THE RONTGEN RAYS IN THORACIC 
DISEASE. 
BY 
FRANCIS H. WILLIAMS, M.D., 
BOSTON. 
Reprinted from 
The American Journal of the Medical Sciences, 
December, 1897. Extracted from The American Journal of the Medical Sciences, December^i89!f’. 
THE RONTGEN RAYS IN THORACIC DISEASES.1 
By FRANCIS H. WILLIAMS, M.D., 
BOSTON. 
About a year ago I had the pleasure of presenting to this Association 
a paper in which I related some of the early steps in my study2 of the 
adaptation of the x-rays to medical practice; x-ray examinations were 
then a novelty, but they must now be accepted as a valuable supplement 
to our other methods of examination. To-day I wish to outline some 
of the results of the work of the past year, during which I have exam- 
ined by means of the x-rays more than five hundred patients—about 
one hundred of which were surgical cases—at the Boston City Hospital 
and at my office.3 The majority of the four hundred medical cases 
were suffering from some thoracic disease; certain of these patients— 
those ill with pneumonia, for instance—have been examined a number 
of times, as I wished to watch the progress of the disease and see the 
conditions presented in its different stages. 
No harmful effects have been received in any way by these patients, 
and there need not be the slightest anxiety on the part of any one if 
proper precautions are taken. I have seen, however, several persons 
who have suffered a more or less severe inflammation of the skin, the 
nails also being sometimes involved, but they were all individuals whose 
occupation brought their hands into close proximity to the Crookes 
tube, or who, for the purpose of testing its possibilities for harm, had 
exposed some part of the body to its action at a distance of a few inches 
for a considerable period; but there are simple ways of obviating these 
effects. 
Before taking up the uses of the x-rays in diseases of the thorax, let 
1 Presented at the meeting of the Association of American Physicians, May 5,1897. 
2 During the progress of this study I have reported my results at medical meetings or by pub- 
lished articles, as follows: 
Meeting of the Suffolk District Medical Society, April, 1896. 
Meeting and Proceedings of the Association of American Physicians, 1896; “ Notes on X-rays 
in Medicine.” Boston Medical and Surgical Journal, October 1, 1896, “ A Method for More 
Fully Determining the Outline of the Heart by Means of the Fluoroscope, together with other 
Uses of this Instrument in Medicine.” 
Meetings of the Boston Society for Medical Improvement, and of the Medical Society of the 
Boston City Hospital, October and November, 1896. 
Medical and Surgical Reports of the Boston City Hospital, January, 1897, pp. 134-190. “ A 
Study of the Adaptation of the X-rays to Medical Practice.” 
3 In making these examinations I have used a Wimshurst machine and an induction coil, 
but principally the former, both of which were designed by Messrs. C. L. Norton and R. R. 
La wrence, of the Massachusetts Institute of Technology. 2 
WILLIAMS: X-RAYS IN THORACIC DISEASES. 
me call your attention to one of the principles upon which their use- 
fulness depends. 
Fig. 1. 
The two upper rows of objects in this radiograph are calculi. The two calculi on the left 
are composed of uric acid and urates ; those on the right of phosphates; and the two in the 
middle of oxalate of calcium and uric acid, the upper one of these last two having an outside 
coating of urates. In the centre of the picture is a round aluminum cup, containing water, 
one inch in depth, and on either side of this cup is a group of gall-stones, and to the right and 
below the cup a single large gall-stone is seen indistinctly. In the left-hand lower corner is a 
decalcified bone, bent into the shape of an inverted u, with a lead tag attached by a copper 
wire. The decalcified bone surrounds an incinerated bone, which is lying on a piece of cotton- 
wool in a wooden box with a glass side. In the right-hand lower corner is a dry bone; in the 
extreme right-hand corner is a triangular piece of lead. The picture is reduced to one-halt 
of its original size. 
The varying resistance which the different tissues of the body offer 
to the passage of the x-rays depends upon difference in bulk and in 
chemical composition ; organic substances made up of carbon, hydrogen, williams: x-rays in thoracic diseases. 
3 
and nitrogen, which have a low atomic weight, allow the rays to pass 
readily, while those like bone, containing calcium, which has a com- 
paratively high atomic weight, offer more resistance to the rays. The 
soft tissues of the body contain a large percentage of water, and most 
of them offer about the same resistance as an equal thickness of water. 
The various fluids found in the body in health and disease, such as the 
blood, ascitic and pleuritic fluid, pus, urine, fluid from hydrocele, etc., 
offer about the same resistance as water. 
Fig. 2. 
Radiograph of equal bulks ol various substances which represent the constituents of the 
body in a general way: 
Weight. Weight. 
1. Carbonate of magnesium . 1 6 grammes. 5. Gelatin 4.0 grammes. 
2. Stearic acid .... 3.8 “ 6. Dried egg albumen . . 6.4 “ 
3. Oleic acid .... 3.5 “ 7. Carbonate of sodium . . 5.9 “ 
4. Palmitic acid . . 4.4 “ 8. Milk sugar .... 11.7 “ 
9. Glycerin .... 4.0 “ 13. Phosphate of calcium . . 2.6 “ 
10. Water 14.0 “ 14. Sulphate of sodium . . 10.8 “ 
11. Oxalic acid . . . .12.2 “ 15. Magnesium ammonium phos- 
12. Phosphate of sodium . . 10.6 “ phate 12.5 “ 
16. Chloride of sodium . .8.5 “ 19. Carbonate of calcium . . 15.3 “ 
17. Sulphur 13.9 “ 20. Fluoride of calcium . . 11.7 “ 
18. Chloride of potassium . 10.1 “ 
The following experiment with calculi (see Fig. 1) illustrates in 
a striking manner how important to us is a knowledge of chemical 
composition in our use of the Rontgen rajs in medicine. Before 4 
williams: x-rays in thoracic diseases. 
attempting to detect any form of calculi in the body I first placed several 
different kinds over a photographic plate, which was enclosed in dark 
paper to shield it from the light, and exposed them for a few minutes to 
the x-rays. The rays penetrated the calculi made up of uric acid, of 
cholesterine and biliary salts very readily, but were obstructed by cal- 
culi containing oxalate of calcium in considerable proportion, phosphate 
of calcium, or other inorganic constituents. These calculi were kindly 
lent to me by Dr. William F. Whitney. 
In order to gain some conception of the susceptibility of the various 
constituents of the body to the x-rays, I made several radiographs of a 
considerable variety of substances (see Fig. 2), and one of them I have 
had reproduced here. 
This experiment suggests how we may recognize some changes in 
chemical composition made in the body by pathological processes. The 
ability to do this without beaker or reagent, or disturbing the vital pro- 
cesses, is a step in the application of chemistry and physics to practical 
medicine which hints at Avhat the future may have in store for us. 
There is one other point which must not be overlooked in this connec- 
tion, and that is the difference in resistance which air and water offer 
to the passage of the x-rays. The rays pass through air much more 
readily than through water, and, as air makes up a certain bulk of the 
body and a large part of the chest is filled with it, while water enters into 
the composition of all parts of the body and forms the chief constituent 
of the soft parts, it is readily seen of how much importance is this 
difference in permeability of air and water by the rays, on account of 
the great contrast which is thereby afforded in health between the lungs 
and their adjacent tissues or organs. Further, as will be shown later, 
one of the best opportunities for the advantageous application of the 
x-rays is obtained from the contrast of the normal lung tissue with that 
offered by pathological conditions which occur in the thorax, involving 
chiefly increase in density in the lungs or in the space usually occupied 
by them. 
To use the Rontgen rays successfully in practice it is first essential 
that the physician become familiar with the appearances in the fluor- 
oscope which present themselves in health by examining a number of 
healthy persons of different ages and weights. This applies particularly 
to the thorax, and the picture of this part of the body, when seen on the 
screen of a large fluoroscope, presents so much that it should be studied 
systematically. The trunk appears lighter above than below the dia- 
phragm, and the rise and fall of this muscle, which is dark in the fluor- 
oscope, are distinctly seen. The chest is divided vertically by an ill- 
defined dark band, which includes the backbone, on each side of which 
the lungs, forming the brightest part of the picture, are crossed by the 
darker ribs; this band varies in width according to the intensity of the WILLIAMS: X-RAYS IN THORACIC DISEASES. 
5 
light, narrowing as this becomes stronger; with a strong light the ver- 
tebrae from the neck to the heart are made out. The pulsating heart is 
seen, especially the dark ventricles, the outlines of the venae cavae and 
of the pulmonary artery, and under favorable conditions the lighter 
right auricle. A small portion of one side of the arch of the aorta 
may be observed in the first intercostal space to the left of the sternum. 
After this general view has been taken the outline of the lungs should 
be noted during full inspiration and expiration, and the excursion made 
by the diaphragm during quiet breathing and during full inspiration 
and expiration (see Fig. 3). 
Fig. 3. 
Diagram showing the heart and the outline of the diaphragm oi normal chest, as seen in the 
fluoroscope during full inspiration. The broken lines show position of heart and diaphragm 
in expiration. 
The lungs usually appear brighter during deep inspiration; in young 
persons brighter than in older persons, as the tissues of the former 
are more easily penetrated by the rays. In the stout, the lungs appear 
darker than in the thin, because the outlines are dulled, as it were, by 
a thicker layer of tissues, which contain much water. It has seemed to 
me that the right apex is normally darker than the left apex. The 
normal brightness of the lungs and the normal outlines of the clavicles 6 
williams: x-rays in thoracic diseases. 
Fig. 4. 
The lungs of a patient who died of pneumonia. The lightest portion is healthy. The darker 
parts have been more affected by the pneumonic process than the lighter. WILLIAMS: X-RAYS IN THORACIC DISEASES. 
7 
and ribs should be observed, for, as we note different degrees of pallor 
by reference to our standard of color in health, in the same way is it 
necessary to know the normal amount of light which should penetrate 
any given part in order to recognize variations from the normal. The 
eye must be trained in the use of the x-rays as is the ear for ausculta- 
tion and percussion, and the fluoroscope, like the ophthalmoscope, should 
be in constant use in order that the practitioner may not lose any of 
the skill acquired in interpreting the conditions presented. 
To test the possibilities of an examination with the fluoroscope in cer- 
tain conditions of the lungs, as when congestion or more or less oedema 
or pleurisy was present, I made one or two simple experiments. On 
full inspiration in healthy patients I found the pulmonary area lighter 
than in other stages of respiration, and the ribs stood out in greater 
contrast, thus showing that there must be less blood in the lung during 
the former period, and that if any part of the lung is much congested, 
or if oedema is present, it would naturally appear darker than the nor- 
mal lung; also when I held a small pasteboard box, about one-half inch 
deep and full of water, over one side of the thorax of a well-developed 
and muscular man with a large chest, I could see its shadow in the 
fluoroscope during about full inspiration, but not at other times. 
In order to get further suggestions in regard to the possibilities of 
the x-ray examinations in diseases of the lungs, I took a number of 
radiographs of healthy and diseased lungs just after death, which were 
removed from the body and put over a photographic plate. As a 
specimen of the latter, see Fig. 4, which shows the lungs of a patient 
who died of pneumonia. The darker was more affected by the process 
than the lighter; the lightest portion is healthy. These lungs were 
kindly sent to me for a few moments by Prof. W. T. Councilman. 
Again I examined with the fluoroscope, two days before his death, 
the chest of A. B., one of my patients who died of syphilis, and found 
his lungs perfectly clear and the outlines well defined. The outlines, 
also, of the front and back portion of the ribs forming a lattice-work, 
a3 shown in the fluoroscope, were well seen. The autopsy confirmed the 
examination made by the fluoroscope, and showed that he had perfectly 
healthy lungs. 
We shall see presently that in certain diseases parts or the whole of 
ene or both lungs appear darker or lighter than in health, and that their 
volume may be greater or less than in health. The respiratory excur- 
sion of the diaphragm may vary from the normal on either or both sides 
of the chest, in position—that is, it may be higher or lower in the body, 
and in amplitude, or it may vary in the curve, or its lines may be wholly 
or partially obliterated. 
In making examinations of the lungs, changes in the amount of light 
seen in the fluoroscope should be carefully observed: for example, 8 
williams: x-rays in thoracic diseases. 
whether or not one lung is darker than the other. In pathological con- 
ditions the indications of change in density, shown usually by dimin- 
ished brightness, may be estimated by comparing the two sides and 
observing whether the outlines of the organs and whether the ribs and 
clavicles are more clearly seen on one side than on the other. When both 
sides are diseased the opportunity for direct comparison with the normal 
is lost, and one is obliged to depend upon the recollection of the normal 
in an individual of the same build. The position, excursion, and curve 
of the diaphragm should also be carefully noted, as compared with the 
normal. 
In six men with healthy lungs the diaphragm moved over an average 
range of two and three-fourth inches on the right side and two and one- 
half inches on the left side. (See Fig. 5.) The maximum excursion in 
any healthy person I have examined was four inches. In eighteen 
Fig. 5. 
Chest of healthy man, aged twenty-one years. Examination with the fluoroscope: The 
dotted lines on each side of the chest indicate the outlines of the fourth rib; the full upper 
horizontal lines on either side of the chest about over the fourth rib, the position of part of the 
diaphragm in expiration ; the broken lines just below these, the height of the diaphragm at 
inspiration during quiet breathing; the full lines below and parallel to these, the outlines of the 
diaphragm during deep inspiration. The full curved line which is nearer the left nipple indi- 
cates the left border of the ventricle during quiet breathing; the full curved line nearly parallel 
to this, the left border and apex during deep inspiration. 
patients with tuberculous lungs the average excursion of the diaphragm 
was one and one-fourth inches; in some cases less than half an inch. 
Patients may be examined standing, sitting, or lying down, with the 
rays passing through the body antero-posteriorly or from side to side. WILLIAMS: X-RAYS IN THORACIC DISEASES. 
9 
Most of my examinations have been made with the patients lying on a 
stretcher (see Fig. 6), and the Crookes tube on an adjustable holder 
under the patient. For careful examination of the thorax, for example, 
Fig. 6 
Showing method of examining a patient who has been brought into the dark-room on the 
stretcher, on which he lies. The Crookes tube is on an adjustable holder below the patient; 
the static machine on the table near him. About two inches below the patient there should 
be a brass plate (not shown in the figure), rather more than a foot square and one-quarter of 
an inch thick, with a circular opening about six inches in diameter. This plate is attached 
to a flat iron bar in such a manner that it may be swung horizontally and brought under any 
part of the body it is desired to examine carefully. The rays pass only through the circular 
opening, and the part to be specially examined is thus more clearly defined. This metal 
diaphragm is used after the general examination of the body has been made without it. The 
plate should be grounded. 
the Crookes tube should be about two feet away from the fluoroscope. 
and its position should be determined by plumb-lines, so as to bring it 
immediately under the middle of the sternum, on a level with the fourth 
rib. The fluoroscope is peculiarly applicable to moving organs, such as 10 
williams: x-rays in thoracic diseases. 
the heart and lungs, and is useful in examining children. I now use 
this instrument in my office as I do the stethoscope. 
Let us now take up individually some of the thoracic diseases, and 
we will first consider pulmonary tuberculosis. 
Pulmonary Tuberculosis. 
In this the fluoroscope may suggest disease in the following ways: 
First, a diminution in the volume of the diseased lung is shown by the 
position and movement of the diaphragm; this movement may be less 
than normal on one or both sides, and will be restricted on the lower 
Fig. 7. 
Diagram illustrating appearances seen in the fluoroscope in a case of tuberculosis of the 
lung. The apex of the right lung is seen to be darker than normal, and the range of move- 
ment of the diaphragm on the right side to be less than normal. The position of.the dia- 
phragm in full inspiration is shown ; broken lines give its position in expiration. 
side. Second, an increase in density by diminution in the normal bright- 
ness, the degree and extent varying in accordance with the increase in, 
and extent of, the density. The lung may become so dense that no 
more rays pass through it than through the liver. The brightness or 
light in the lungs indicates the amount of air in the chest. The dia- 
phragm lines may be partially or wholly obliterated, as well as the 
outline of the heart. WILLIAMS: X-RAYS IX THORACIC DISEASES. 
11 
I have examined more than one hundred cases of tuberculosis1 with 
the fluoroscope, and found a correspondence between the physical signs 
and the x-ray examination in a considerable number of cases; in cer- 
tain cases this instrument showed that the disease was more extensive 
than the physical examination indicated; in others it showed increase 
in density in the lungs earlier than was detected hy the physical exam- 
ination; and while in some of these no signs in the lungs were detected 
prior to those found hy the fluoroscope, in others, although one lung was 
ascertained hy the physical examination to he seriously involved, its 
companion was not suspected until the x-ray examination revealed its 
increased density. In most cases of pulmonary tuberculosis the fluor- 
oscope enables us to estimate the amount of lung involved better than 
any other method of examination. Most of the tuberculous patients 
that I examined at the Boston City Hospital presented well-marked 
signs of the disease when they entered, but in prviate practice the pro- 
portion of patients who are seen in the early stage, when there is greater 
opportunity for successful treatment, is larger; and therefore the fluor- 
oscope might be of special value in these cases on account of the earlier 
diagnosis it assists us to make. 
The following case, which one of my colleagues kindly permitted me 
to examine with the fluoroscope, shows that this instrument detected 
increase in density in the right lung when it was not found by auscul- 
tation and percussion. It likewise indicates the significance of the 
diaphragm lines in tuberculosis: 
H. A., aged twenty years. Tuberculosis(?). Duration, four weeks; 
family history not tubercular. Medium dry rales at left apex, with 
slight dulness ; right apex normal. 
Examination with fluoroscope: Left lung extending to level of the 
fourth rib very dark ; there is also some involvement of right apex. The 
maximum respiratory movement of the diaphragm on the left side is 
only three-quarters of an inch; on the right side one inch only. This is 
less than half the normal. 
[Later tubercle bacilli were found.] 
Let me also give the following case in which increase in density was 
detected earlier by the x-ray examination than by the older method. 
I examined this patient because he had a pericardial effusion, but the 
increase in density at the apex of the right lung was so marked in the 
fluoroscope that it attracted my attention. The usual physical exam- 
ination was then made, but I could find no evidence of pulmonary tuber- 
culosis. I examined the lungs by the fluoroscope from week to week, 
and saw that the denser, diseased area extended, while the movements 
of the diaphragm became less and less on that side. After about six 
1 See “A Study of the Adaptation of the X-Rays to Medical Practice,” Medical and Surgical 
Report, Boston City Hospital, January, 1897, pp. 153-165, for short abstracts of some of these 
cases, as well as those of pneumonia, etc. 12 
WILLIAMS: X-EAYS IN THORACIC DISEASES. 
weeks the fluoroscope showed that the left lung also had become denser 
at the apex, and the excursion of the diaphragm on this side was also 
lessened. No signs were found by auscultation and percussion on 
this side at this time. There has been no cough, the patient is about 
as usual in weight, has no night-sweats, and no bacilli have been 
found; but about two months after his entrance to the hospital he 
reacted very strongly to tuberculin, and the diagnosis of tuberculosis 
was established. Four months after entrance: still no bacilli have 
been found, although many examinations for them have been made. 
There are, however, some cases where the bacilli are found before 
marked signs in the lung can be detected by the fluoroscope; it may be 
that in these cases the disease begins in the larynx. 
Again, a woman twenty years old, unusually well developed and nour- 
ished, entered the hospital with phlebitis of the leg. Two of her sisters 
had died of tuberculosis. By auscultation and percussion the heart’s 
area, action, and sounds were normal; resonance and respiration good 
over the whole of both lungs. After she had been in the hospital two 
weeks an x-ray examination was made, chiefly because I had established 
the routine of so examining many of my patients. This examination 
showed that the maximum movement of the diaphragm on the right 
side was one and seven-eighths inches, and on the left side two inches. 
The apices of the lungs were darker than normal on both sides, more 
so at the right apex than at the left. The outline of the heart showed 
that this organ was smaller than normal. Tuberculin was given and 
was followed by a typical and well-marked reaction. The tubercular 
family history, diminished movement of the diaphragm, increased density 
of the apices of the lungs, and the small heart, all pointed to the diag- 
nosis of tuberculosis, and this was confirmed by the tuberculin-test. As 
yet there have been none of the ordinary symptoms or signs of disease 
of the lungs, except those seen in the fluoroscope. 
We can detect an abnormal condition of the lung in some cases of 
tuberculosis earlier by means of the fluoroscope than by auscultation 
and percussion. How much earlier these signs can be anticipated 
depends upon the rapidity of the progress of the disease, and this varies 
in different persons and under different conditions. Of course, a diag- 
nosis of tuberculosis is not made by the appearances in the fluoroscope 
alone, they simply indicate an abnormal condition of the lungs. I 
shall consider more fully the use of the fluoroscope in pulmonary tuber- 
culosis in another article. 
Pneumonia. 
I have examined more than fifty patients with pneumonia by the fluor- 
oscope, and some of them, as already stated, a number of times while 
watching the progress of the disease, and found in a few cases that the WILLIAMS: X-RAYS IN THOEACIC DISEASES. 
13 
lung had not become normal after months. In patients ill with pneumonia 
the increase in density in the lungs is very marked in the fluoroscope dur- 
ing the active stage of the disease [Fig. 4 suggests the distribution of 
the darker areas as seen in the fluoroscope], and by its means we may 
estimate how large an area of the lungs is involved, and by observing 
the patients at intervals of two or three or more days, as they improve, 
we may see the dark areas become lighter and lighter, and finally disap- 
pear ; and we may see the excursion of the diaphragm, which has been 
restricted and restricted on the lower side, become gradually longer as 
the lungs clear up. I have examined patients while they were conva- 
lescing from pneumonia, both by auscultation and percussion and by 
the fluoroscope, on the same day, and while by the former I could not 
detect that the lungs were denser than normal, I was able to recognize 
the continued presence of abnormal density by means of the fluoroscope, 
and even when this was no longer possible I could still easily see by 
means of this instrument that the diaphragm did not descend to its 
normal limit, thus showing that the lung was still in an abnormal state. 
Later the normal limit was reached. This method of examination 
enables us to judge better than any other when the lungs have cleared 
up after an attack of pneumonia, and if we can obtain, by means of 
the fluoroscope, later evidence of the presence of a pathological process 
during its subsidence than by auscultation and percussion, we may also 
reasonably expect to recognize its onset sooner, and I am satisfied that 
we can. Further, this ability to detect that the lungs are in an abnor- 
mal state weeks after a physical examination has ceased to indicate it, 
shows the delicacy of the test, and is an added assurance that we can in 
some cases of tuberculosis recognize an abnormal condition of the lungs 
earlier by means of the fluoroscope than by auscultation and percussion. 
A slight central pneumonia is at times overlooked when its early detec- 
tion by the fluoroscope might, in certain cases at least, prevent its 
progress to a more severe attack. 
During the past winter I have seen three patients where the diagnosis 
would have been difficult had not the fluoroscope led to that of central 
pneumonia; one of these cases was seen by three physicians, and we all 
failed to make the diagnosis. The examination with the fluoroscope 
caused me to make a diagnosis of central pneumonia, and the further 
progress of the case confirmed it. 
The following case shows the significance of the diaphragm lines in 
pneumonia: 
L. B., aged nineteen years. Pneumonia. Examination with fluor- 
oscope: On seventh day of disease, right lung dark from middle of first 
intercostal space to fourth rib; the upper and lower border of this dark 
area were marked; outlines in chest rather less clear than normal on 
both sides. Diaphragm moved one-quarter inch on right side, and one 14 
WILLIAMS: X-RAYS IN THORACIC DISEASES. 
and five-eighths inches on left side. Fifteenth day of disease, diaphragm 
moved one inch on the right side; two and one-half inches on left side. 
Nineteenth day of disease, diaphragm moved two inches on right side; 
two and three-quarter inches on left side; original dark area on right 
side not so bright as other portions of the lung. On the twenty-second 
day of the disease, diaphragm moved two and one-half inches on right 
side and three inches on left side. 
The abnormal condition of the lungs in tuberculosis and pneumonia 
may be shown not only by the obstruction which the affected parts offer 
to the passage of the rays, but also by the restriction of the excursion 
of the diaphragm. In some cases the latter is a more delicate test. 
In pleurisy with effusion we can estimate the amount of fluid in a 
general way by the amount of light which passes through the thorax, 
and can follow the subsidence of the fluid. When the effusion is large 
no more rays pass through it than through the liver, and the outlines of 
the diaphragm, ribs, and heart are obliterated on the side of the effusion. 
If there is a smaller amount of fluid, the outlines of some of the upper 
ribs are seen, and with a small effusion the outlines low down in the 
thorax only are ill defined. The fluoroscope assists us to distinguish be- 
tween an effusion and a thickened pleura. In some cases of effusion the 
fluoroscope shows us displacement of the heart, to the left when there is 
a large effusion on the right side and a much greater displacement to 
the right, and this displacement is of more frequent occurrence when 
the effusion is on the left side. This displacement of the heart to the 
right may not be recognized by percussion even when it has been pushed 
much beyond its normal place. In one patient the heart was seen to be 
displaced more than two inches to the right, but no displacement was 
detected by percussion. While examining some cases of pleurisy with 
effusion by the fluoroscope, I have found indications of tuberculosis in 
the lung where it was not previously suspected, and these indications 
were confirmed later by finding the bacilli or by the tuberculin-test. 
Pleurisy. 
Emphysema. 
In emphysema we see in the fluoroscope that the lungs are unnaturally 
clear and that their volume is increased ; the dilated right auricle and 
pulmonary artery are observed, and the whole enlarged heart is seen 
more clearly than normal, although by percussion its true outline cannot 
be determined; it is also seen to lie lower than in health, and in the 
later stages in a more vertical direction. The diaphragm is seen to be 
lower than normal, and the excursion which it performs between deep 
inspiration and expiration to be less than normal. In some cases the 
emphysematous condition may be greater on one side than on the other. WILLIAMS: X-RAYS IN THORACIC DISEASES. 
15 
The lower position and the more limited excursion of the diaphragm 
give a means of making a diagnosis of this condition probably earlier 
than has hitherto been possible, or in some cases the lack of these signs 
enables us to exclude it. 
Fig. 8. 
Emphysema. Dotted line marks cardiac area by percussion; full line, by fluoroscope. Dia- 
phragm lines, in expiration and inspiration, are shown on each side of chest below the 
nipple ; they are lower and nearer together than normal. Broken line below inner end of left 
clavicle shows position of arch of aorta. 
The following case was sent to me with a diagnosis of emphysema 
with asthma: 
B. F. Examination with fluoroscope: Diaphragm moved on the 
right side two and one-half inches, and on the left side three inches. 
The excursion of the diaphragm being normal assures us that no serious 
amount of emphysema is present. 
I have seen patients, both young and old, who complained of getting 
out of breath on exertion, and the cause in some cases would have been 
obscure but for the fluoroscope ; this instrument showed that the dysp- 
noea in both young and old was due in some instances to emphysema, 
and in others to oedema of the lungs. 
If some other disease is associated with emphysema, as, for instance, 
some form of bronchitis, the excursion of the diaphragm is character- 
istic, but the abnormal clearness of the lungs may be wanting. 
Bronchitis. 
The appearances of bronchitis in the fluoroscope vary; they may 
differ very little from those in health, or both sides of the thorax may 16 
WILLIAMS: x-rays in thoracic diseases. 
be less bright than normal. The respiratory movement of the diaphragm 
was not especially impaired in the cases I have seen. 
Pneumothorax—Hydrothorax—Pneumohydrothorax— 
Pneumopyothorax—CEdema of the Lung. 
In pneumothorax the fluoroscope shows that the affected side of the 
■chest is lighter than normal, that the heart and vessels may be much 
displaced, and that the diaphragm is much lower than normal on that 
side, and has a characteristic curve. 
In pneumohydrothorax or pneumopyothorax, when the patient is 
examined lying down, the whole of the affected side of the chest is seen 
to be dark ; if examined in a sitting position the upper portion of the 
chest is clear and the lower dark. The appearances remind one of a 
tumbler half-full of ink; when the patient bends forward or backward 
the height of the fluid on the chest-wall changes; if the patient is 
shaken gently the surface of the dark fluid is seen to be agitated. In 
pneumohydrothorax or pneumopyothorax on the left side the surface of 
the fluid is seen to be disturbed by the pulsations of the heart. 
In hydrothorax and oedema of the lungs the fluoroscope is also of 
service. In these conditions, as well as in empyema, the outlines of the 
diaphragm are wholly or partially obliterated. Some partial oedema of 
the lungs is, I am inclined to believe, a more frequent condition than 
has been supposed. On first examining a patient of this class, his con- 
dition being unknown, I was surprised to find how difficult was the 
passage of the rays, and when I saw that the picture of the patient’s 
thorax in the fluoroscope was unusually dark, supposed something was 
wrong with my Crookes tube; but after trying another I realized that 
the patient’s chest was denser than normal; the tube was not in fault. 
I have examined a number of cases which illustrate the aid the fluor- 
oscope renders in congestion or oedema of the lungs; this instrument 
showed that one of these conditions was present when it was not made 
out by physical signs, and it thus assists the physician to recognize the 
interference that may occur in the pulmonary circulation in cardiac or 
renal disease. 
I have found it instructive to study, by means of the fluoroscope, 
cases of dyspnoea on exertion, and note the amount of congestion or 
oedema of the lungs present in them. Cases of this kind have already 
been referred to under emphysema. 
H. E., aged twelve years. Entered the hospital with an old endo- 
carditis following rheumatism. There was a systolic souffle at the apex 
of the heart transmitted to the axilla; enlarged heart; orthopnoea, 
oedema of the lungs, and intense dyspnoea. Digitalis given. Three 
days after entrance examination with the fluoroscope showed that the 
lungs were denser than normal below the second rib on the right side, WILLIAMS: X-EAYS IN THOEACIC DISEASES. 
17 
and the third rib on the left side. Four weeks later, second examina- 
tion with fluoroscope: Lungs perfectly clear, heart smaller. The patient 
had been up and about for some time. 
Aneurisms. 
I have examined with the fluoroscope and taken radiographs of one 
subclavian and several thoracic aneurisms. The heart in some of these 
latter cases was much displaced. Aneurisms of the arch of the aorta 
are most clearly outlined when their borders are nearest the fluoroscope ;• 
those on the left when examined from the back, those on the right when 
examined from the front. It is obvious that aneurisms of the thoracic- 
aorta can sometimes be detected earlier by x-ray examination than in 
any other way. In obscure thoracic cases, where an aneurism of certain 
portions of the aorta is suspected but does not exist, it may be excluded 
by an x-ray examination. 
Fig. 9. 
Thoracic aneurism. Examination with fluoroscope: The curved line in the upper part of 
patient’s left chest, and the curved line on his right chest indicate the outline of the aneu- 
rism as seen in the fluoroscope. The lower curved line on the left chest marks the outline 
of the heart; the lowest curve on the right front, part of the outline of the diaphragm; the 
dotted line, the cardiac area as determined by percussion. This case shows how a large 
aneurism may exist in the chest without giving rise to marked physical signs. 
I have recently seen in consultation a patient who had had excellent 
advice in Boston and New York, as well as elsewhere, and the diag- 
nosis was obscure until my x-ray examination showed an aneurism of 
the aorta. In another case my x-ray examination showed that there 
was no aneurism where it was thought to exist. 18 
WILLIAMS: X-RAYS IN THORACIC DISEASES. 
Fig. 10. 
Fig. ll. 
Figs. 10 (front) and 11 (back) show a smaller aneurism of the aorta. The arrow in Fig. 11 
points to where the pulsation was best seen. WILLIAMS: X-RAYS IX THORACIC DISEASES. 
19 
Let us now consider the position, size, and movement of the heart in 
health as shown by the fluoroscope, before taking up some of the appli- 
cations of the x-ray examinations in cardiac diseases. The best view 
of the heart is obtained during full inspiration, as then the diaphragm 
is so depressed as to expose a much greater part than during quiet 
breathing, and with more air in the lungs the outlines of the heart 
stand out better on account of the greater contrast thus produced. 
On the left side of the sternum the objects seen most clearly are a 
considerable part of the ventricle, including the apex, and the pul- 
monary artery; on the right of the sternum the right auricle, from 
about the second to the fourth rib, and the venae cavae; the right auricle 
and the venae cavae are not so dark as the ventricles, as they are not 
so thick. 
When the space occupied by the lungs is in a normal condition the 
outline of the portion of the heart on the left of the sternum can be 
followed by means of the fluoroscope with more certainty, accuracy, 
and more fully than by percussion. The lower border of the heart near 
the apex is not obtained by percussion, but part of it is seen in the 
fluoroscope during deep inspiration. Also, on the right of the sternum 
the position and size of the right auricle, although it is not distinctly 
outlined, can be better ascertained by the fluoroscope than by other 
means; likewise the right border of the bloodvessels, which are much 
more marked in the fluoroscope than the right auricle; but the right 
border of the ventricle, being behind the sternum in health, is then 
better determined by percussion than by the fluoroscope. 
The position of the heart varies in health in different persons. With 
deep inspiration it moves downward and toward the median line nearly 
an inch. While watching the pulsations of the heart in the fluoro- 
scope I observed that the most marked changes in the outlines were 
not at the apex, but at the left side at the point corresponding to the 
cavity of the ventricle, the maximum pulsation being about where the 
outline of the ventricle crosses the fourth rib. I could see the ventricle 
contract and expand as it emptied and filled. 
The change in the position of the heart, due to conditions outside of 
itself, such as pleurisy with effusion, pneumothorax, emphysema, etc., 
may be seen in the fluoroscope, as already stated, or the change in posi- 
tion due to its own enlargement. We may also recognize, for example, 
enlargement of the ventricles and see a dilated right auricle and pul- 
monary artery, and pulsations in the venae cavse. Differences in size 
may likewise be observed, for instance, the diminution which is found 
in anaemic patients with tuberculosis, or increase in size which takes 
place in hypertrophy or dilatation. The ability to observe such changes 
The Heart. 20 
williams: x-eays in thoeacic diseases. 
as the above enables us to obtain a more accurate knowledge of the 
condition of the heart in disease than has hitherto been possible. 
The so-called apex-beat, which physicians use so much as a point of 
reference in examining the heart, is not the apex-beat in all cases, but 
sometimes an impulse given by the side of the ventricle; the apex of 
the heart is then seen in the fluoroscope to be lower down, usually 
much below the point where the impulse is felt on the wall. 
Calcareous deposits may be seen in some cases, but at present only 
when the disease is unusually well marked. In one of my patients I 
saw a dark area in the aorta, and in portions of the heart contiguous to 
it, which were pushed over to the right of the sternum. The autopsy 
showed that this dark area seen in the fluoroscope was a calcareous 
deposit. 
The fluoroscope assists us to make a differential diagnosis between a 
pericardial effusion and an enlarged heart. Not only are the outlines 
seen to be different in the two cases, but in pericarditis with much effu- 
sion the characteristic pulsations of the heart are not seen. 
In some diseases of the heart its outlines, to the left of the sternum, 
as found by percussion, are not correct. In order to compare the size 
and position of the heart, as obtained by this method and as seen in the 
fluoroscope, I drew on the skin the cardiac outlines found by percussion, 
and directly afterward these outlines as seen in the fluoroscope. I have 
done this in about thirty cases. Both sets of outlines were then traced 
on tracing-cloth, held carefully over the skin, the one in red and the 
other in blue lines. (In other patients I photographed the two sets of 
lines.) Comparison between these lines showed that in some cases the 
outlines obtained by the two methods, namely, by percussion and by the 
fluoroscope, agreed very well; in others the difference was marked. It 
should be stated, however, that although percussion does not indicate in 
some cases the true size and position of the heart, a proper examination 
of this organ with the fluoroscope is difficult to make, needing careful 
adjustment of the x-ray apparatus and experience with a considerable 
number of cases. 
I have used several methods for recording the outlines of the heart seen 
in the fluoroscope; one record is made by means of a flexible, fluorescent 
screen which has a smooth surface like a porcelain slate. The screen is 
placed on the chest of the patient, the room is darkened, and the out- 
line traced with an ordinary lead-pencil. These lines may be afterward 
rubbed out with a moist sponge and the screen used again. Another 
method, alluded to above, and one which allows of a ready comparison 
of results, is to draw the outlines of the organs on the skin by means of 
a special pencil, while looking through the fluoroscope, and then to place 
a piece of tracing-cloth, about a foot square, on the chest, and trace 
upon it the outlines that have been made on the skin. It is well in WILLIAMS: X-RAYS IN THORACIC DISEASES. 
21 
these tracings to include the sternal notch, the nipples, the fourth rib, 
the ensiform cartilage, and the border of the ribs on either side and 
below the latter, as these serve as points of reference and comparison. 
Care must be taken that the tracing-cloth be held smooth and that the 
skin be not moved or stretched. These cloth tracings may be placed 
one over another and readily compared, as, for instance, the abnormal 
with the normal, or the size and shape of the heart in different diseases 
or in different stages of the same disease. 
In the mediastinum new-growths or abscesses may be expected to give 
evidence in the fluoroscope of their presence by displacing the vessels 
and changing the normal outlines of the latter before they are large 
enough to be themselves seen by means of this instrument. 
I wish to point out the advantages that may follow a study of carefully 
made radiographs. I have taken radiographs that indicate, for example, 
adipose tissue, the outlines of muscles, tendons, and arteries in healthy 
persons, both children and adults. Possibly we may by this means obtain 
useful clinical information as to the condition of the arteries in arterio- 
sclerosis before it is recognized in other ways. 
Summary. 
No harmful effects have been received by the patients—more than 
five hundred in number—that I have examined with the x-rays. 
The varying resistance which the different tissues of the body offer to 
the passage of the Rontgen rays depends upon the difference in bulk 
and in chemical composition. 
The difference in permeability of air and wate'r by the x-rays is of 
great importance in thoracic diseases. 
The normal brightness of the chest having been observed in the 
fluoroscope, the departure from the normal in two directions may be 
noted by comparison. First, a given part of the chest may be darker 
than normal on account of the obstruction offered to the passage of the 
rays, which is due to the increase of density that occurs in tuberculosis, 
pneumonia, infarction, oedema, congestion of the lungs, aneurisms, new 
growths, or to fluid in the pleural and pericardial sacs, that occurs in 
pleurisy with effusion and pericarditis with effusion; the distribution, 
location, and amount of this increase in density which the fluoroscope 
shows, assists us in some cases to distinguish between these diseases or 
conditions. Second, a given part of the chest may be brighter than 
normal, because it is more permeable than in health by the rays on ac- 
count of the diminution in density, due in the case of emphysema to 
increase in the amount of air in the lungs, or, in the case of pneumo- 
thorax, to increase in the amount of air entering the thorax and dis- 
placing the lung. 22 
williams: x-rays in thoracic diseases. 
Importance of the diaphragm lines: The normal diaphragm lines on 
both sides of the chest (these include position, excursion, and curve of 
the diaphragm and the clearness with which they are seen) having been 
observed in the fluoroscope, departure from the normal may be noted by 
comparison. In tuberculosis and pneumonia the excursion of the dia- 
phragm is restricted, and restricted on the lower side; in emphysema, 
on the contrary, although the excursion of the diaphragm is restricted, 
it is restricted on the upper side—the diaphragm may go lower down to- 
ward the abdomen—and in pneumothorax on the affected side it has a 
characteristic curve and moves only on its median end. In tuberculosis, 
pneumonia, pleurisy, hydrothorax, empyema, and oedema of the lungs, 
the diaphragm lines, as well as those of the heart, may be wholly or 
partially obliterated, owing to the abnormal density of the lungs in 
their lower portion. In some cases of tuberculosis and pneumonia the 
lessened range of movement of the diaphragm is a more delicate test 
than the diminished brightness of the lungs. The normal outlines of 
the diaphragm may also be changed by an abscess or a new growth 
contiguous to it. 
The fluoroscope gives us better assurance that the lungs are in a 
healthy condition than other methods of physical examination, and, in 
connection with auscultation and percussion, teaches us in disease to 
interpret better the signs found by the older method. 
The fluoroscope gives us earlier evidence of disease in some cases of 
tuberculosis and more accurate information of its extent (this affects the 
prognosis) than can be obtained by the usual physical examination. 
The fluoroscope gives us more accurate information of the extent of 
the disease (this affects the prognosis) in pneumonia and of the duration 
of an abnormal condition of the lungs. 
It shows a displacement of the heart in pleurisy, which is sometimes 
not recognized by other means, and assists us to recognize and estimate 
the amount of fluid in the pleural and pericardial sacs. 
It enables us to recognize or exclude emphysema. 
It enables us to ascertain the cause in some cases of dyspnoea that 
would otherwise be obscure. 
It assists us to recognize oedema of the lungs, pneumothorax, hydro- 
thorax, and pneumohydrothorax. 
It gives us the means of making an earlier and more certain diagnosis 
of some cases of thoracic aneurism than any other method, and enables 
us in certain cases to exclude it where it has been suspected but is not 
present. 
It enables us to outline the heart more accurately and completely 
than has hitherto been possible and to observe certain changes in it; 
and it especially assists us to a more accurate determination of the WILLIAMS: X-RAYS IN THORACIC DISEASES. 
size, movement, and position in disease, and in some cases to observe 
not only the heart as a whole, but the auricle and ventricle separately- 
Further, it enables us to recognize earlier associated conditions, such as 
oedema of the lungs, and assists us to recognize pericardial effusion. 
We may sometimes make a diagnosis by an x-ray examination alone, 
in certain cases of aneurism and emphysema, for example, but it is, as 
a rule, only one method of examination, and its value in assisting us to 
establish a diagnosis varies, of course, in different diseases. The x-ray 
examination should be used in connection with other methods; the 
information derived from it in suitable cases is more definite and accu- 
rate than that obtained from auscultation and percussion. The fluoro- 
scope and the stethoscope aid each other. 
As is the case with all other observations on which a diagnosis is 
founded, the conditions which are revealed by the fluoroscope are only 
to be rightly interpreted after experience in making x-ray examinations 
has enabled the physician to give these observations their proper weight. 
I have had the privilege of studying the physics of the x-rays in the 
Rogers Laboratory of the Massachusetts Institute of Technology, and I 
am under obligation to Professor Charles R. Cross and two of his assist- 
ants, Mr. C. L. Norton and Mr. R. R. Lawrence, for their aid in this 
study. I also desire to express my appreciation of the active interest 
taken by the trustees of the Boston City Hospital in my work, and the 
kindness of my colleagues on the staff for affording me an opportunity 
of examining many of their patients.