III.—B. C., twenty-nine years of age, male nurse in 
the Boston City Hospital. Patient in Hr. Withington’s service. 
Admitted May 11, 1898. For past two months the patient 
has had cough with yellowish expectoration; about one week 
ago the sputum was streaked with blood. Slight dyspnoea after 
exertion. The patient thinks he has not lost weight or strength. 
No chilly sensation ; no sweating; appetite fair. 
May 11. Physical examination: Heart not enlarged to the 
right or upward; apex in fifth space in nipple line; action 
regular; lungs normal, save that breathing is somewhat jerky 
in places, and fremitus is slightly increased all over right chest. 
Best of physical examination was normal. 
12th. Few rfiles at inner edge of left scapula; no difference 
in fremitus or in voice. 
14th. An occasional indeterminate rale here and there over 
the chest, not permanent in character; no abnormality in 
breathing or voice; resonance good. 
15th. Breathing very little modified qualitatively. Occa- 
sionally rales as before, and after cough they are more numer- 
ous in right axilla than elsewhere. Tubercle bacilli found in 
sputum. 
16th. X-ray examination: Whole of the right lung darker 
than the left, especially at base. Excursion of diaphragm on 
right side seven-eighths of an inch; on left side, two and five- 
eighths inches. 
August 22. Dulness at both apices and moist, bubbling 
rfiles; moist rfiles also present in both axillae. Right apex, 
bronchial breathing, with increased resonance and fremitus. 
Process is diffuse in both lungs, but most marked in the right. 
X-ray examination: Right side much darker throughout than 
the left. Excursion of the diaphragm one-fourth of an inch on 
the right side and three-fourths of an inch on the left side. 10 
FRANCIS H. WILLIAMS, 
The fluoroscope afforded evidence of tuberculosis in the fol- 
lowing case, where the physical signs were not conclusive: 
Case IV.—Murdock M., carpenter, twenty-three years of 
age, an out-patient of the Boston City Hospital, September 17, 
1896. History of two hemorrhages : one four years ago and 
one a year ago. Now complains of pain in the right chest, 
with slight cough and slight expectoration. Physical exami- 
nation by Dr. Ames was negative, except for a few “clicks” 
at the junction of the second rib and the sternum on the right 
side and at left apex behind. 
September 17. The patient was brought to me for an x-ray 
examination, which was as follows : Two-thirds of right lung, 
beginning at apex, darker than normal, as well as apex of left 
lung. Excursion of diaphragm shorter and higher up than 
normal on the right side. 
October 3. Physical examination by Dr. Tenney : Slight 
dulness at left apex, back and front, with harsh respiration 
and increased voice sounds. It was learned at this time that 
the father and three brothers had died of phthisis. 
Two examinations for tubercle bacilli had been made with 
negative results. 
Case V.—H. C., twenty-six years of age, entered the hos- 
pital January 24, 1898, in Dr. Shattuck’s service. Family 
history negative. Had not felt well for three weeks; head- 
ache, pain in back, anorexia; pain in the stomach for two 
weeks. Had been in bed three days prior to entrance. Epis- 
taxis four days before entrance. Bowels regular ; no cough ; 
pulse, 80 ; respiration, 20 ; temperature, 101°. Heart: right 
border at middle of sternum ; left border, three centimetres in- 
side nipple line; apex, two centimetres inside nipple line; 
sounds normal. Lungs: resonance and respiration good 
throughout; no chest symptoms whatever. Spleen not felt. 
Abdomen tympanitic; tenderness more marked on right side. 
Widal’s serum-test was made eight times, always with a nega- 
tive result. Leucocyte count normal; no arsenic or lead in the 
urine. 
February 12. The patient was in my service from Feb- MEDICAL USES OF RONTGEN LIGHT 
11 
ruary 1st until his discharge. The finger-ends are markedly 
clubbed. 
X-ray examination: Both sides of the chest darker than nor- 
mal; no special area markedly dark, but rather the darkness 
was uniformly distributed. Excursion of the diaphragm on the 
right side one and three-fourth inches from the upper border of 
the fourth rib to the upper border of the fifth rib; on the left 
side, one and one-fourth inches from the middle of the fourth 
rib to the upper border of the fifth rib. 
25th. Patient is losing ground. Has no pain, no cough ; 
appetite is good. 
March 3. Resonance : both front and back unusually good ; 
suggests emphysema rather than consolidation; no r&les. 
4th. Still losing weight; no improvement. 
X-ray examination : Right side darker than left throughout. 
Upper two-thirds of left chest so dark that the ribs are barely 
seen, and only during full inspiration; diaphragm barely seen 
on inspiration on right side; on left side seen only during in- 
spiration. 
7th. Resonance over both fronts is increased rather than 
diminished; respiration normal; expiration not prolonged ; 
resonance and respiration over backs normal. 
8th. Since admission the temperature has run an irregular 
course and the patient has grown weaker and thinner. (Four 
days after entrance the temperature rose to 104.5°, varied for 
ten days from 99° to 102°, then from 102° to 103° for six 
days, after which it was very irregular for several weeks, vary- 
ing from normal to 103°.) 
10th. Respiration over a small area in right front just below 
clavicle is harsh ; tactile fremitus slightly increased; no rales. 
Resonance not so good over right base behind as elsewhere, and 
respiratory sounds are diminished. 
Ylth. X-ray examination: Right side darker than left dur- 
ing expiration; lung nearly as dark as liver. Only a portion 
of left border of heart is seen. Diaphragm on right side moves 
one inch; on left side, one and one-eighth inches. 
20th. There has been much improvement; patient is now up. 12 
FRANCIS H. WILLIAMS, 
April Ath. X-ray examination : Both chests clearer than at 
last x-ray examination; ribs can now be seen on both sides; 
both borders of heart seen. Diaphragm on right side moves 
one and one-fourth inches; on left side, one and one-eighth 
inches. 
19th. X-ray examination: Outlines of the heart and of all the 
ribs are seen clearly. Excursion of the diaphragm on right side 
one and three-eighth inches ; left side, one and one-half inches. 
Temperature has been between normal and 100° for nine 
days, and the opportunity was given to try the tuberculin test. 
One-half milligramme of tuberculin was injected; temperature 
rose to 102.8° eighteen hours later, and then fell to 99.5°. 
Malaise; patient complained of feeling sore all over. 
To recapitulate : This patient’s illness began about January 
1, 1895. He was first thought to have typhoid fever, but later 
this diagnosis was regarded with suspicion. During February 
he failed very much; had to be fed for about three weeks, was 
losing in weight and strength, and I gave a very unfavorable 
prognosis to his relatives. On March 9th the outlook for the 
patient’s recovery was still less hopeful, but on March 20th he 
was up and dressed. Ho definite diagnosis was made until Feb- 
ruary 12th. I then examined him with the fluoroscope, and 
made the diagnosis of disseminated pulmonary tuberculosis. 
On April 19th, as already stated in the physical examination, 
he reacted to the tuberculin test. The patient was discharged 
from the hospital on April 22d. He had gained in weight 
and strength, although still rather thin; color good. 
June 24, 1898. Has gained three pounds in the past four 
weeks. 
X-ray examination : Excursion of diaphragm on right side, 
one and three-fourth inches; on left side, one and five-eighth 
inches.1 
In pneumohydrothorax (Fig. 9), when the patient was sitting 
up, the appearances were as shown in the diagram. The fluid 
1 I have given in Med. and Surg. Report, Boston City Hospital, January, 1897, an 
outline of thirty cases of pulmonary tuberculosis chosen from more than fifty ex- 
amined in 1896. MEDICAL USES OF RONTGEN LIGHT. 
13 
was on the left side and the heart was displaced to the right. 
The level of the fluid changed as the patient bent backward or 
forward. When he was gently shaken the splashing of the fluid 
was clearly seen, and while quiet the waves made by the heart- 
beat were clearly visible on the surface of the fluid. In the 
summer of 1897 I demonstrated this to Dr. Buckingham, who 
related what he had seen to other medical men, but they could 
not be induced to believe it was not a joke. 
In pneumothorax (Fig. 10) the diaphragm on the affected 
side is much depressed, and its slight movement during respira- 
tion is in the portion near the median line, and is probably 
imparted by the movement of the right side. The heart is 
pushed to the other side. This patient also had tuberculosis 
on the right side. 
Let us now take up x-ray examinations in disease of the 
heart, and first recall that the normal heart is a very movable 
organ ; that it varies in size and position within certain limits; 
that it is readily pushed out of place, and that the direction of 
its long axis is not always the same. In some persons the axis 
is more inclined; in others more vertical. 
The diagram of the heart-movements (Fig. 11) shows what 
is seen in the fluoroscope when placed on the front of the chest. 
The heart is seen to change its position during deep inspiration, 
being moved downward and inward. 
Triangle. While looking through the body from side to side 
during a deep inspiration, a light triangular area (Fig. 12) comes 
into view, the sides of which are formed respectively by a part of 
the heart line, of the diaphragm line, and of the spine, or rather 
what lies anterior to the spine. The last line is less defined than 
the two others. The triangle varies very much in size and in shape 
in different individuals, and also varies according to the side on 
which the observer stands. It is smaller when seen through the 
fluoroscope on the left side than on the right side. In a patient 
with a transposed heart this condition was reversed, the tri- 
angle being smaller when seen from the right than from the 
left side. This was due to the fact that the transposed heart 
was nearer the right thoracic wall than the normal heart, and 14 
FRANCIS H. WILLIAMS, 
it is obvious that the nearer the heart to the side of the body 
where the observer stands with the fluoroscope the smaller will 
the triangle appear. This triangle should always be seen in 
health; if not seen, the physician should investigate the cause 
of its absence. 
Let us now return to the usual direction for examining the 
heart. The position of the heart is seen to be changed in 
diseases affecting the lungs, pleura, or bloodvessels, or by con- 
ditions in the abdominal cavity pressing the diaphragm up. A 
change in cardiac outline, the result of an upward displace- 
ment of the heart may be attributed by auscultation and per- 
cussion to an alteration in the size of the heart, whereas by 
the x-ray examination it could be rightly interpreted. 
A lessened movement of the heart in deep inspiration may 
be seen to occur in emphysema, or where the pleura or peri- 
cardium is adherent. In one patient I saw the apex tilted up 
during deep inspiration instead of moving down. This was 
due, I suppose, to adhesions. We may thus follow some of the 
effects on the heart of changed conditions in its vicinity. Some 
diminished or abnormal movements of the heart during a deep 
inspiration may be evidence of adhesions. 
Let us consider now some of the changes which affect more 
nearly the heart itself. 
Warning may be given by a passive congestion or oedema of 
the lungs of a serious condition of the heart or kidneys, as 
shown in the diagram (Fig. 13), though it may be more marked 
than is here indicated. The lower portions of the lungs are 
dark, the outlines of the diaphragm cannot be seen, and only a 
portion of those of the heart. By such appearances as these I 
was led to warn one of my patients who had renal disease to 
put his affairs in order; he died suddenly within three months. 
By auscultation and percussion I had not appreciated the seri- 
ous condition of his lungs. 
In pericardial effusion (Fig. 14) the outlines of the heart 
may be obliterated, and, instead of the usual pulsating heart, 
we see a much larger dark area. The size, shape, and position 
of the pericardial effusion, and the fact that the outline of the MEDICAL USES OF RONTGEN LIGHT. 
15 
pulsating heart cannot be seen, assist in making the diagnosis. 
New growths about the heart may sometimes be seen. 
An enlarged heart, as in arteriosclerosis or valvular disease, 
may be recognized in the fluoroscope, and also a heart smaller 
than normal, with which anaemia is sometimes associated, may 
be readily seen in the fluoroscope. It is, I believe, important 
for the physician to be aware of the existence of a small heart 
in any of his patients, both as a guide to the mode of life to be 
pursued when the patient is in health, and as a factor in prog- 
nosis in some diseases, pulmonary tuberculosis for example. 
A transposed heart (no diagram of this is shown) may easily 
be seen in the fluoroscope. During my recent service at the 
Boston City Hospital my senior house physician asked me to 
■explain to him the conditions present in the heart of a patient 
who had been admitted the day before. I examined the pa- 
tient, but withheld my opinion until I made an x-ray examina- 
tion, as the heart-sounds and murmurs were unlike any I had 
ever heard in that place. On examination with the fluoroscope 
I found the patient’s heart was transposed, the left ventricle 
could be seen beating to the right of the sternum, and the right 
auricle was on the left of the sternum. When the patient was 
turned around and the fluoroscope was placed on her back, the 
transposed position of the heart was also very evident. This 
patient was examined by five physicians previous to the x-ray 
examination, and we all failed to recognize the transposition of 
the heart. 
To arrive at a knowledge of the heart’s condition in disease 
it is of importance to know its size as nearly as possible, and 
this can obviously be satisfactorily accomplished by means of 
the fluoroscope, except where pathological conditions partly 
obliterate the cardiac outlines, as in pleurisy with effusion or 
oedema of the lungs for instance. Of course, in very stout 
patients or those with pulmonary emphysema it is often im- 
possible to determine the size of the heart by percussion, but 
stoutness is no serious obstacle to an x-ray examination, and 
emphysema is a positive advantage. In fifty-eight patients 
who were not stout and had no emphysema—that is to say, in 16 
FRANCIS H. WILLIAMS, 
whom the conditions were not unfavorable for the use of per- 
cussion—I compared the size of the heart as obtained by per- 
cussion with that obtained by an x-ray examination. The 
percussion lines were drawn on the skin in blue and the other 
lines in black. The outlines drawn by the aid of the fluoro- 
scope were, of course, more complete than those obtained by 
percussion. The percussion lines varied considerably in a 
portion of the cases, in some patients an inch or more, from 
the size of the heart as seen in the fluoroscope; sometimes 
they indicated a smaller but usually a larger heart than the 
reality. Twenty-two of the fifty-eight patients had organic 
disease of the heart, and a more frequent disagreement in 
regard to one or both borders of this organ, as obtained by 
percussion on the one hand and an x-ray examination on the 
other, was found among them than in the remaining thirty-six 
cases, who were suffering from other than cardiac diseases. I 
am therefore satisfied that in some—particularly in cardiac 
cases—we have not determined with exactness the size of the 
heart by percussion, and, unfortunately, we cannot tell in which 
of our patients percussion will fail in accuracy. It is well, 
therefore, that we should realize this in those cases in which 
we desire precise information about the size of the heart. 
Let us compare these two diagrams—namely, Heart-move- 
ments (Fig. 11) and Aortic Insufficiency (Fig. 15)—the first 
of which was made from a healthy individual and the other 
from a patient who was unconscious of any cardiac disease, but 
who had a marked insufficiency of the aortic valve. It is ob- 
vious that the left side of the heart in the patient with disease 
of the aortic valve is much larger than normal. I could see 
the great left ventricle making a large excursion between sys- 
tole and diastole, and appreciate better than ever before what 
an extraordinary quantity of blood is delivered into the aorta 
with each systole in order to make up for the large amount 
which was sure to leak back during each diastole. Further, it 
could be distinctly seen that the excursion of the left side of 
the ventricle was diminished when a full breath was held, as 
then the heart was compressed by the lung. I refer to this MEDICAL USES OF RONTGEN LIGHT. 
17 
patient in order to indicate to you that it is now possible to 
examine more completely than hitherto patients who have or 
are feared to have cardiac disease. 
To carry out this new method of examination properly 
requires large and expensive apparatus and experience in using 
it with a considerable number of patients. The x-rays do not 
burn, and there need be no fear of injury from the accompany- 
ing electrical discharge to any individual if the examinations 
are properly conducted and simple precautions are taken. At 
the Boston City Hospital I have made about two thousand x-ray 
examinations, and no one has received any injury or even in- 
convenience from them. It is easy to burn the fingers if they 
are put too near a candle, but it is not therefore dangerous to 
read by its light. 
This new method of examining our patients has now passed 
the stage of mere interest and novelty, and in its own special 
field, if suitable apparatus is used, can be counted among our 
trustworthy aids to diagnosis. In some cases it gives us more 
accurate information, and in certain others information that we 
have hitherto been unable to obtain. 
I desire to record my appreciation of the value of Hr. William 
H. Rollins’ investigations, published in the Electrical Review, 
which have promoted the usefulness of the Rontgen light in 
medicine and in surgery, and to express my gratitude to him 
for his untiring readiness to aid me to overcome the obstacles 
which have beset those who are using x-ray apparatus. 
DISCUSSION. 
Dr. F. I. Knight : I would say that Dr. Williams, before the 
meeting, told me that he hoped there would be a very free discussion 
of his paper. I do not consider myself able to discuss it, but an- 
nounce Dr. Williams’ desire to those gentlemen who are. He wants, if 
possible, criticism, for it is a new field, and he would welcome it. 
For my own part, I feel with him that the fluoroscope is a very 
important addition to our armamentarium. In a case of suspected 18 
DISCUSSION. 
aneurism, I appreciate its possible great value when I recall the 
number of cases I have seen in which there has been doubt as to 
what was compressing the trachea. If we could get such a picture as 
this on the wall there would be no question but that it was an aneu- 
rism ; and so in regard to the size of the heart. I was particularly 
impressed with what Dr. Williams said about emphysema being an 
aid rather than a hinderance, as emphysema interferes so seriously -with 
the results of percussion, and he also tells us that excessive fatty con- 
dition of the chest-walls, which renders percussion in the cardiac 
region difficult, is very little hinderance to examination with the flu- 
oroscope. And even in tuberculosis, notwithstanding the criticism of 
my learned brother yesterday, I do think that every aid we can get to 
an early diagnosis is going to be of much importance. As yet it 
seems, perhaps, that it is of less advantage in that disease than in 
others. It is evident, from wdiat I have seen and from what Dr. 
Williams himself admits, that this art is difficult, and for a time, 
perhaps, it must rest in the hands of those who have had long experi- 
ence, like Dr. Williams; but in the end perhaps methods may be 
simplified so that we can all avail ourselves of it. At any rate, in 
doubtful cases wre can have the aid of our brothers who become 
expert in it as Dr. Williams has. 
Dr. Quimby : Will Dr. Williams tell us just his rule for placing 
the x-ray tube behind the patient as regards a definite distance from 
and its relations to the spinous processes ? I would also ask if he has 
found any fluoroscopic screen which can be made to conform to the 
chest-wall. It would seem that absolute uniformity in placing the 
tube, both as to distance from and relation to the spine, would be im- 
perative to avoid relative distortion of the outlines of the heart upon 
the screen. I understood the doctor to say he had not seen the heart 
shorten. It wras my good fortune recently, through the courtesy of 
Mr. Tesla, to see a most perfect demonstration of the heart. When 
the tube was more nearly in the plane of the spine the lateral excur- 
sion of the heart was prominent, but when carried more to the left 
and lower, then the shortening was equally prominent and distinct. 
Dr. J. E. Stubbert : I did not have the pleasure of hearing the 
first part of Dr. Williams’ paper, but I believe he wrote the most 
scholarly article, about a year ago, that ever appeared on the subject, 
and I am thoroughly familiar with his views. It is hardly necessary 
to add anything to what he has said, but with reference to a remark 
of Dr. Quimby’s as to the shortening of the heart, I wish to state 
that I have observed it a number of times. When I first began work- 
ing in this line it was my custom to bring into the dark-room lay- 
men who would naturally have no knowdedge of what they were to 
see, and they have often described to me the shortening of the heart 
in action ; I have repeatedly noticed a dimpling of the apex. MEDICAL USES OF RONTGEN LIGHT. 
19 
The doctor referred to some one considering the examination by 
x-rays a joke; I have gone through the same experience. I remember 
Dr. H. P. Loomis once came to Liberty and told me he did not 
believe in the x-rays at all. I brought in a case which neither of us 
nor my house physician had seen before. I asked Dr. Loomis to 
examine the case, and he diagnosed it as consolidation of the right 
apex, with beginning of softening and some infiltration in the lower 
lobe. He made the rather significant remark that he might not have 
a cavity, but was beginning to excavate. I then examined the patient 
and agreed with Dr. Loomis’ diagnosis. I sent for the house-doctor, 
and he made an x-ray examination ; after a moment he said, “ This 
man has consolidation of the right apex, he has infiltration of the 
lower portion of the lung, and while he may not as yet have a cavity, 
he is going to have one in a short time.” Dr. Loomis said : “ Well, 
if it can be diagnosed in that way I will have nothing more to say,” 
and he is now a convert. There is no doubt in my mind that we can 
diagnose, especially in thin subjects, very slight infiltrations at the 
apices of the lungs. We all know how difficult it is to educate our 
ears sufficiently to distinguish indistinct sounds, but with the x-ray 
the very slightest infiltration is shown in the form of a slight haze. 
Four brothers were brought to me, one with laryngeal tuberculosis 
and infiltration of the apices. There was a bad family history ; the 
examination of the remaining three by the ordinary methods revealed 
nothing, but with the fluoroscope I was able to distinguish a very 
slight haze at the top of one lung in two of them. The result was 
that those boys were left in the country for a winter, and when I 
examined them some twelve months later the haziness had disap- 
peared, and they were apparently saved from a more serious form of 
tuberculosis by the examination with the x-rays. 
The question of burns is a very interesting one to me, as early in 
my experiments two patients were rather severely injured. At first I 
used a coil, and the accident happened in attempting to photograph 
lesions of the lungs. One of the patients recovered in a very short 
time, and the other one died from his pulmonary disease before the 
skin lesion had healed. We now use the static machine, from which 
I have never seen bad results. 
Another form of tuberculosis that I think is more easily demon- 
strated by the fluoroscope than by ordinary methods of examination 
is the disseminated one. The condition of pericarditis with effusion 
is one that I have never seen. Pleurisy with effusion is very easily 
marked out. 
One more point regarding the remarks of Dr. Butler last night as 
to the shape of the right side of the heart. I would like to ask Dr. 
Williams what his experience in that line has been. It never having 
been brought to my mind, I have not studied the exact outline of the 20 
DISCUSSION. 
right side of the heart, but, speaking from memory, I remember only 
three or four cases in which the outline was vertical, as stated by the 
doctor last night. In most cases the right side of the heart shoots 
off rather abruptly above the margin of the fifth rib, and I should be 
inclined to think that the shadow thrown can be more depended upon 
than the percussion note. 
Dr. E. G. Curtin : It occurred to me, when Dr. Williams told us 
that in one case where the lung was a little cloudy the use of digi- 
talis cleared it up, that the patient might have had oedema of the lung 
which was cleared up by the treatment. I would like to ask Dr. 
Williams what the appearance is of old pleural effusions, especially 
those in which the pleura was thickened. It has occurred to me that 
it would be difficult to distinguish between the catarrhal process and 
that of tubercular infiltration, that is, if the sputum on examination 
yielded no bacilli. 
Dr. Vincent Y. Bowditch: It is hardly necessary for me to 
speak on this paper; it is, however, my pleasure and privilege to 
testify to Dr. Williams’ painstaking, careful work in the City Hos- 
pital, where I have been associated with him. One point comes to 
my mind, and that is the apparent ease of recognition of incipient 
tuberculosis by means of the x-ray machine. It seems hard to 
realize, knowing the translucency of most tissues, that by the x-ray 
machines we can discover a very slight beginning tuberculosis when 
we cannot discover it by auscultation and percussion. I should like 
to have Dr. Williams enlarge a little more on that subject. 
Dr. Williams : I did not take up the methods of examination in 
this paper because I had described them in previous articles.1 My 
patients at the hospital were brought into the x-ray-room on a 
stretcher, which fits on to supports attached to the stand of the x-ray 
machine. If a patient is too ill to be moved he cannot very easily 
be examined, although this is possible by means of a portable x-ray 
machine. The anode of the Crookes tube should be, at least, two 
feet away from the patient for examining the thorax, and usually 
under the point where the median line is crossed by a line joining the 
nipples ; this position should be determined by plumb-lines. The 
median line is obtained by sighting from a permanent plumb-line, 
that is fastened to the middle of the support upon which the head of 
the stretcher is placed, to another fastened to the support at the foot 
in the same way. The other line is determined by putting a string 
seven or eight feet long, with a weight on either end, across the chest 
from nipple to nipple; that is to say, on a level with the fourth ribs. 
The line hangs down on either side of the patient, and the point is 
1 “ A Study of the Adaptation of the X-rays to Medical Practice.” Medical and 
Surgical Report of the Boston City Hospital, January, 1898. “ X-rays in Medicine.” 
Medical News, May 14,1898. MEDICAL USES OF RONTGEN LIGHT. 
21 
obtained by sighting, as before, from weight to weight, and the anode 
may then be brought into line with these weights. The patient should 
be lying on his back when he is examined if the plumb-lines are 
used, but can be turned afterward if desired. In this reclining po- 
sition the patient is perfectly comfortable and his strength is not 
taxed. I tested the correctness of the plumb-lines as a guide to the 
position of the tube by making two successive examinations, the pa- 
tient getting up and the tube being moved after the first examination, 
and both patient and tube being rearranged for the second. The out- 
lines of the heart and ribs, traced by means of the fluoroscope in these 
two examinations, differed only by the width of the line. (See Fig. 16.) 
The essential part of the fluoroscope is the screen, and if the room 
is properly darkened this may be used alone, as the box part of the 
fluoroscope, which excludes the ordinary light from the eyes, is not 
then necessary and prevents them from being brought as near to the 
screen as is sometimes desirable. This screen should be twelve by 
fourteen inches, and for making a permanent record of a case may 
be covered to advantage with a piece of thin glass or a film of cellu- 
loid or gelatine—these do not obstruct the light. If the surface of 
the film is ground an ordinary pencil may be used, but for smooth 
surfaces a lithographer’s pencil is necessary. The outlines of the 
heart and diaphragm, for instance, that have been drawn on the film, 
may be traced, after the patient has been taken away, on a suitable 
sheet of paper placed over the film if both are held up against a 
window. The patient’s name, the diagnosis, date, etc., may be added 
and the paper filed away for future reference. Some of the exami- 
nations1 I have made were recorded in this way, but more by using 
tracing-cloth that was placed directly on the patient, and the lines 
which had been drawn on the skin2 by means of the fluoroscope were 
traced upon the cloth. 
For purposes of study the best machine is necessary; but, having 
learned to identify the appearances in the chest, for instance, under 
both normal and abnormal conditions, a portable x-ray machine may 
be used with satisfactory results if the patient is too ill to come to the 
office or, in case of a hospital patient, to be moved to the x-ray room, 
but if the physician is not familiar with these appearances a small 
machine of this kind is unsatisfactory. 
I have not discussed the heart’s pulsations fully, but I did not 
mean to suggest that the heart appears to have no motion at the apex, 
but merely that its most conspicuous motion is on the left side, as 
shown in the diagram. To show the apex of the heart another posi- 
tion of the tube is better than the one chosen for these diagrams. 
1 I have now tracings and notes of more than one thousand x-ray examinations 
which are classified according to diseases, but thus far I have not had the opportunity 
of publishing as many of the results as I shall hope to later. 
2 It is not necessary in most cases to remove the clothes. 22 
DISCUSSION. 
The normal heart varies in size and position within certain limits. 
I have already referred to the great importance of determining 
whether or not the heart is smaller than normal. We also need to 
know if the heart is of unusual size, and, if this is the case, in what 
part the organ is enlarged. The right border of the heart is difficult 
to determine by auscultation and percussion, but it is seen in the 
fluoroscope, during full inspiration, about one inch and three-quar- 
ters to the right of the median line. In women and boys and girls 
the distance is less. 
We can see the right auricle in both health and disease, and in cer- 
tain diseases a part of the left auricle also. 
Aneurism of the heart may be seen in the fluoroscope ; also aneu- 
rism of the aorta. The outlines of an aneurism of the aorta, which 
appears on the screen as a dark area, may sometimes be seen to move 
with the pulsations of the heart, but when these pulsations are not 
seen the diagnosis with the fluoroscope must be based on the posi- 
tion and shape of the dark area. 
Let me refer for a moment to the diagram of pericardial effusion 
taken from a patient in my service in the early part of 1897.1 I 
examined him with the fluoroscope because of this effusion, but while 
doing so observed that the apex of the right lung was darker than 
normal. I then made a physical examination of the lungs, but could 
find no evidence of phthisis. I continued to examine the lungs in 
the fluoroscope from time to time, and noticed that the diseased area 
extended and the excursion of the diaphragm on the right side 
diminished; finally the left lung also became involved, and the move- 
ment of the diaphragm on this side was also shortened. No physical 
signs were found on the left side at this time by auscultation and per- 
cussion, but they were now marked on the right side. I gave the 
patient tuberculin, to which he reacted. The excursion of the dia- 
phragm is sometimes seen in the fluoroscope to be restricted before a 
diminution in the brightness of the lungs is observed. 
Among the cases of pleurisy with effusion that I examined with 
the fluoroscope there were some in which a darkened area of the lung 
and a diminished excursion of the diaphragm led me to suspect 
tuberculosis when it had not been detected by physical examination. 
This suspicion was afterward confirmed in certain cases by the tuber- 
culin test, or by the finding of bacilli, or the development of the case. 
(Edema of the lungs may be distinguished from early tuberculosis 
by means of the fluoroscope. In the former the lower part of the chest 
on both sides is dark, whereas in early tuberculosis the darkness is 
usually on one side and at the apex. 
i I reported this case in an article entitled “ The Rdntgen Rays in Thoracic Dis- 
eases.” American Journal of the Medical Sciences, December, 1897. MEDICAL USES OF RONTGE N- LIGHT. 
23 
Adhesions of the pleura without thickening would not obstruct the 
passage of the rays and, therefore, could not be seen in the fluoro- 
scope, but, if the movement of the diaphragm were restricted, an 
adhesion might be suspected. 
Auscultation and percussion may leave us uncertain whether we 
have to deal with an adhesion with thickening, or with a pleuritic effu- 
sion ; but the fluoroscope can tell us certainly if fluid is absent, unless 
it is encysted. If present the diaphragm line is obliterated on the side 
of the effusion, especially in the outer portion where this muscle curves 
down to the side of the chest, because fluid would sink and fill-in this 
lower and outer angle unless it were encysted. The ability, then, to 
follow this portion of the diaphragm line proves the absence of fluid, 
except in the particular case just mentioned. Even in such a case I 
have suspected the presence of fluid by means of the fluoroscope, and 
this suspicion was confirmed in one case by an autopsy and in another 
by tapping. The x-rays enable us to choose the most desirable place 
for inserting the needle. Calcareous deposits in the pleura are seen 
as dark areas in the fluoroscope. This is also true of some calcareous 
deposits in the aorta or in certain portions of the heart. 
A suitable outfit for making x-ray examinations will cost at least 
$500. I have been obliged to have mine made to order, and thus had 
the opportunity to devise the various adjustments necessary for a 
practitioner. 
Burns may be produced when either the static machine or the coil is 
used, but with the simple precautions now known to the practitioner 
they are wholly avoidable. None of my patients have ever been burned, 
and I have been making x-ray examinations, sometimes with the static 
machine and sometimes with the coil, during about two and one-lialf 
years. Tesla suggested placing a screen of aluminum wire or a thin 
sheet of aluminum, which should be grounded, between the tube and 
the patient to prevent any risk of burns. The following experiments 
of an electrical engineer, made upon himself with a static machine, 
suggest that burns may be prevented by grounding the anode. Dur- 
ing the first fourteen days of November, 1896, he exposed his skin to 
the Crookes tube at a distance of less than two inches. The first 
exposure was three-quarters of an hour; the second, half an hour; 
the third, one hour; and the fourth and fifth, half an hour each. 
These successive exposures were at intervals of about three days. 
The anode was always grounded, and there were no untoward results. 
On December 21st he exposed the same portion of his skin in a 
similar manner for half an hour, without grounding the anode. 
Twelve days later the skin was blistered, and a severe ulceration 
followed. 
Photography gives more detail than the fluoroscope; for instance, 
I have taken x-ray photographs which showed normal arteries ; these 24 
MEDICAL USES OF RONTGEN LIGHT. 
could not be readily seen in the fluoroscope; but the latter has the 
advantage in examining the thorax, for example, as the movements of 
the diaphragm and heart can be watched, and the examination with 
this instrument can be made more quickly. Photography requires a 
great deal of time, even with the dark room at hand, as it is necessary 
to wait for the plate to be developed; but I use either the fluoroscope 
or the x-ray photograph as occasion requires. 
I do not know exactly how many hospitals have x-ray machines; 
I am told that at least thirteen in New York have them. We have 
them in Boston, and they are also to be found in Philadelphia, Balti- 
more, Chicago, St. Louis, San Francisco, and, probably, in all the 
large cities in the country. 
One last word about this method of examination. In hospitals it 
will be always desirable to have a photographer to take the x-ray 
photographs, to keep everything in order, and manage the apparatus ; 
but it is not practicable for other than medical men, trained in this 
special work, to make the x-ray examinations with the fluoroscope. 
You would not send a patient to a man who was not a physician for 
auscultation and percussion. FIG. 1. 
Tracing made by means of the fluoroscope from a girl seven years old, showing the 
outline of the stomach one hour after a meal of bread and milk containing subnitrate 
of bismuth. The full horizontal line is at the level of the iliac crests ; the full lines at 
right angles to it are the outlines of the body; the other full lines indicate the posi- 
tion of portions of the diaphragm, heart, and stomach during full inspiration. Broken 
lines show position in expiration. One-half its original size. 
Mr. W. B. Cannon, a student in the Harvard Medical School, who has published an 
excellent article on the movements of the stomach in the cat, as seen by the Rontgen 
rays, has made, with me, some observations on the size and shape of the stomach in 
human beings during digestion, which are as yet unpublished. Fig. 2. 
Full Inspiration During Health. 
The broken lines show the position of the diaphragm and heart in expiration, but 
the diagram does not indicate that during this time the light area is narrower. The 
anode of the Crookes tube in Figs. 2 to 15 inclusive, except in Fig. 12, was placed under 
the median line, where it is crossed by a line joining the nipples. The tube should 
be two feet or more away from the patient. Fig. S. 
Aneurism ok the Descending Aorta. 
Broken lines show position of diaphragm in expiration; a dilatation of the ascend- 
ing portion of the aorta would cast a shadow on the right side of the sternum. Fig. 4. 
Emphysema of Both Longs in Full Inspiration. 
Broken lines show position of diaphragm in expiration. Fig. 5. 
Pleurisy, with Large Effusion. 
Broken lines show position in expiration. Fig. 6. 
Pleurisy, with Small Effusion. Fig. 7. 
Pneumonia. Seventeenth day of disease. 
Dark area and restricted movement of the diaphragm on the left side; the move- 
ment is also less than normal on the right side. The dark area diminished gradually, 
and the excursion of the diaphragm on both sides increased from week to week. Fig. 8. 
The excursion of the diaphragm is restricted, and restricted to the upper part of 
its excursion in this disease. In emphysema the movement is restricted to the lower 
side. In tuberculosis it may he higher in the thorax than in health, in emphysema 
lower. 
In the diagram the apex is darker, and the excursion ot the diaphragm is more 
restricted than in the very early stage of the disease. 
Pulmonary Tuberculosis. Right side. Fig. 9. 
Pneumohydrothorax. Left side. Fig. 10. 
Pneumothorax on Left Side, and Tuberculosis on Right Side. Fig. 11. 
Heart-movements. 
Diagram representing the borders of the bloodvessels, heart, and diaphragm—the 
full lines in deep inspiration, the broken lines in expiration, the dotted lines just 
below the broken ones the position of the diaphragm in ordinary inspiration. 
The line of large and small dots inside the left border of the heart shows the posi- 
tion of the left border in systole, and the full line in diastole, during full inspiration. 
The other movements of the heart—namely, those of the apex, the right ventricle, 
and the right auricle—are not indicated in the diagram. 
It is obvious how the fluoroscope may assist to determine the position, size, and 
mobility of the heart. Fig. 12. 
Triangle. 
The outline of the body and the ends of the ribs have been traced from an anat- 
omical plate, which represented a section of the body through the left parasternal 
line. The heart-lines and the outlines of a portion of the diaphragm and spine, or 
rather what lies in front of the spine form the triangle, and were drawn while look- 
ing through the fluoroscope on the left side of a patient during full inspiration and 
then sketched—in about the proper position—on the drawing from which this dia- 
gram was made. This triangle is usually closed at the anterior angle, although it 
did not happen to be in this patient. 
It will be seen that the outline of the heart is indicated partly by a full and partly 
by a dotted line. The full line shows the extent of the border usually seen in the 
fluoroscope in health; the dotted line the additional amount seen in this special 
individual in health. Fig. 13. 
Passive Congestion, or (Edema, of the Lungs. 
In valvular disease I have seen much darker lungs than the diagram indicates 
become clear, and the dyspnoea cease after treatment by digitalis. Fig. 14 
Pericardial Effusion. 
Broken lines show outline by percussion, full line by fluoroscope. Fig. 15. 
Aortic Insufficiency. 
Diagram of heart in a patient with aortic insufficiency. Compare with Fig. 11. 
Diastole and systole during ordinary respiration are indicated by the arrows and 
the broken and the dotted lines respectively. The line made up of dashes and dots 
shows where the left border of the heart is in systole during deep inspiration. When 
a full breath is taken the heart is compressed, and the diastolic excursion is less than 
in ordinary breathing. The movements of the heart could be followed in this patient 
unusually well. Fig. 16. 
Indirect Plumb-line. Scale one-eighth of an inch to one inch. 
An instrument, which is a form of plumb line, to be used when the patient is lying 
on the stretcher, that I have devised for determining the exact position of the Crookes 
tube when it is desired to place it directly under the point to be examined. This in- 
strument is especially useful in cases where the median line is not available as a 
point of reference. I have used it from time to time for more than a year. By it the 
right and left borders of a large heart may be determined separately. 
This instrument is made of strips of cedar one-eighth inch thick and one inch wide. 
There is a counterpoise of lead on the end of the arm beyond A. The vertical piece 
from which the arms A and B extend is made of two strips of cedar, fastened at either 
end and separated three-quarters of an inch in the middle by a piece of cork. This 
is done to give stiffness. 
A piece of thin wood about two inches square with a depression in the centre (not 
shown in the figure) is placed on the patient so that the depression is over the point 
to be examined, directly under which it is desired to bring the Crookes tube. 
The rounded point, A, is placed in the depression, and the rest of the instrument 
being free to swing, the weight, B will hang directly under A; the position for 
the anode of the tube is just under B.