TM 8-275 WAR DEPARTMENT TECHNICAL MANUAL MILITARY ROENTGENOLOGY January 26, 1942 TM 8-275 TECHNICAL MANUAL No. 8-275 WAR DEPARTMENT, Washington, January 26, 1942. MILITARY ROENTGENOLOGY Prepared under direction of The Surgeon General Paragraphs Section I. General__ __ 1 11. Procurement and supervision of X-ray equip- ment 2-15 III. Field X-ray equipment 16-26 IV. Foreign body localization 27-34 V. Localization of intraocular foreign bodies 35-40 VI. Roentgen examinations 41-52 VII. Diagnostic aspects 53-56 VMI. Roentgen therapy _ 57-61 IX. Protection against X-radiation hazards 62-70 Pagr Appendix 146 Index 149 Section I Paragraph Purpose and scope 1 GENERAL 1. Purpose and scope.—a. The held of roentgenology is quite a comprehensive specialty, covering as it does the broad scope of medi- cine and various aspects of physiology, pathology, and biophysics. It includes a number of subspecialties, any one of which might easily consume a lifetime of effort. For instance, extremely hard-working scientists are devoting full time to a career in roentgen physics; others are concerned entirely with roentgenography; many doctors are de- voting their practices to diagnostic roentgenology, while others are confining their efforts to roentgenotherapy. h. Today, it would be impossible to compile in one volume even the essentials of each of these subfields. Certain aspects of roentgen physics and roentgenography have been presented in TM 8-240. This manual is merely intended to describe those special responsibilities 431112°—42—1 1 TM 8-275 1-3 MEDICAL DEPARTMENT which are entrusted to the Army roentgenologist and which are addi- tional to the average diagnostical and therapeutic requirements. Section II PROCUREMENT AND SUPERVISION OF X-RAY EQUIPMENT Paragraph General 2 Requisitioning 3 Standard and nonstandard items 4 Expendable and nonexpendable supplies 5 Deteriorating and nondeteriorating supplies 6 Initiating requisition 7 Periodic estimates 8 Handling of property 9 Accounting for consumption of X-ray films 10 Accounting for intensifying screens 11 Accountability and responsibility 12 Property credits 13 Transfer of property 14 Supplies in theater of operations 15 2. General.—The Army radiologist must be acquainted with the normal procedures which pertain to procurement of X-ray equip- ment and materials and, thereafter, their proper handling. With most civilian institutional connections, the radiologist may sense merely a moral responsibility for protection of the equipment in his department. Unless he has actually purchased it. paying from his own resources, it is quite natural that he should consider it the property of the institution and it is quite unlikely that unservice- ability of any part of the apparatus would result in any financial loss to the doctor. Not so in the case of the Army radiologist. Though the equipment belongs to the United States Army, it is necessary that it be entrusted to a responsible individual, an officer. The Army radiologist is therefore held strictly responsible for it. In case proper accounting cannot be made for unserviceabilities or losses, a depreciated value of the equipment may be deducted from the pay of the officer; hence, the importance of his interest in this subject. 3. Requisitioning.—a. A listing must be made of the equipment and materials needed, with request that they be obtained by the medical supply officer. These requests serve to initiate requisitions (see par. 7). b. The listings are compiled according to the character of the items. In general, items are classified its standard or nonstandard. 2 TM 8-275 4 MILITARY ROENTGENOLOGY 4. Standard and nonstandard items.—a. Standard.— (1) All standard items are listed in the Medical Department Supply Catalog. Therein, they are grouped according to classes. The classification has been made on the basis of general purposes or the type of the commodity in the following manner: Class 1: Drugs, chemicals (including X-ray processing chem- icals, laboratory stains, biological products, articles fur- nished by medical supply depots, by Army Medical Center, or by corps area or department laboratories. Class 2: Surgical dressings. Class 3: Surgical instruments, surgical appliances, miscel- laneous diagnostic instruments, and surgical supplies. Class 4: Laboratory equipment and supplies. Class 5: Dental equipment and supplies (including dental film-viewing boxes). Class 6: X-ray equipment and supplies. Class 7: Furniture, physiotherapy equipment, hospital linen and bedding, mess equipment and supplies, cleaning and preserving equipment and supplies, stationery, miscellaneous office equipment and supplies, miscellaneous hospital equip- ment and supplies. Class 8: Veterinary equipment and supplies. Class 9: Field equipment (including field X-ray equipment) and supplies. In addition, the supply catalog contains an appendix wherein ex- planatory information is presented, with the inclusion of photo- graphs. (2) Thus the radiologist is mainly concerned with class 6 or class 9, class 7, and class 1. Class 6 contains a listing of standard X-ray equipment which might be needed for installations such as the and peacetime installations. Class 9 contains a similar listing of equipment which might be needed for installations such as the mobile hospital or the evacuation hospital in the theater of opera- tions. Class 1 contains the processing chemicals needed for either occasion. For the police and maintenance of the clinic itself, furni- ture, cleaning items, stationery and miscellaneous office equipment, linen, etc., are listed under class 7. (3) The listings in the supply catalog include a brief description of the item and one or more symbols which characterize it. These symbols will be found in the second column identified as “Notes” (see fig. 1). The significance of these symbols is as follows: 3 TM 8-275 4 MEDICAL DEPARTMENT *Mt»—Ml 7* MEDICAL DEPARTMENT SUPPLY CATALOG No N'OM I lota Unit Allowance par Prtoa 1.000 3.000 26.000 (4) X.. .. |l. SO 1.00 ADAPTER. BYNARU F«r .x>dooc(1o< un-IrraJ ralbaUr with Low *rrtn»t Each 1 1 e 99090 X.... ADAPTER TURING Male rllp )olol lor alUchin* Low ooodW to nibtwr kiMoc Each . 16 1 9 10 ANUTUUIA APPARATUS. INTRATRACHEAL: Sued mmJ ran Each IE 60 1 (1).. ANESTHESIA APPARATUS. NITROUS OXIDK Oiyyoa. ecrboo dkaMe. and ether with carbon dkoxi-W •boorber Each u i n 1 9 4 ““ JX(0... 1 OD- | ANr.8Tlir.HIA APPARATUS, SAG Per lototo. Karb U' R K R t OD. ANESTHESIA APPARATUS. PRESSURE REOU- LATOR AND OAUOK; Each u o 1 I 2 MO 70 |X(I).. 1 no... 1 ANR8TBKSIA. APPARATUS, RIM FOR FAl'E. 1 MASK Robber Each 1.44 R B R !«<»■ I ANESTHESIA APPARATUS. RIM FOR NASAL, Each. .70 1 CD.. |X(»... | ANESTHESIA APPARATUS. TUBING Rubbw. Each .. ISO R R R 1 «... 1 to (abater. —nafl • (I)-. Each. . ioa os .74 KTBBR TIP: MlOO «- ANESTHESIA AND SUCTION APPARATUS. SUCTION TIP Each ... IOC R R R 11 80 SO X EM OB Min X «.. ATOMIZER BET, BOTTLE (Abo r»t*lcoeoMOl to 0410] Each R R B 80 BO SO Mice X (1) BAO. POUTSKR 6m. with rmlra. MITO «... BALKAN BRAKE. Compton P*A 11 3D UUA. IM4. Kaob IS 71 1 4 » M17A X BALKAN FRAME. BAG. BUCKSHOT. 4-INCB By Adaob. Uoeb opaotar sum. *01 bold 1 lb. Each *09 R E R Ml 77 X BALKAN FRAME. BAG, BUCKSHOT. 4-INCH Bp Moeb. |-laob opaotag. nan* a*. wOJ hold 6 lbs. Saab .n E R R Ml 70 X BALKAN FRAME. BAG. BUCKSHOT. S-INCH By B4noto. 4o» duck, with handle, opao mootb. far bold lac boabahoi ban. Kaob *M R R R Clam 3.—Surgical Appliance*, KJuecUantcui LHagnotltc InalrumenU, and Surgical Supplia* Fiockk 1. 4 TM 8-273 4-5 MILITARY ROENTGENOLOGY Symbol Significance X Expendable. No mark or a series of eight dots. Nonexpendable. $ Expensive items. (1) Deteriorating. (2) Refer to appendix for description of item, formula, contents of case, etc. (3) Requisition should state manufacturer, type, description, size, and serial number of item or part required. (4) Requisition should state voltage, current, d-c or a-c (if a-c, cycle and phase), or kind of gas, steam, etc. (5) Item will not be issued to hospital smaller than 50 beds. (“SG”) Under allowances, indicates that prior authority must be obtained from The Surgeon General to requisition. The necessity of such items will be clearly stated. (c) Controlled items. Request for the disposition of such items should state classifi- cation under paragraph 5, AR 35-6640, date of receipt and source, manufacturer, model, serial number, nature and manner of unserviceability, or the estimated cost of repair. (4) Standard items are stocked in general depots and issued to the various hospital installations when requisitioned and, if it is deemed proper by the office of The Surgeon General that the par- ticular installation be allocated, either the type or the quantity re- quested. Approximately 90 percent of the items used by the Medical Department are standard items. (5) Replacement and spare parts for standard items are not usually listed in the Medical Department Supply Catalog and should be secured on quarterly nonstandard or emergency nonstandard requi- sitions in the manner directed by AK 40—1705 and current circular letters issued from the medical supply office. (See figs. 7 and 8.) h. Nonstandard.—Items which are not listed in the supply catalog but which might be needed for particular purposes are called non- standard items. They are not ordinarily carried in stock but are obtained either by local purchase (if local funds are available) or by requisition on a general depot. (See figs. 8 and 9.) 5. Expendable and nonexpendable supplies.—Medical sup- plies are further classified for stock record accounting as expendable and nonexpendable. a. Expendable items include those items which are to be consumed in service. As listed in the supply catalog, they are identified by the letter “X.” It is usually taken for granted that they will be used within 12 months from the time of their being issued. X-ray films, stationery, chemicals, cleaning materials, lubricants, etc., are examples of expendable items. Records of these items are not ordi- narily required by stock record cards (that is, in the files of the medi- 5 TM 8-275 5-7 MEDICAL DEPARTMENT cal supply officer) though the radiologist must bear responsibility for waste or loss of them. h. Nonexpendable items include those items which are not con- sumed by use and which, due to their cost and length of life in service, must be accounted for on the stock record account of the medical supply officer. As listed in the supply catalog, they are identified by not having the letter “X” in the “Notes/’ The radi- ologist must be able to account for all such items which have been entrusted to him, in accordance with the listings on individual memo- randum receipts or consolidated memorandum receipts compiled by the medical supply officer (see par. 9). 6. Deteriorating and nondeteriorating supplies. Both ex- pendable and nonexpendable items are further classified as deteriorat- ing or nondeteriorating. a. A deteriorating item is one which, whether used or not. might be expected to become unserviceable within a period of 1 to 2 years after being issued. X-ray films and printing paper are examples of expendable deteriorating items, while lead aprons and lead gloves are examples of nonexpendable deteriorating items. h. A nondeteriorating item is one which can reasonably be expected to be serviceable for a period of time longer than 2 years. Most of the items in the Medical Supply Catalog are nondeteriorating. 7. Initiating requisition.—a. The official form, W. I)., Q. M. C. Form No. 400 (Requisition), is used by the medical supply officer for compiling the actual requisition. The radiologist directs his requests for supplies to the medical supply officer by means of issue slips or memoranda which serve to initiate the actual requisitioning. All of these forms identify standard versus nonstandard supplies; the char- acter of either in terms of expendable, nonexpendable, deteriorating, or nondeteriorating items; and the character of the request or requi- sition with respect to the period of the fiscal year covered. h. To indicate these purposes, the following forms may be used by the radiologist: (1) W. D., M. D. Form 16a (Issue Slip, Expendable Medical Prop- erty) (white), Medical Department, is actually an issue slip but it provides for requesting expendable items which are ordinarily con- sumed from week to week—items such as listed in figure 2. (2) W. D., M. D. Form 16b (Issue Slip, Nonexpendable Medical Property) (blue), Medical Department, is also an issue slip but it is actually used as a request for nonexpendable items included in stock supplies in the local warehouse of the medical supply officer. (See fig. 3.) 6 TM 8-275 7 MILITARY ROENTGENOLOGY Form 16a Medical Department, U. 8. Army (Revised April 21, 1030) ISSUE SLIP EXPENDABLE MEDICAL PROPERTY To the Medical Supply Officer: Please issue the following for use in A.Y..CJLANJLCL. ITEM No. Quantities ARTICLES UNIT On hand Re- quired 60050 BRUSH, CAMEL HAIR EA 0 1 60330 HOLDER, FILM EXPOSURE, 8 IN. EA 4 8 61120 OIL,TRANSFORMER GAL 0 5 I certify that I have personally verified the quantities on hand, that the amounts shown are correct, and that the quantity requested is necessary to meet actual re- quirements. \ s~\ /'\ /Till 1 V aLaa —■» H.R. JAN BLARICON.2ND LTs'vM.'A’iC. Issue articles and auantities, as altered: mXZL F-R. W1NTKER.1ST LT. Received: wesley/moore,st.sgt. Date AUGUSJ...4.,...154.1 ,MED, wWf. t—MOX Figure 2. 7 TM 8-275 7 MEDICAL DEPARTMENT Form 16 t> Medu ai. Department, V. 8. Army (Authorize* J»n 21, 1016) • ISSUE SLIP NONEXPENDABLE MEDICAL PROPERTY To tiik Mkdicai. Supply Officer: Please issue the fnllowiiiK for use in . X BAY CLINIC AltTICI.KS Quantities 60090 CASSETTE, 8 X 10 INS. WITH 2 INTENSIFYING SCREENS EACH 10 61660 TANK, 4 1/2 INCHIBY 14 3/4 X 20 INCHES, EACH 2 ROE , CART . M, COfficer in Charge. Issue articles and quantities, as altered: < Supply Ogicer. Received: • G.D.DOE , PVT. Wardmaeter, MAY 45v 4941 — ORIGINAL Figure 3. 8 TM 8-275 7 MILITARY ROENTGENOLOGY (3) Standard deteriorating items are requested quarterly in time for the medical supply officer to requisition them March 1, June 1, September 1. and December 1. These are items which are not ordi- narily carried in the stock of the medical supply officer. (See fig. 4.) (4) Twice yearly, an estimate is developed as to needs of standard items not contained in the supply of the local medical supply officer. These items are of a relatively inexpensive character (therefore not captioned “SG” in their listing in the medical supply catalog). This estimate is developed by way of a memorandum which must reach the ARMY MEDICAL SCHOOL ARMY MEDICAL CENTER Department of Roentgenology WASHINGTON. D. C. MAY 15, 1941. MEMO TO: THE MEDICAL SUPPLY OFFICER, POST. 1. IN COMPLIANCE WITH YOUR MEMORANDUM NO. 22, DATED MAY 9, 1941, THE FOLLOWING ESTIMATE FOR SUPPLIES IS HEREBY SUBMITTED: A. STANDARD QUARTERLY DETERIORATING SUPPLIES FOR THE PERIOD REQUESTED 60020 APRON, LEAD: IMPREGNATED RUBBER, 24 BY 33 INCHES. EACH 2 60300 GLOVES, OPAQUE, PROTECTIVE PAIR 2 |C()3k Z' John k. roe, cart., m.c. DIRECTOR. jr/hv Figure 4.—Quarterly request for standard deteriorating supplies local medical supply officer prior to March 1 or September 1. (See % 5-) (5) Twice yearly, an estimate must be developed, listing the more expensive (nonexpendable) items which require the authority of The Surgeon General for their purchase and issue. This estimate is com- piled on a memorandum to the local medical supply officer and must reach him prior to April 1 or August 1. (See fig. 6.) (6) In case an item is desperately needed because of an unexpected requirement or sudden breakdown of equipment, an emergency request may be initiated. This may be submitted at any time on a memoran- dum to the local medical supply officer. (See fig. T.) This type of request should be avoided as much as possible since it requires special provisions as to funds, etc. 9 TM 8-275 7 MEDICAL DEPARTMENT c. Nonstandard items may be obtained by— (1) Listing such items on a memorandum described as “Quarterly Nonstandard Medical and Dental Supplies.” This estimate should ARMY MEDICAL SCHOOL ARMY MEDICAL CENTER Department of Roentgenology WASHINGTON. D. C. FEB. 16, 194-1. MEMO to: THE MEDICAL SUPPLY OFFICER, POST. 1. IN COMPLIANCE WITH YOUR MEMORANDUM NO. 22, DATED FEBRUARY 9, 1941, THE FOLLOWING ESTIMATE FOR SUPPLIES IS HEREBY SUBMITTED: A. STANDARD SUPPLIES, SEMI ANNUAL. ITEM NO. ITEM UNIT AND AMOUNT 60079 CALIPER, RULE TYPE EACH 1 60200 FILTER, 1 MM. THICK EACH 8 60310 GOGGLES, OPERATORS PAIR 3 60400 ILLUMINATOR, RADIOGRAPHIC EACH 2 60490 LIGHT, SAFE: DARK ROOM EACH 8 61675 TANK, DEVELOPING; 3 COMPARTMENT, WITH INTAKE, OVERFLOW AND OUTLET FITTINGS. EACH 1 61677 TANK, DEVELOPING BASE; MOUNTED ON CAST IRON LEGS. EACH 1 A. A. DE L0R>MIER, MAJOR, MEDICAL CORPS, DIRECTOR, DEPARTMENT OF ROENTGENOLOGY. AAD/HRV Figure 5.—Semiannual request for standard nondeteriorating supplies, be in the hands of the medical supply officer prior to March 1, June 1, September 1, or December 1. (See fig. 8.) (2) If local funds are available, nonstandard items may be pur- chased by a local purchase order, in which case a request is sub- mitted to the medical supply officer. (See fig. 9.) d. All correspondence of this character is conducted directly be- tween the X-ray department and the medical supply officer. The commanding officer of the hospital or medical installation later 10 TM 8-275 7-9 MILITARY ROENTGENOLOGY reviews all requests and requisitions as compiled by the medical supply officer. 8. Periodic estimates.—The local supply officer must anticipate the needs for the hospital as a whole and he may request estimates as to requirements of standard and nonstandard equipment for a stated future period. Such estimates are usually made out infor- mally. They are most likely to cover deteriorating items. ARMY MEDICAL SCHOOL ARMY MEDICAL CENTER Department of Roentgenology WASHINGTON, D. C. MARCH 15, 1941. MEMO to: the medical supply officer, post 1. IN COMPLIANCE WITH YOUR MEMORANDUM, DATED MARCH 9, 1941, THE FOLLOWING ESTIMATE FOR S G ITEMS IS HEREBY SUBMITTED: 60890 MACHINE, X RAY, STATIONARY, COMPLETE: TO OPERATE ON 220 VOLTS, A.C., SINGLE PHASE, 60 CYCLE CURRENT. SET 1 61360 STEREOSCOPE, COMPLETE EACH 1 A. A. DE LORIM*IER, MAJOR, MEDICAL CORPS, AAD/HRV DIRECTOR, DEPARTMENT OF ROENTGENOLOGY. Figure 6.—Semiannual request (or expensive nonexpendable items (requiring special authority of The Surgeon General). 9. Handling1 of property.—a. The actual professional duties of the radiologist are usually so extensive that it is not possible for him personally to attend to all the details for which he is responsible. Ordinarily, the writing of requisitions, the coordinating with the local supply officer, and the keeping of departmental stock records are duties which are delegated to a trustworthy sergeant or to some other one of the enlisted personnel. However, this does not relieve the officer of his responsibility. When property is issued, the medi- cal supply officer receives for it a memorandum receipt signed by the receiving and responsible officer. A duplicate copy of this mem- orandum receipt is kept on file in the department. (See fig. 10.) 11 TM 8-275 9-10 MEDICAL DEPARTMENT b. As property is issued from time to time, a number of these receipts are accumulated. At intervals, there may be developed a compiled memorandum receipt. Either the separate listings or the compiled record should be used for interval checking of the property. Paragraph 19«(2), AR 35-6520, as amended by section III. Circular No. 30, W. D.. A. G. O., February 20, 1941, states that inventory of property will be made by the “responsible officers annually, or more ARMY MEDICAL SCHOOL ARMY MEDICAL CENTER Department of Roentgenology WASHINGTON. D. C. JULY 4, 1941. MEMO TO: THE MEDICAL SUPPLY OFFICER, POST. SUBJECT: EMERGENCY REQUISITION FOR MEDICAL SUPPLIES. 1. REQUEST THAT THIS DEPARTMENT BE FURNISHED WITH THE FOLLOWING NEEDED EQUIPMENT; GLASS LEAD, FOR USE AS PROTECTIVE COVERING FOR FLUOROSCOPIC SCREEN. SIZE*. 14 X 17 INCHES, SELECTED QUALITY, APPROXIMATE COST! $20.00. 2. THIS ITEM, GLASS LEAD, IS URGENTLY NEEDED TO REPLACE PRESENT GLASS ON OUR FLUOROSCOPIC UNIT WHICH IS CRACKED AND PERMITS THE PASSAGE OF X RADIATION TO THE RADIOLOGIST. A. A. DE LOR^MIER, MAJOR, MEDICAL CORPS, AAD/HRV DIRECTOR, DEPARTMENT OF ROENTGENOLOGY. Figure 7.—Emergency requisition. often if the commanding officer requires it.'- Usually the local com- manding officer requires that these inventories be accomplished each month. Each nonexpendable item should actually be seen. In the case of expendable items, the number on hand should be subtracted from a quantity received during the month and thereby the consump- tion analyzed. 10. Accounting for consumption of X-ray films.—a. Illegal sales have been made of all types of Government property but in particular “consumption” of X-ray films must be watched. It is ad- visable that films be stored within a locked cabinet or a locked room 12 TM 8-275 MILITARY ROENTGENOLOGY and that the key to such be held by one person in the department. A tabulated record of quantities received versus quantities removed from this storage should be posted within this cabinet or room. This record should include the date, the film size, and the quantity ARMY MEDICAL SCHOOL ARMY MEDICAL CENTER Department or ROENTCENOLOr.V WASHINGTON O C FEB. 14-, 194-1 , MEMORANDUM TO; THE PROPERTY OFFICER, ARMY MEDICAL SCHOOL, THRU: THE DIRECTOR, ARMY MEDICAL SCHOOL, POST. SUBJECT: ESTIMATE FOR QUARTERLY NON STANDARD SUPPLIES. 1. IN COMPLIANCE WITH YOUR MEMORANDUM DATED FEBRUARY 8, 1941, THE FOLLOWING ESTIMATE FOR NON STANDARD MEDICAL AND DENTAL SUPPLIES IS HEREBY SUBMITTED: CAT.NO. ITEM UNIT AMT. PRICE 4897 SOLDERLESS LUGS NO. 4 TO NO. 8 EA. 100 $ 5.23 6202 HACK SAW BLADES, 10 INCH, 24 TEETH EA. 144 6.00 TOTAL $ 11.23 ABOVE ITEMS CAN BE PURCHASED FROM, AMERICAN ELECTRICAL SUPPLY CO., 329 WEST MADISON STREET, CHICAGO, ILLINOIS. 130 SET OF EIGHT TURNING TOOLS EA. 1 $ 7.50 ABOVE ITEMS CAN BE PURCHASED FROM, DELTA MANUFACTURING CO., MILWAUKEE, WISCONSIN. V£—. S30HN ROE, CAPT., M.C. JR/HV DIRECTOR. Figure 8.—Quarterly nonstandard requisition. concerned with each increment or issue, together with the initials of the individual concerned. This record need not be elaborate but it should be complete. h. In larger X-ray clinics, besides keeping a record of all films received and all films issued, it is advisable that each roentgeno- graphic technician and also those concerned with processing in the 13 TM 8-275 i n MEDICAL DEPARTMENT darkroom be required to report the total number of films used or handled each day or each week, as well as the number of films wasted. Pur. Ordor No. ARMT MEDICAL CENTER medical department photbssional service schools, Washington, D. C. MAY 15, 1941. MEMORANDUM TO: The Medical Supply Officer, Post. 1. Request that the articles listed below he furnished for use in DEPARTMENT: DEPARTMENT OF ROENTGENOLOGY DIVISION: RESEARCH AND TESTING tal _ „ Item: Unit: Quantity Cost: Cat. Bo. - "■ ' 1 SINGLE EMULSION FILMS EXPERIMENTAL FOR PHOTOROENTGENOGRAPHY, SIZE: 4X10 INCHES. DOZ. 12 $ 11.48 ’THESE FILMS CAN BE PURCHASED FROM: THE SUPER SPEED FILM CO., 149 W. MOORE STREET, GAS CITY, INDIANA. CHARGE TO: SPWCIAI FUND Mf>. AUftft ; PROJECT. RESEARCH I CERTITT that the above-named non-standard items are needed in the Army Medical School, that there are no suitable substitutes on the standard Medical Supply Table, and same is not available at the Army Medical School. Qtfrtwi Hnief of Division: JOHN ROE, CAPT., MC, DIRECTOR. APPROVED: TOR THE ASSISTANT COMMANDANT: DON LONGTELLOW. Major. Medical Corps APPROVED: RALPH W. TRENCH. Major. SN-Coms. Property Officer. Figure 9.—Purchase order. This system provides for checking the reports of the individual roentgenographic technicians with the summation report by the technician or technicians in the processing room, and both reports 14 TM 8-275 10-11 MILITARY ROENTGENOLOGY with the records contained in the film cabinet or film storage room. Usually, the psychological effect of such a system will counteract any inclination toward “bootlegging” of X-ray films. MEMORANDUM RECEIPT XOSSCXX * debit sup •JWX#XK»)i x RAY CL1N1C PlareARMY MED.SCHOOlDate MAY 1 5-* 19 -4.1 MEDICAL Property (Name at supply branch) NO 10 STOCK NO ANTIQUES 6009Q CASSETTE, 8 X 10 INCH, WITH 2 INTENSIFYING SCREENS. — — Recelv No. .. O. M. lUvtMC cd the articles. j LI (Hlgnaturs with rack and organisation) JOHN ROE, CART., M. C. OFFICE*. Korm 487 Mayl4.ini *8(rlk4 out words Dot applicable. O oro 11. Accounting for intensifying screens.—There is a similar temptation for certain people to enter into illegal sales of intensify- ing screens. These screens are very expensive. They can easily be Figure 10. 15 TM 8-275 11-13 MEDICAL DEPARTMENT removed from cassettes and second-hand screens, or blank cardboards may be used as substitutions. Because of such practices, it is advis- able to identify each screen with the words ‘‘Property of the United States Government.” This description might be written with indel- ible ink along a margin of the screen whereby the wording will not be reproduced onto useful portions of the roentgenograms. If these captionings are accomplished in the handwriting of the radiologist, there will be provided a challenge in case screens are found in the department which do not bear his handwriting or that of his predecessor. 12. Accountability and responsibility,—An accountable offi- cer is one who conducts a stock record account and who must be in position at all times to account for all items charged against the entire hospital installation or post. This officer is responsible for property storage, issuing, and accounting, and the maintenance of rec- ords, files, and inventories. He is the medical supply officer. In contradistinction, a responsible officer is an officer to whom Govern- ment property has been entrusted. Usually, there is one officer in each department responsible for its property. He is responsible for all properties which have been issued to him by memorandum re- ceipts. The radiologist is ordinarily one of the property “responsible officers.” 13. Property credits.- a. Several conditions might arise wherein responsibility for certain items should not be incurred or continued. For instance, supplies might be unserviceable because of damage when received in the department; deteriorating items might become unserv- iceable through “fair wear and tear”; nonexpendable (standard or nonstandard) items might become unserviceable through “fair wear and tear”; property might be damaged, destroyed, or might disappear through no fault or neglect of the personnel of the department (or the same may happen because of carelessness or even willful intent). As long as an item is listed on a memorandum receipt, responsibility for it continues whether it is serviceable or not. If an inspecting officer discovers that an item or items are unserviceable or missing, the radiologist may be ordered to explain these discrepancies or to pay for them. Moreover, even though unserviceable, all items listed on memorandum receipts are charged against the department; these rec- ords may interfere with the obtaining of very much needed equipment. Therefore, credits should be obtained promptly for all useless charges. h. If property is damaged when received by the department, the medical supply officer should immediately be notified. This measure instigates development of an “over, short, and damaged” report by 16 TM 8-275 13 MILITARY ROENTGENOLOGY the medical supply officer. The item is charged against the department pending the outcome of the “O., S., and D.” report. Usually, the item is eventually returned to the medical supply officer and adjust- ments of the records are made or the item is replaced or repaired. c. When a nonexpendable item becomes unserviceable “through fair wear and tear in military service,” credit may be obtained. W. I)., M. D. Form 16c (Credit Slip—Nonexpendable Medical Property) Form 16 0 Medical Department. U. S. Armi (Authorized Jan. 21, 1916.) • CREDIT SLIP NONEXPENDABLE MEDICAL PROPERTY To THE Property Officer; The following articles no longer needed are turned in from..l!——.C.U..N..L5 ♦ A AA C_ rr*—fwrg =rr ARTICLE* QuAMMTlC* 61305 SCREEN, INTENSIFYING BACK, 14 INCH, BY 1? INCHES. 1 THIS ITEM HAS BECOME UNSfi ABLE THRU FAIR WEAR AND TEAP MILITARY SERVICE, THRU THE F NO ONE CONCERNED. LENGTH OF SERVICE: 8 YE/ QA^~ JOHN ROE, CAPT., M. C. OFFICER IN CHARGE. RVICE 1 IN THE AULT OF RS. <■ . JOHN' ROE. CAPT... M. IJK,n CW!,< -gJL l| vti ARTHUR. ML 1 OF . CAPT. Received into storage^ K. t: SHOOK, SGT. Rate UAV 1 K - 1QA1 Ed. J»n. ORIGINAL 1—»•*$ Figure 11. 431112° 42 —2 17 TM 8-275 13-14 MEDICAL DEPARTMENT (pink), should be used, listing the item number, description or nomen- clature of the item, the unit, and quantity of the item or items being returned. This slip must be signed by the responsible officer. It must include a statement to the effect that “I certify that the articles of medical supply property listed hereon have become unserviceable through fair wear and tear in the military service through no fault or neglect of anyone concerned.” If the item or items are controlled (identified by the symbol “C” in the “Notes” column of the supply catalog), this credit slip must contain all information described in paragraph 4a(3) (that is, classification under par. 5, AR 35-6640. date of receipt and source, manufacturer, model, serial number, etc.). d. The above procedure is also followed in the case of deteriorat- ing items. e. When property is (willfully or accidentally) damaged, de- stroyed, or disappears through the faidt of the department personnel, the radiologist must institute a survey, W. D., A. G. O. Form No. 16 (Report of Survey), together with affidavits, signed by a notary public or the adjutant, containing statements and all pertinent facts relative to the item or items being surveyed. These data are sub- mitted to the medical supply officer. A survey officer then takes action regarding final disposition of the charge. If the survey is approved, the radiologist is relieved of responsibility and given credit for the item or items (note that affidavits are needed here while not necessary on a W. D., I. G. D. Form No. 1 (Inventory and Inspection Report) instituted by a medical supply officer). /. The same procedure must be followed in order to receive credit for items which become unserviceable or disappear (because of theft or fire) through no fault or neglect of the personnel of the depart- ment, though in such cases no charges are included against enlisted personnel or other parties. g. Upon receipt of credit requests covering unserviceable proper- ties, the medical supply officer may institute a W. I).. I. G. D. Form No, 1. (See AR 20-35.) 14. Transfer of property, a. It is customary for officers in the service to be transferred after a certain length of time. Therefore, it is necessary to transfer the responsibilities for the property of a department. The following is the ordinary procedure. The officer assuming responsibility for the property obtains from the medical supply officer a list of property which is charged against the depart- ment (as listed on the memorandum receipts). After checking this list and identifying each item in the department, the officer (the new officer) advises the medical supply officer, in writing, of all 18 REPORT OF SURVEY UFD1 CAL TH..W.H, ARMY MEDICAL CENTER, WASH 1 NOTON, D. C., (Class 0f pr i.ccounta d party, ordnance, etc j ‘ ' (Stock record account and station) blo officer HENRY ZOE , CAPT. , MAC „ Date ,^Y 15,..1?*1.. STOCK NO. ARTICLES ■ QUANTITY TOTAL COST • DISPOSITION • Destroy Saitaoe Othi 50090 APRON, LEAD, IMPREGNATED RUBBER. 2* X 33 INCHES 1 Grand total * $ 13.3A % 13.34 DATE AND CIRCUMSTANCES • OH APRIL 2ND. 19*1, A FIELD TRIP WAS MADE TO CARLISLE BARRACKS, PENNSYLVANIA. NUMEROUS ITEMS CONCERNED WITH ROENTGENOGRAPHY WERE TAKEN ALONG TO BE USED IN DEMONSTRATIONS. PART OF THIS EQUIPMENT WAS THREE .3. LEAD RUBBER APRONS. UPON RETURN TO THIS STATION FROM THE TRIP ONLY TWO .2. OF THE APRONS COULD BE LOCATED. CORRESPONDENCE WITH THE C.O. AT CARLISLE, REVEALED THAT THE APRON HAD NOT BEEN LEFT THERE. A THOROUGH SEARCH HERE HAS ~ ..... ... ... . .......Tio . . .TU » nrfWAUPian 1 TV/ PCI CACC AFFIDAVIT I do solemnly swear (<5SS44lfcJI that the articles of public property shown above TtUTOWWITOItl T ■ CEBTIFICAT I rxrnri that lbs toss. ntjrvr E • . — —* w at caused lK®|( mm nAniw flUl W VG 8u beat bod fore me atA this lA 1 ’4-^ a lAfn nr dt \J ROE , J CART ■. , ».C-. IS) tifir Vpu&«(Ar 9 and sworn to (or affirmed) be- RMY MED* CENTER, mY. .. ...19. 4.1 (Or«M ami ore . am kid Lab U or rwpocuibto offloor Hq Station Date To who la appointed surveying officer. By order of — T. G. HESTER, ATxJUTANT, MAJOR, M. A. C. Property Voucher No (Otad» sad omanJsaiion or Uli», 1/ ooimrj pubUe. tffli Ml) A4)uUfd. WA* O. O. POl lit No* U a—loAsl July I&. I8U Figure 12. 431112°—42 (Face p. 18) TM 8-275 14-16 MILITARY ROENTGENOLOGY overages and shortages. The medical supply officer then advises the responsible officer (the officer to be relieved) of the overages and shortages which can be adjusted. Those items which cannot be ad- justed are then listed on a report of survey such as shown in figure 12. This report is made out by the responsible officer (the officer to be relieved) in accordance with paragraph. 8, AK 35-6640. h. When the new officer assumes responsibility for the property, be is furnished a memorandum receipt, listing all property charged against the department and which he has found and accepted. This is a compiled memorandum receipt. The original copy of it is signed by the new officer and returned to the medical supply officer. A duplicate copy is retained in the department. The transfer is then complete. 15. Supplies in theater of operations.—When engaged with activities in the theater of operations, being confronted with actual combat, the distribution and handling of supplies must be greatly simplified. However, the same degree of responsibility as described above should be exercised. For detailed description concerning administration of supplies in the field, see paragraph 34, FM 8-10. Section III FIELD X-RAY EQUIPMENT Paragraph General — Supply catalog listings H Film chest 18 Film loading bin, dryer, and loading bench combination 19 Gasoline generator 20 Portable grid unit : 21 X-ray machine unit 22 Mobile chassis unit Film-processing unit 24 X-ray table unit 2o Darkroom tent 26 16. General.—a. For the theater of operations, the designing of X-ray equipment has been governed by at least three axiomatic principles: (1) Versatility of adaptation to the extent that eacli piece of equip- ment may function not merely for a single purpose but for several requirements and installations. (2) Portability to the extent that disassemblage of each item can be easily accomplished and that the component parts can be easily car- ried, the weight of any one part not exceeding 200 pounds. 19 TM 8-275 16-17 MEDICAL DEPARTMENT (3) Practicability of design to the extent that the equipment can serve the requirements of function in peacetime installations as well as in the zones of combat. b. Relative to this last principle, this equipment should be thor- oughly understood by those who are to use it under occasions of combat, A thorough acquaintanceship as to handling it can best be obtained by using it day after day for ordinary routine activities. Moreover, it is reasonable that usage of this equipment in time of peace might lead to improvements in its design, from time to time, so that it will not be necessary on mobilization day suddenly to develop new designs in order to incorporate new principles which may be discovered. This last policy provides for two further attributes: (1) A war reserve stock of supplies whereby, in case of a sudden emergency, equipment will be available for moving into the field without awaiting supply from manufacturers, (2) On the basis of expected more or less steady purchasing, the manufacturers will be informed as to just what the Army would need in larger quantities on mobilization day. so that they will therefore have set up the necessary jigs, dies, and other tools for large-scale uniform constructions. 17. Supply catalog1 listings.—Following these plannings, nine items have been developed for X-ray service. These nine items are included under the general item No. 96010 which consists of com- ponent units, captioned as follows: Item No. 96025, X-ray Field Unit, Chest, Film, X-ray; com- plete with lead lining. Item No. 96055, X-ray Field Unit, Dryer and Loading Bin Combination; complete with air circulator, for field proc- essing unit. Item No. 96060, X-ray Field Unit, Generator, Gasoline, Elec- trical ; complete in chest. Item No. 96070, X-ray Field Unit, Portable Grid; for use with Item No. 96145. Item No. 96085, X-ray Field Unit Machine, for field fluoro- scopy, roentgenography, and superficial roentgenotherapy, complete in chest. Item No. 96090, X-ray Field Unit, Mobile X-ray Chassis; for converting item No. 96085 into a mobile unit for ward usage. Item No. 96115, X-ray Field Unit, Processing Unit for Dark- room ; for film processing. 20 TM 8-275 17-19 MILITARY ROENTGENOLOGY Item No. 96145, X-ray Field Unit, Table Unit; for field fluoroscopy, foreign body localization, and roentgenography, complete in chest. Item No. 96175, X-ray Field Unit, Tent, Darkroom; for fluoroscopy and/or film processing. 18. Film chest.—a. Item No. 96025 is simply a standard Medical Department field chest containing an inner lining of sheet lead. The sheet lead is of such thickness (approximately 1.5 mm) that, with the capacity of the chest itself, there is provided protection against X-rays having a quality such as produced with kilovoltages as great as 100. Since it is anticipated that most of the film proc- essing will be done within the tent (item No. 96175), which is non- protective against X-radiation, it is important that all reserve films be kept in this chest. The usual wall protection afforded by a properly constructed darkroom likely would not be available. h. This special chest is for use particularly at the evacuation hos- pital and for those occasional times when films would be wanted for use in a truck at the mobile surgical hospital. It is not recom- mended for the shipment of cassettes, cardboard holders, or film preservers. These should be packed in the ordinary Medical De- partment chests. The additional weight of the lead lining contained in the special chest is unnecessary and would be undesirable. 19. Film loading bin, dryer, and loading bench combina- tion.—Item No. 96055 is intended for evacuation hospitals, general hospitals, and station hospitals. Occasionally it may be needed for use in a truck. It is easily portable, being composed of two com- partments. The upper compartment is completely lead-lined so as to afford protection against X-radiation. It consists of two sections: a film storage section occupying the right half, and a loaded cassette section occupying the left half. Racks have been provided in each of these two sections to accommodate the three standard dimensions of X-ray films as used by the United States Army: 8- by 10-inch, 10- by 12-inch, and 14- by 17-inch films. The lower compartment of the unit contains a drawer type of drying rack, a heater, fan, and a floor loading shelf. The drying rack has accommodations for 18 films (as suspended on standard film hangers). After mount- ing the upper compartment (the film and cassette loading bins) onto the lower compartment (the dryer), there is provided a loading bench. The fixation of these two compartments is accomplished by means of a spring type of lock which will be found on the inside of the base compartment and beneath its top. This lock must be 21 TM 8-275 19-20 MEDICAL DEPARTMENT disengaged before attempting to disassemble this unit in case of having to move it to a new installation. These construction features are indicated in figures 13 and 14. LOADED CASSETTES FILM DO MOT OPEN IN WHITE LIGHT Film and cassette loading bin. ® Dryer. FKJUUE ]o. 20. Gasoline generator.—a. Item No. 96060 is a specially de- signed gasoline electrical generator. It is intended particularly for use with the mobile surgical hospital and for emergency needs at other hospital installations. Its functioning capacity is such as to permit the delivery of 2,500 watts at unity power factor. No 22 TM 8-275 20 MILITARY ROENTGENOLOGY small, portable electrical generator other than that with the iden- tification “Item 96060” should be used to operate the X-ray machine. When the capacity load of a generator is taxed, there ordinarily results a slowing down in the speed of its action. With a sudden release of the load, as intermittently occurs during fluoro- scopy. the engine is likely to “race” unless its governor control is adequate. Since X-ray machines function by way of tAvo main Pffil'EB 14.—Unit assembled as loading bench. avenues of circuits (the autotransformer and the main transformer circuits as one avenue of load, and the filament* transformer circuit as a parallel avenue of load), when the load of one avenue is released, the load of the other avenue is likely to be increased. Extensive testings have proved that with certain types of portable gasoline electrical generators the governor action is so inadequate in this respect that with release of the main X-ray load there results an overload upon the filament of the X-ray tube, and the filament is 28 TM 8-275 20-21 MEDICAL DEPARTMENT soon destroyed. The caption “Item 96060” lias been applied to gen- erators which have been tested at the Army Medical School and which have been found satisfactory in this respect. The requirement of immediate response to the governor is only one of the prerequisites. It is a most important one, however. Other performance charac- teristics required include— (1) Surge voltage. (2) Inverse voltage. (3) Distortion of wave form. h. These characteristics are especially important because of utiliz- ing self-rectification and because of having the X-ray tube detached from the high-tension transformer with connections by way of shock- proof cables. When operating with the X-ray machine unit, the surge or inverse voltage must not exceed the useful voltage by more than 15 kvp with the useful kvp of 85 and a milliamperage of 25. The kilovoltage calibrations of the prereading voltmeter have been made on the basis of the wave form of the average community line. With great variation in wave form performance for the same auto- transformer settings, the resultant peak kilovoltages may be high or low in relation to the calibrated values, depending upon whether the wave form of the current supplied more closely simulates a pure sine wave or whether it is further distorted from it as compared with that of a community line. c. The instructions pertaining to fuel, lubrication, and general care of this item will be found on the inside of the lid of its special chest. These should be followed closely. 21. Portable grid unit.—Item No. 96070 has been designed par- ticularly for use in the emergency receiving ward of the evacuation hospital or of the general hospital. It is a wafer type of grid sup- ported in an adjustable housing. This housing is adaptable to the horizontal member of the table. A patient can be carried in on a litter and the litter placed upon the table ends so that roentgenog- raphy can be accomplished without moving or disturbing the pa- tient. The wafer grid itself can be removed and used in immediate contact with the cassette at the bedside. When the entire unit is used with the table’(see fig, 20), both, the grid and the cassette (con- tained in a standard cassette tray immediately beneath the grid) can be adjusted to one or another level, depending upon the degree of sag in one or another portion of the litter. It is advisable to raise the grid and film until it rests just beneath the sag of the litter. The wafer grid is contained in a frame 17 inches square. It can be slid into position so that the lead strips of the grid are directed 24 TM 8-275 21 MILITARY ROENTGENOLOGY either longitudinally or transversely in relation to the body of the patient. The lead strips of this grid are unusually thin. There are 55 strips per inch width of the grid itself—thus, even though it is a stationary type, grid marks are inconspicuous. The lead strips Figdee 15.—Gasoline electrical generator are focused, their spacing being such as to provide for a true center- ing (grid radius) at 36 inches. However, the focal film distance may be reduced to as little as 28 inches or it may be increased to as much as 45 inches without an appreciable cut-off. The grid ratio 25 TM 8-275 21-22 MEDICAL DEPARTMENT is 5 to 1. Because of the fact that the lead strips are focused, it is important that the top side of the grid he placed toward the patient and X-ray tube (that is, the opposite side toward the film). For a 10-centimeter thickness of part it is necessary merely to increase the milliampere-second factor to twice that required if it were not used (whereas with moving grids—“Potter Bucky” diaphragms—ap- proximately three times the milliampere-seconds are required for I his grid ratio). 22. X-ray machine unit.—a. Item No. 9(5085 is intended for all types of hospital installations. It may he packed in three field chests. Two of these chests are modified Medical Department field chests; the other one is of special construction for accommodation of the high-tension and filament transformers. The X-ray tube in its housing may be packed by setting it in a nest supported by eight springs which are attached to the inside corners of a compartment contained in one of the Medical Department field chests. In addi- tion, this particular chest accommodates a drum for packing the two shockproof cables, as well as smaller items such as the four filters (to be used in roentgenotherapy) and the several aperture dia- phragms. This chest has a gable type of superstructure which has heeu added in order to emphasize that the chest should be placed on end during transit. This is important in order to provide the greatest protection to the X-ray tube. The second standard Medical Department field chest is modified for accommodations of the control unit, the interconnecting cables, the timer, and the foot switch. A lead apron, a pair of lead-impregnated gloves, and a pair of goggles can be accommodated in this chest. b. This unit has been designed to operate on line voltages between 100 and 130, with 60-cycle, single-phase, alternating current. In terms of milliamperage, its maximum capacity is 30. The construc- tion of the high-tension transformer is such as to tolerate 60 milli- amperes but the design of the autotransformer prohibits this. The reserve capacity has been provided in order to obtain the desirable minimal inverse voltage. Regardless of the fact that this unit is self-rectified, the inverse voltage exceeds the useful voltage by less than 10 kvp—a most important feature. c. In conjunction with the X-ray table unit (item No. 96145) or the mobile X-ray chassis (item No. 96090), this X-ray machine unit is adaptable nine ways: (1) Horizontal fluoroscopy. (2) Foreign body localization by means of a rapid fluoroscopic method (see sec. IV). 26 TM 8-275 22 MILITARY ROENTGENOLOGY Figure 16.—Item No. 96085 in field chest. 27 TM 8-275 22 MEDICAL DEPARTMENT (3) Sitting fluoroscopy. (4) Standing fluoroscopy, to the extent of accommodating routine chest studies and also gastro-intestinal studies. (6) Horizontal roentgenography, using focal-film distances from 25 to 40 inches. (6) Six-foot vertical chest studies. Figure 17.—Foreign body localization, item No. 96085 being adapted to item No. 96145 within tent (item No. 96175). (7) Six-foot horizontal chest studies, the patient lying on the litter upon the floor. (8) Ordinary bedside work in the wards, by means of mounting the component parts of the X-ray machine upon a mobile chassis. (9) Superficial roentgenotherapy, to the extent of milliamperage capacities of 4 and kilo voltage potentials up to 100. 28 TM 8-275 22-23 MILITARY ROENTGENOLOGY d. Precautions and general instructions are inscribed on the top of the control. Information is contained in the instruction manual as to packing and assembling the unit. This manual will be found in the tool compartment contained in the base portion of the control. Similar information is also provided by an instruction placard which Figure 18.—Item No. 96085 assembled with item No. 96145 and in position lor sitting fluoroscopy. is located on the inside of the lid of the two modified Medical Department field chests. 23. Mobile chassis unit.—a. Item No. 96090 has been designed to convert item No. 96085 into a mobile unit for nse in the wards and at the bedside. It should he of service in the hospitalization section of the mobile surgical hospital, in the evacuation hospital, 29 TM 8-275 23 MEDICAL DEPARTMENT the genera] hospital, and the station hospital. In times of peace it is packed in a single Medical Department field chest. h. In wartime, in addition to the wheeled pedestal and vertical column, this item will include an extra tube unit and an extra pair of shockproof cables. With such, a second chest will be included. This second chest will be identical with that described for accom- modating the X-ray tube and shockproof cables in the case of the X- ray machine unit (item Xo. 96085), In the theater of operations. Figure 19.—Item No. 96085 assembled with item No. 96145 and in position for standing fluoroscopy. where replacements of tube units would be a difficult problem, this item will thus provide a spare tube. Otherwise, a spare tube will not be carried forward. Moreover, during wartime, this arrange- ment provides for an easy change-over of the X-ray machine unit from a coordinating component in connection with the X-ray table unit (item No. 96145) to that of a bedside unit. Having the X-ray 30 TM 8-275 23-24 MILITARY ROENTGENOLOGY tube and shockproof cables mounted onto the mobile chassis, it is merely necessary to disconnect the shockproof cables of the table unit; to place the transformer chest into the well of the pedestal; to mount the control unit onto the transformer chest; and then to con- nect the shockproof cables of the chassis tube unit, without having to remove the tube unit or cables which were attached to the table unit. Particularly, where superficial X-ray therapy is to be given to ward patients, it becomes practical to accomplish the rounds in the Figure 20.—Item No. 96083 assembled with item No. 96145 and item No. 96070—the adap- tation for routine roentgenography. ward once or twice daily and to wheel the bedside unit back to the fluoroscopic compartment, and there simply to detach the cable con- nections of the chassis tube and to connect the table connections of the table tube unit, in order to proceed with fluoroscopy and/or roentgenography. 24. Film-processing unit.—a. Item No. 96115 has been devel- oped for use in any type of hospital installation. It has been designed as two sections: a master chemical section, and an auxiliary wash section. When using the master chemical section alone, 30 to 50 large films (depending upon the availability of community 431112°—42 -3 31 TM 8-275 24 MEDICAL DEPARTMENT plumbing connections and the temperature of the community water) can be accommodated within an 8-hour period. With the addition of the auxiliary wash section, these accommodations are increased to 200 or more such films. Thus it is believed that the master chem- ical section alone is practical for smaller station hospitals, for many corps area hospitals in times of peace, and for evacuation hospitals in the theater of operations. With the addition of the auxiliary wash Figure 21.—Item Xo. 00085 assembled with item No. 00145—adapted tor 0-foot vertical chest studies. section, the unit is considered practical for large station hospitals, for larger corps area hospitals, and for general hospitals as well as induction centers. In a few such locations, it may be necessary to have two such complete installations. h. The master chemical section consists of a tank compartment and a pedestal or base compartment. The tank compartment has a volume capacity of approximately 50 gallons. Three-gallon, 6-gallon, or 10- gallon insert tanks may be accommodated in it. Ordinarily, when this section is to be used alone, the insert tanks should be of 8-gallon (for developer) and 6-gallon (for the fixing bath) capacities. Two 10- 32 TM 8-275 24 MILITARY ROENTGENOLOGY gallon insert tanks for developer may be used when the auxiliary wash section is adapted. The pedestal or base compartment contains a water-circulator unit, a refrigerator unit, a heating unit, a mixing chamber, and a thermostatic regulator. The unit is assembled by simply setting the tank compartment upon the pedestal compartment and connecting three water couplings, which can be connected without the need of tools. After adding water and making the electrical con- nections, the processing section is ready for use. The electrical supply should be OO-ci'de, single-phase. It might be provided by community supply lines or by means of a portable gasoline electrical generator unit such as item No. 9G06O. though the precise regulation of that Figure 22.—-Item No. 96085 assembled with item No. 96145—adapted for 6-foot horizontal chest studies. particular generator is not required. When the water-circulator pump alone is operating, the electrical load is approximately 100 watts; when the cooling unit is operating with the circulator, the load is increased to approximately 700 watts, while with the heater unit it amounts to approximately 400 watts. It was not possible to obtain dual regulator switches at the time when the first of these units were constructed. Therefore, their function is such that either the refrig- erator unit or the heater unit operates at all times. To counteract this adverse feature, a triple switch was incorporated in a second 33 TM 8-275 24 MEDICAL DEPARTMENT Figure 23.—Item No. 9G085 assembled with item No. 96090—the adaptation as in mobile X-ray machine unit. (Note position of shockproof cables serving to counteract sharp angulations and kinkings.) 34 MILITARY ROENTGENOLOGY TM 8-275 24 Figure 24.—Item No. 96090. 35 TM 8-275 24 MEDICAL DEPARTMENT group. This triple switch is located in the upper right-hand corner of the front of the pedestal compartment. One switch is intended to open the entire electrical circuits; a second switch controls the heater unit alone and should serve in warm weather to prevent heating when the temperature of the water bath is reduced to 62° F.; the third switch is intended to open the refrigerator circuit alone and should serve in cold weather to prevent cooling of the wash water after bring- ing the temperature to 68° F. The refrigeration unit lias a capacity of 4,000 Btu per hour. The heating unit has a capacity of 3.000 Btu per hour. These limitations must be respected with consideration as to the volume of water which might be allowed to flow through the unit, in the case of community water connections. If the temperature of the community water supply is excessive—above 90° F. or below 40° F. (as can be expected in climates of extreme temperatures and where the piping is close to the surface of the ground)—the rate of fresh water supply must be more limited than where the temperatures are within the ideal range of 60° to 70° F. For these reasons a cali- brated inflow valve has been provided. This will be found in the upper right anterior corner of the pedestal compartment. The cali- brated values represent 50 percent of the maximum water pressure estimates. Openings are indicated for occasions of various tempera- tures of the community water. It is the responsibility of the roent- genologist to adjust this valve in accordance with the conditions of the day. The temperature of the community water might be checked by drawing water from any spigot though this should not be neces- sary. It should be practical merely to note whether the heating or cooling unit can accommodate the volumes admitted. The water pump can accommodate only 20 to 25 gallons per hour. In case of inflow at a rate greater than this, recirculation of the water is opposed and the incoming water will flow into the master tank both by way of the normal inflow stem and also by way of the circulating stand- pipe, thereby completely inhibiting recirculation and effective heating or cooling of the wash water. c. The auxiliary wash section also consists of two compartments: a tank compartment which is identical in dimensions with those of the master chemical tank described above, and a pedestal compart- ment. The tank compartment contains two baffles to provide for a cascade type of washing, as shown in figure 26. The pedestal com- partment contains a precooling system. It will be noted that sep- arate inflow valves are provided for the auxiliary wash tank and the master chemical tank. These provide for individual rates of water flow through the two tanks. The temperature of the water in the 36 MILITARY ROENTGENOLOGY TM 8-275 24 auxiliary wash tank is regulated merely by the temperature exchange from the water overflow of the master chemical tank. This is prac- tical because the temperature of the wash water may be as low as 40° F. or as high as 8'0° F.—not necessarily within the temperature range of 60° to 70° as required for the chemical solutions. Circulation and Figure 25.—Item No. 96115. volume of fresh water flow are the more important requirements as far as the wash section is concerned. d. Both sections of the processing unit are composed of two com- partments. This provision is for the sake of portability, making the unit practical both for peacetime installations and for use in the field. In case of aerial attack it can be carried in parts to a location where activities will be relatively safe. The heating and cooling 37 TM 8-275 24 MEDICAL DEPARTMENT REFRIGERATION / UNIT 4 MIXING CHAMBER DEVELOPING SOLUTION RECIRCULATION STANDPIPE INSERT TANKS FOR CHEMICALS PREREGULATOR MASTER CHEMICAL SECTION PIPING FIXING SOLUTION MASTER CHEMICAL SECTION INFLOW VALVE (CALIBRATED) 5uj 05: 6| U Figure 26.—Processing unit. WATER LEVELS 3D 2D I ST WASH WASH WASH ofr' WASH TANK A INFLOW VALVES COMMUNITY I WATER INFLOW TO SEWER AUXILIARY WASH SECTION DOWN DRAIN FOR FURTHEST-TO- THE-LEFT COMPARTMENT TANK COMPARTMENT PEDESTAL COMP. 38 TM 8-275 24-25 MILITARY ROENTGENOLOGY units as well as the precooler are self-contained. No special servicing is required after assembly. All connections can be made by hand. 25. X-ray table unit.—a. Item No. 96145 is an emergency fluoro- scopic and roentgenographic table unit. It is considered practical for usage in any type of hospital installation. It is anticipated that in the mobile surgical hospital it will be set up for fluoroscopic work. In the evacuation hospital it will likely be adapted both for fluoro- scopy and roentgenography. This may also pertain to the station hospital. In the general hospital it will probably serve, especially in the admitting ward, for both of these functions. It is issued in field chests or shipped in crates. As packed in chests (for duty in the combat zone), all of the components can be accommodated in two special field chests. b. Essentially, this unit is composed of two fabricated steel end- pieces, three rails (each composed of three sections), a horizontal carriage, and a C-shaped supporting arm for accommodation of the X-ray tube unit and also of the fluoroscopic screen. These compo- nent parts and their assembly are shown in figure 28. c. Detailed instructions covering the packing arrangement of these parts in the field chest and the means of assembly of the unit are given in the pamphlet which accompanies each unit, and also in in- struction sheets which can be found on the side of the lid in the field chests. The reinforcing bolts used with the rails should be clamped tightly when assembling the table chassis. Otherwise, it is impor- tant that all clamps and boltings be tightened with finger pressure rather than with hand or arm strength. Engraved captions can be found in various locations on the C-shaped member as well as on the horizontal carriage. It is important to heed these captions, par- ticularly the ones pertaining to releasing the clamps for fixation of the telescoping vertical member of the C-shaped arm. Two fixation clamps have been provided for this member. One of these clamps resists rotation of the telescopic portion while the other resists vertical movement of it. Unless these clamps are released before attempting either of the movements, they will soon become unserviceable. Their reinforcement is important only during foreign body localizations. d. The C-shaped arm may be adjusted in several ways (figs. 18 to 22, inch) : (1) The X-ray tube and fluoroscopic screen may be positioned so as to provide for horizontal fluoroscopy, with an allowance of vertical shifting through a range of 16 inches. (2) They may be positioned so as to provide for vertical fluoros- copy, the patient being in the sitting position. 39 TM 8-275 25 MEDICAL DEPARTMENT Figdke 27.—Item Iso. 96145 packed in field chests. 40 TM 8-275 25 MILITARY ROENTGENOLOGY (3) They may be positioned to one end of the table chassis so as to provide for standing fluoroscopy. (4) The tube housing itself may be rotated to a position so as to provide for chest studies with focal-film distances as great or greater than 6 feet. (5) In the position for conventional horizontal roentgenography, the tube housing may be raised or lowered so as to provide focal- film distances varying from 29 inches to as much as 45 inches, the Figure 28. I tom No. 9G145 assembled. (C-shaped member in position for horizontal fluoroscopy and foreign body localization.) patient lying on a litter at the table-top level (in which case the portable grid unit (item No. 96070) may be used or the cassette placed immediately beneath the patient, whereupon the focal-film distance may be reduced to any desired minimum). (6) The X-ray tube may be rotated in the horizontal plane so as to provide for chest studies of focal-film distances as great as 6 feet, the patient lying upon a litter placed upon the floor. e. As described in section IV, two simple auxiliary parts are pro- vided with this unit for adaptation of it to a simple fluoroscopic method of foreign body localization. 41 TM 8-275 26 MEDICAL DEPARTMENT 26, Darkroom tent.—a. Item No. 96175 has been designed for usage particularly at the mobile surgical hospitals where it is ex- pected that it will be needed both with the mobile operating section and with the hospitalization section. Its design is such that it can be erected indoors in any room 8 by 10 feet in area and 8 feet in height (as well as within a tent or dugout) or by itself, in the open. It is therefore quickly adaptable for use in a temporary building or Figuhe 29.—Item Xo. 9G175, the adjustable inner curtain set forward with auxiliary drape; in position for providing largest available space as needed in fluoroscopy. any building taken over for service as an evacuation hospital. It may even serve a purpose at a general hospital, though at this in- stallation it is more likely that substantial darkroom construction will be had. Its design includes a two-way adaptation for fluoros- copy and/or for film processing. It provides for a quick change- over where lightproof conditions are essential. When erected on the outside, very sturdy support of it is available by means of weight- 42 TM 8-275 26 MILITARY ROENTGENOLOGY ing its overlength apron (which extends from the ground extremities of its siding). Additional support may be provided by utilizing auxiliary guy ropes. The guy ropes are not actually included with this item but eyelets have been provided in eaves which extend from the top sides of the tent. It should not be necessary to use these guy rope supports when the tent is erected within another tent or within a room or dugout. Figure 30,—Item No. 96175, the adjustable inner curtain set back with auxiliary drapes extended so as to provide the labyrinth as needed when the tent is to be used for film processing. b. Detailed instructions as to assembly of this tent are appended to the inside of the lid of the chest which accommodates the frame support of the tent. As indicated, assembly of the roof frame should first be accomplished, the outer tentage being placed upon this frnme so that the end and sides of it are thrown uppermost. The vertical members are then adjusted to each of the four corners so that they project toward the center of the area covered by the tent. The roof frame should then be elevated by lifting each of the four vertical members. The lower horizontal members should then be fixed and the tiller rope attachments applied and tightened. The sides of 43 TM 8-275 26-27 MEDICAL DEPARTMENT the outer tentage should then be lowered and the inner curtain and auxiliary drapes adjusted. The fan for forced ventilation should then be installed in the posterior end gable. This should be inclosed by the zipper to provide for light tightness. When used for fluoros- copy, the inner curtain should be set forward (the auxiliary drapes being folded), and the zipper of this curtain should be opened so (hat with the door drapes extended, it will be possible to enter the passageway head first without lifting the drapes. For film process- ing, the inner curtain should be set back (20 inches) and the auxiliary drapes should be extended so as to provide a labyrinth. These two adaptations are shown in figures 29 and 30. Section IV FOREIGN BODY LOCALIZATION1 Paragraph General 27 Working parts w-J — 28 Preliminary testings 21) Localization procedure 30 Geometric analysis of method 31 Accuracy of method 32 Precautionary measures 33 The biplane marker 34 27. General.—The X-ray table has been designed to provide for a rapid fluoroscopic method of localization of X-ray opaque bodies. The method is based upon triangulation principles, utilizing large dimensional relations. This particular method has been selected be- cause of several favorable features: a. Simplicity of the auxiliary parts required. h. Ease of making the alinements. Instead of wires or diaphragm cut-off to be visualized through the density of an overlying part, clearly discernible intersecting lines on the fluoroscopic screen are used. c. Short time requirement for localization of any one foreign body— less than 1 minute. d. Minimal X-ray exposure imposed upon the patient—no greater than 150 milliampere-seconds with a focal-skin distance of 12 inches or more (with negligible secondary radiation directed toward the exam- iner and assistants). e. Accuracy of localization. This method is limited only by tech- nical discrepancies on the part of the operator (provided the reading 1 As provided with X-ray field table unit, item No. 96145 44 TM 8-275 27-28 MILITARY ROENTGENOLOGY level is properly adjusted before making the calculations (see par. 29)). f. Provision for positioning of the fluoroscopic screen either in con- tact with the skin surface or at a distance above it, thereby permitting clearance for manipulation. DEPTH SCALE (FLUOROSCOPIC SCREEN TO SKIN SURFACE) INTERSECTING LINES ADJUSTABLE READING LEVEL FLUOROSCOPIC SCREEN SKIN MARKER (COMBINED WITH DEPTH SCALE) SUPPORTING COLUMN (FOR VERTICAL ADJUSTMENT OF C-SHAPED MEMBER) HORIZONTAL CARRIAGE " LOCALIZATION SCALE -X-RAY TUBE C-SHAPED . MEMBER 'ADJUSTABLE POINTER Figure 31.- Design and construction features of item No. 96145, providing for foreign body localization. g. Convenience in marking of the skin surface. This can be accomplished with true alinement relations but without resorting to the application of the skin marker through an opening in the fluoro- scopic screen. 28. Working parts.—a. To provide for this method of localiza- tion. only two auxiliary parts are required. Neither of these is easily detachable nor small enough to be easily lost. These parts are— 45 TM 8-275 28-29 MEDICAL DEPARTMENT (1) Combination depth scale and skin marker which should be mounted on the supporting; arm of the fluoroscopic screen. (2) Localization scale and its adjustable pointer which are attached to the horizontal carriage. h. The focal spot of the X-ray tube is located at a distance of 66 centimeters (plus or minus 1.5 centimeters) beneath the center of the fluoroscopic screen. There are inscribed upon the fluoroscopic screen three sets of intersecting lines. One of these sets is located in the center of the screen; another. 11 centimeters beyond the central set toward one end of the screen; while the third set is located 11 centimeters in the opposite direction from the central set. Thus the spacing between the outer intersecting lines is 22 centimeters or one- third of the focal-screen distance (except for minor variations in the latter). 39. Preliminary testings.—a. An adjustable reading level has been provided in connection with the depth scale. This reading level is incorporated for accuracy and to compensate for variations in the position of the focal spot with considerations of one or another X-ray tube—variations which might produce plus or minus changes in the focal-screen distance of as much as 1.5 centimeters. As the equip- ment is shipped from the factory, the reading level is positioned properly in relation to the average X-ray tube assembly. However, in order to be certain that this level has not shifted, as well as to compensate for parallax, it is important to conduct preliminary test- ings of localization, making use of the depth phantom which is car- ried in the tool compartment of the larger of the two field chests (in which the table unit is packed). This preliminary testing should be conducted in the following manner: (1) Place a board across the litter (table top) to provide for a rigid surface (comparable to the patient). On this board, 4 or 5 centimeters beneath the fluoroscopic screen, place the depth phantom in position so that the lead letters are on planes which respectively represent their distances below the top surface of the phantom as shown in figure 32. (2) Aline one conspicuous point of the number “12” to either of the two outer intersecting lines of the fluoroscopic screen. (3) Adjust the pointer on the horizontal rail and clamp it to a position so that it points to “12” on the localization scale, this ad- justment being made to the “12" on the end of the localization scale coinciding with that of the intersecting lines selected for the aline- ment of the lead number “12” of the depth phantom. 46 TM 8-275 29 MILITARY ROENTGENOLOGY (4) Shift the tube and the screen in the opposite direction until the very same point of the lead number “12” of the depth phantom is alined to the opposite outer intersecting lines of the fluoroscopic screen. (5) Read the new value indicated on the localization scale by the pointer on the horizontal carriage. FOCAL SPOT OF TUBE 'LOCALIZATION SCALE POSITIONING OF READING LEVEL FOR DEPTH SCALE READING OF STEP "S" SHOULD CORRESPOND WITH THAT OF STEP"e- / READING LEVELS (MOUNTED ON ARM SUPPORTING SCREEN) Figure 32.—Positioning of reading level for depth scale. DEPTH SCALE - SHIFTING OF TUBE AND SCREEN HAS CAUSED POINTER TO COME TO POSITION AT OPPOSITE END OF SCALE. Dl RECT ION OF TRAVEL ALINEMENT OF POINT ON LEAD NUMBER "12" (DEPTH PHANTOM) TO OUTER SETS OP INTERSECTING LINES. DIRECTION OF TRAVEL DEPTH PHANTOM POINTER SET TO "12" ON LOCALIZATION SCALE: THE 'll’ON END OF SCALE BENEATH INTERSECTING LINES OF SCR.EEN,USED FOR. ALINEMENT. fLUOROSCOPlC SCREEN (6) Shift the fluoroscopic screen and X-ray tube to a position for alinement of the lead number “12” (of the phantom) to the central set of intersecting lines. Superimpose the skin marker into this alinement and lower the depth scale until the skin marker rests upon the top surface of the depth phantom. Head the value indicated on 431112°—42 4 47 TM 8-275 29 MEDICAL DEPARTMENT the depth scale—the indicated depth of the top of the phantom (substituting for the skin surface) beneath the fluoroscopic screen. (7) In case the depth scale value indicated in (6) above does not coincide with the value indicated in (5) above, release the setscrew DIRECTION OP TRAVEL POINTER. NOW INDICATES DEPTH OF FOREIGN . BODY BENEATH SON \ Figure 33.—-Procedure diagram for localization. DIRECTION OF TRAVEL 'arbitrary zero- set POINTER, TO VALUE DETERMINED By DEPTH , SCALE MARKER AS SHOWN E1L 'NW / SLIDE RAIL'* \ SKIN MARKER PAD fOILEI&N BODY FLUOROSCOPIC SCREEN WITH THREE SETS OF INTERSECTING UNES . POINTER CUFF LINEAL SCALE DEPTH (cm. depth of skin beneath scueni used with the reading level (as shown in fig. 31) and, readjust the reading level to the value indicated in (5) above. h. Once having set this reading level in this manner, it should not be necessary to readjust it. unless there are extreme changes in weather conditions and provided the X-ray tube is not changed. 48 TM 8-275 29-30 MILITARY ROENTGENOLOGY The setscrew should be securely clamped for fixation of the reading level. Should there be extreme changes in weather conditions so that the bakelite support of the fluoroscopic screen becomes buckled or changes from a buckled state to that of a true plane, a recheck as above described should be accomplished. Such changes in the level of the fluoroscopic screen are likely to alter the degree of parallax and, unless the reading level is readjusted, errors to the extent of several millimeters may be incurred. It is important that several testings be conducted in order to establish the correct position for this reading level. It is recommended that these testings be made with the use of the “3” centimeter level as well as with the use of the “12” centimeter level and that these be checked for various positions of the fluoroscopic screen (that is, obtained by shifting the position of the fluoroscopic screen and the tube in the vertical plane). c. This preliminary testing procedure is the opposite of the actual procedure concerned with localization for foreign bodies. 30. Localization procedure.—a. Having accomplished a trust- worthy adjustment of the reading level for the depth marker scale, the actual steps of localization should also be practiced with the use of the depth phantom. The procedure is as follows: (1) Check fixation locks on C-shaped member; secure alinement of focal spot to center of fluoroscopic screen (fig. 31). (2) Aline a prominence on foreign body to intersection of central intersecting lines. (3) Dampen skin marker pad with tincture of iodine or ink and adjust it to this alinement (foreign body and intersection of central intersecting lines) ; lower skin marker pad until it rests on the skin (or top of the depth phantom), thereby marking it. (4) Read distance between fluoroscopic screen and skin (or top of the depth phantom) by way of scale on depth marker (fig. 330). (5) Shift tube and fluoroscopic screen so as to aline the same prominence of the foreign body, as considered in (2) above, to the intersection of either of the outer intersecting lines (fig. 330). (6) Slide localization scale and adjust pointer to the centimeter value coinciding with the centimeter distance between the fluoroscopic screen and the skin as measured in above—this is the arbitrary zero. Clamp cutf for fixation of pointer to side rail of table. (7) Slide X-ray tube and fluoroscopic screen in direction opposite to that used in (5) above, until the same prominence on the foreign body becomes alined to the intersection of the opposite outer inter- secting lines (fig. 330). 49 TM 8-275 30 MEDICAL DEPARTMENT (8) Read on localization scale the depth of foreign body beneath the skin (or top surface of depth phantom). h. Reporting of actual localizations should be accomplished on the skin surface of the patient and also by a written report, using standard forms such as W. D., M. D. Form No. 52b (Emergency Medical Tag) (fig. 34) or the medical tags. W. 1)., M. 1). Form No. 55-series, as used in the theater of operations. On the skin surface of the patient 6,011230 SUPPLEMENTAL RECORD rj / yOJr' A --hr^^hr^ S 3 x / /yifajis - - oJMst'S't) % / Surname Christian njmt BaJdUis !/)jJJ(noxs -tfr B«A £fJL Company 0 Regiment or Staff Corps 901 tUf. X*.(T».) Race u) nativity ServiJe (Yrs.) 8 x/k Dal*, hoar, and atation where tagged: hpm j£^ St /*\ ~fa faus^MUAL, yic' (TIMA Treatment: ‘— Disposition: ffmAo. jfr ll'L'^’ Signature: jj 1/ Form 58b MEDICAL DEPARTMENT, U. 8. A. (I mamtaed ffe M, IMP) t-*m. Fkjuub 34.—Showing front and back of Medical Department field tag with report of localizations of foreign bodies. a dot should be marked over the foreign body. Since several such dots might be made, either carelessly or because of there being a number of foreign bodies contained, the precise marking should individually be identified fey means of an outer character such as an outer circle, square, or triangle; an intersecting line; a nearby acute, obtuse, or right angle, etc. Near such identification the depth of the foreign body should be recorded. These same characters should be used in making the written reports, in which case the depth values should be recorded 50 TM 8-375 30-31 MILITARY ROENTGENOLOGY beneath the character serving to identify each foreign body. Unnec- essary details should not be included, though information should be recorded as to the position of the patient when the localization was accomplished, the approximate size and character of the foreign body, its relations to anatomical landmarks, and the apparent condition of the tissues (particularly the skeleton). 31. Geometric analysis of method.—Geometrically, the prin- ciples concerned with this method of foreign body localization might be described as follows: a. AB equals the spacing between the outer intersecting lines; it is equal to 22 centimeters. h. FS equals the focal-screen distance (focal spot to intersection of central intersecting lines) ; it is equal to three times AB. or 66 centi- meters (plus or minus minor deviations in the position of the focal spot). c. If a foreign body were located at S (that is, just beneath the inter- section of the central intersecting lines), for alinements of it to the intersection of the outer intersecting lines at A and then at B. the X-ray tube would have to be moved with the fluoroscopic screen for distances equal to SB and then SA, respectively, in order to provide for alinements of the foreign body to the intersections of the lines at A and then at B. On the localization scale, the distances of such movements would be represented by FC and FD, since the gradations on this scale are limited to a total range of 22 centimeters (same as the spacing between the outer intersecting lines described upon the fluoro- scopic screen). In the case of foreign bodies located at other levels below the plane AB. this same ratio relationship would hold true with respect to the distance of shifting requirement and the distance between the focal spot of the X-ray tube and the foreign body. Similar tri- angles are involved, and since the ratio relationship between AB and FS is as 1 to 3, for foreign bodies located at any level beneath the fluoroscopic screen and between it and the X-ray tube, the distance of shift required for similar alinements would equal one-third of the distance between the plane of the focal spot and the plane of the for- eign body. Actually, the measurement between the focal spot and the foreign body is unimportant. Instead, the important measure- ment is that between the level of the fluoroscopic screen and the for- eign body. This measurement can be estimated by calculation, not of the distance of shift required for the alinements described above, but instead by calculating on the basis of the difference between that dis- tance and the extreme range of shifting possibility, that is, the 22 centimeters. Thus the calculation as to the depth of the foreign body 51 TM 8-275 31 MEDICAL DEPARTMENT beneath the plane of the fluoroscopic screen is based upon the untrav- eled distance. This can be explained as follows : GEOMETRIC DETAILS (SHOWING NORMAL AND ABNORMAL FOCAL-FLUOROSCOPIC SCREEN DISTANCES) PRIME LETTERS = ± VARIATIONS Figure 35.—Geometric details, showing normal and abnormal focal-fluoroscopic screei distances. (1) Since triangle EJG is similar to triangle Jill, the distance SJ bears the same ratio relationship to HI as does JF to EG, that is. a 3 to 1 ratio. 52 TM 8-275 31-32 MILITARY ROENTGENOLOGY (2) HI is equal to HS plus SI. (3) HS equals (ID while SI equals GK; therefore. Til equals CK plus GD. GE plus Gl> is the uutraveled distance (22 centimeters minus the distance of shifting of the X-ray tube and fluoroscopic screen). (4) The distance from the fluoroscopic screen to the skin is sub- tracted by making the adjustment of the pointer to an arbitrary zero as shown in figure 33(2) and as described in paragraph 30(6). Therefore, the reading of the untraveled distance (as indicated on the localization scale) indicates the measurement of depth of the foreign body beneath the skin level. 32. Accuracy of method,—a. The actual error incurred because of variations in the position of the focal spot of an X-ray tube is very small. This can be proved by geometric analysis, referring to figure 35. (1) Formula A.-—EG represents the distance of shifting required for the alinements of a foreign body at J. first in relation to the intersection at A and then at B. Ideally (when the focal screen distance is exactly 66 centimeters) : EG/FJ = CD/FS. EG X FS=GD X FJ. Therefore: CD EG Substituting: 22 X F•—== 66 TM 8-375 44 MILITARY ROENTGENOLOGY 44. Equipment requirements.—The equipment should include the following items: a. Office. 1 stereoscope complete, item No. 61360. to accommodate 14- by 17-inch films. 1 stereoscope to accommodate 4- by 5-inch (or 4- by 10-inch) films. 1 standard typewriter, 11-inch, item No. 76680. 1 office desk. 2 typewriter desks. 3 chairs. 1 filing cabinet. h. Hallway. 1 typewriter desk. 1 special typewriter (bulletin type characters). c. Exposure room. 1 item No. 60890. machine, radiographic and fluoroscopic, sta- tionary, complete, 200 Ma. 1 item No. 61692, tube column unit, rail-mounted, heavy duty. 1 item No. 60117, cassette changer, stereoscopic, upright, mag- netically controlled to accommodate two 14- by 17-inch films. 1 photoroentgenographic camera unit, complete with stereo- scopic shifter and remote control device for making two 4- by 5-inch films of chest on one 4- by 10-inch film. 2 item No. 61310, screen, lead protective. 1 bin, film, portable, lead-lined, two-compartment. 1 adjustable wafer grid. 1 caliper, rule type. 1 machine, electric, for perforating lead strips. d. Film processing room. 1 item No. 96055, loading bin, dryer, and loading bench com- bination. 1 item No. 96115, film-processing unit. Lightproofing provisions; if necessary, darkroom tent (item No. 96175). 8 packages item No. 13800. powder, fixing, photographic, 4 cans item No. NS-1, developer, Kodalk. q. s. 10 gallons. 2 spools, item No. 20340, plaster, adhesive, 1-inch. 4 item No. 60110, 14-inch cassettes. 10 dozen item No. 60190, X-ray films, 14- by 17-inch. 6 packages item No. 61240, preserver, negative, 14-inch. 100 dozen, films, X-ray, single emulsion, 4- by 10-inch. 67 TM 8-275 44-45 MEDICAL DEPARTMENT 36 hangers, film, holding 3 each 4- by 10-inch films. 100 dozen, preserver, negative, for 4- by 10-inch films. 24 item No. 60390, holder, film development, 14-inch. 6 rolls, paper, bond. 3% inches wide, perforated every 2hi inches, length 250 feet. 900 item No, 75415, envelopes, white. 2 packages lead foil strips (100). 45. Camera unit.—a. The camera unit as used for photographing the fluoroscopic image consists of a lens, a film holder, a lightproof compartment inclosing these, and a supporting column (see fig. 44). b. There is no unanimity of opinion as to the best type of fluorescent screen. Some of the screens in use today fluoresce wave lengths of the CAPTI ONS LOCATION OF LENS STEREOSCOPIC FILM SHIFTER. X-RAY TUbE LIGHT TIGHT COMPARTMENT -FLUOUOSCOPIC SCREEN HOUSING Figure 44.—Photography of fluoroscopic image. blue-violet range while others fluoresce wave lengths of the yellow- green range. The wave lengths of the fluorescent rays determine the type of film which should be used and vice versa. Some concern has been mentioned relative to the size of crystals contained in the fluores- cent screen. In the case of certain screens, it is true that the greater the intensity of fluorescence, the larger is the dimension of the crystals. Because of the factor of reduction, as utilized in this type of work, the size of the crystals of the fluorescent screen is unimportant, pro- vided the films are viewed in relatively small dimensions—dimensions considerably less than those of the fluoroscopic screen image. 68 TM 8-275 45 MILITARY ROENTGENOLOGY c. It is desirable that the lens of this unit have a uniform refractory power which is equivalent to that of F 1.5. With such a lens, when using a focal-fluoroscopic screen distance of 40 inches, the exposure technique required for these chest studies is little more than that re- quired for standard 6-foot chest studies (provided a suitable fluores- cent screen and film are used). With the use of lenses of slower refractory powers, as for instance a lens of F 2.0 or slower speed, the exposure requirements are more than doubled, thereby requiring con- siderably greater punishment upon the X-ray tube with resulting shorter tube life, d. The film should have the smallest grain size possible, otherwise unsharpness of detail will result. The reduction factor does not offset the adversities concerned with grain size of the film emulsion as it does with grain size of the fluorescent screen emulsion. It is advisable that the film have a single coating of emulsion with a nonhalation backing, rather than that it be a duplitized film as conventionally used in X-ray work. Light rays are readily reflected and diffracted. Since fluorescent rays are light rays, they are subjected to deviations in direction when passing through a front layer of film emulsion and through the film base, finally to become effective upon a second layer of emulsion. This accounts for considerable unsharpness of detail when photographing the fluoroscopic image with the use of duplitized films. To some extent, this effect is found with the use of conventional intensifying screens in ordinary roentgenography, but when applied to photoroentgenography, because of the miniature dimensions of the total image, the relative degree of unsharpness is of greater importance. e. To meet the requirements of almost automatic coordination with the other examiners of the team, it is advisable that the two projec- tions concerned with each candidate be included on one film. Particu- larly with smaller miniatures, this may be accomplished with the use of a roll type of film. These provisions lessen confusion in the darkroom and alleviate a “bottleneck” which may otherwise occur because of having to match the two-exposure studies concerned with each individual. The services of one technician are practically elimi- nated thereby. f. In order to provide for true stereoscopic projections, it is im- portant that provision be made for automatic shifting of the film. The direction of this shifting must be coordinated with respect to the direction of the movement of the X-ray tube and the design of the stereoscopic viewing apparatus. These interrelationships must be checked by preliminary exposures. With stereoscopic viewing, these 69 TM 8-375 45-47 MEDICAL DEPARTMENT films should project the image in the very same relationship to the viewing eyes as the part bears a relationship to the X-ray tube. Other- wise, only pseudostereoscopic studies will be obtainable. Hence it is important that the design of the film holder be such as to provide for movement of the film, either upward or downward, and that it be adapted to the particular design of X-ray tube column and stereo- scopic viewing unit in use. Electromagnetic or remote control of the film shifting should be coordinated with the remote control of the X-ray tube shift in order to accomplish satisfactory results, obtaining two exposures within the time limits during which the average indi- vidual is able to withhold breathing. 46. X-ray machine unit.—It is preferable that a high milli- amperage capacity unit be used. If the exposures are made at milliamperages of 400 or 500. the exposure time can be reduced to values whereby voluntary movements and movements of the vessels might not be troublesome. Lower milliamperage values may be used; in fact, milliamperages as low as 30 have been used (with the focal-fluoroscopic screen distance reduced to 30 inches), though in such cases the exposure time must necessarily be increased, with the attendant adversities. For most of the installations it has been found practical to use 200-milliampere full-wave (rectified) equip- ment. Particularly when utilizing an X-ray machine unit at its rated capacity load, it is important that the regulation of the trans- former be such that its wave form is not distorted at the high milli- amperage settings, so that the radiation performance will be truly con- sistent with the milliamperage. 47. X-ray tube.-—Because of the reduction factor, the dimensions of the effective focal spot of the X-ray tube are not important. The detail obtainable when using a small focal spot such as that of a rotating anode tube is not discernibly different from that obtainable when using a tube with a large focal spot. Therefore, it has been considered practical to use a stationary anode tube. To accommodate repeatedly a milliamperage load of 200, it has been considered prac- tical to use an effective focal spot dimension of 5 millimeters square (plus or minus 2 millimeters). Since this work requires exposures of high capacity values, and since these exposures must be made in rapid succession, it is important that, in addition to milliamperage tolerances, both heat storage capacity and heat dissipation character- istics of the X-ray tube are respected. With consideration of 30 centi- meter chests and the handling of one such per minute, the require- ments would approximate 860,000 heat units (KvpXMaXtime and seconds) per hour. 70 TM 8-275 48 MILITARY ROENTGENOLOGY 48. Film processing equipment.—a. Because of having to uti- lize large film roentgenograms for some cases, film processing equip- ment should be of design adequate to accommodate standard 14- by 17-inch films. b. The equipment should provide for controlling the temperature of the chemicals (the developer and the fixing bath) to within a range of between 60° and 70° F. This is best accomplished with the use of a thermostatic regulator. The time-temperature method of processing should be practiced. The temperature of the final wash water may be as low as 50° F. or as high as 80° F. For adequacy of washing, the most important factor is circulation of the water and supply of fresh water. If a cascade design of wash compartment is provided, the movement of the water is more effective than in the case of a large, open tank and therefore exchange of water may be less. In order to accomplish satisfactory washing within 10 to 15 minutes with an open tank, it has been estimated that a fresh water supply of eight times the volume of the tank per hour is required, whereas with a cascade arrangement only four times the volume is needed. In the case of the United States Army processing unit (par. 24), when the auxiliary wash section is used this comparison would mean 60 gallons per hour (4 times the volume of the final wash com- partment) versus approximately 360 gallons per hour (8 times the volume of the circulating water) when the master chemical section alone is used. c. Since film life is so important where the film studies are to serve as legal records, as in the induction board activities, it is very essential that adequate washings are accomplished. Otherwise resid- ual sulfur on the film emulsion will produce a staining of the film within a period of a few years and the film will become brittle and fragment within 4 or 5 years. Periodic testings should therefore be accomplished to ascertain the adequacy of the washing. A simple yet accurate qualitative test for residual hypo may be performed with the use of a very dilute solution of potassium permanganate (KMn04) as an indicator. This may be made up from a stock solution such as the following:1 Metric Avoirdupois Potassium permanganate 0. 5 gram 7. 5 grains. Sodium hydroxide (caustic soda) 1.0 gram 15.0 grains. Water (distilled) to make 1.0 liter 32.0 ounces. Use 1 part of stock solution to 20 parts of water. In lieu of these detailed preparations, it is practical merely to add a small 1 Courtesy Mr. F. C. Martin, Eastman Kodak Company, Rochester, N. Y, 71 TM 8-275 48-50 MEDICAL DEPARTMENT crystal of the potassium permanganate to approximately 500 cubic centimeters of distilled or ordinary tap water. In case tap water is used, the resulting solution should be allowed to stand for 10 or 15 minutes in order to make certain that the organic content is not sufficient to reduce the manganese ions. The solution thus made should be pinkish violet in color and should remain so regardless of standing for 10 or 15 minutes. Twenty to 40 cubic centimeters of the very dilute indicator, prepared by either method described above, should be poured into each of two test tubes or beakers (one aliquot for the testing, the other for a control). A film should be removed from the wash section and allowed to drip into one of these two testing- containers; 15 to 20 drops should suffice. If within a period of 5 minutes there results a change in the color of the indicator from a pinkish purple to orange, yellow, or a colorless solution, the washing of the film has been inadequate. Such testings should be accomplished periodically after allowing the routine periods and conditions of washing the films. 49. Time requirements.—With improvements of chemicals, the time required for developing may be reduced to 31/, minutes (though 6 minutes may be given, with reduction of 3 to 6 kilovolts in the ex- posures as compared with regular techniques) ; the intermediary wash should not require more than a few seconds; 10 minutes should be allowed for adequate clearing in the hypo bath, and the films should be washed for 10 to 15 minutes (provided cascade type of washing is used). The time required for drying will depend to some extent upon the design of the film hangers. When stereoscopic viewing is to be accomplished, the films should be dried thoroughly. However, for direct viewing, the wet films can easily be handled and it is not impractical nor annoying to study them in that condition. Thereby, reporting of the films can be accomplished within one-half to three- quarters of an hour following the time of making the exposures. Thus the roentgenological team can coordinate very closely with the activities of the other examiners. 50. Film captions.—a. To provide for adequate identification of the films, two captions should be used. The characters of these cap- tions should be of a vertical dimension of no less than one-quarter inch. Their style should be of plain block bold-face capital letters such as those of “bulletin type.” Otherwise, reading them may be difficult after reduction to the dimensions of the miniature films. Detailed information should be recorded. This may be accom- plished with the use of two small captions, utilizing the spaces of the screen and film, above the shoulders. One of these captions should 72 TM 8-275 50-51 MILITARY ROENTGENOLOGY include the following information: location of the examination; ex- amining board number; date; and orientation as to the side of the body. This caption may serve for all the examinations conducted during any 1 day. It may be left in place, either in the upper right or left corner, depending upon the arrangement of the room and ease of handling the other caption. The other caption should in- clude name of the candidate (last name, first name, and middle initial) ; street address and locality of residence; local board number; color, age, height, and weight. The following are sample captions: Caption 1 Caption 2 STATION HOSPITAL FT. SAM HOUSTON, TEX. ARMY EX. BD. NO. 54 DEC. 12, 1941 LEFT VAN BEAR ICON, HAROLD R. 1548 HANOVER ST. DALLAS, TEX. LOG. BD. NO. 169 W, 32, 68, 154 h. After making the exposures on each candidate, caption 2, as shown above, should be removed and placed in a basket and later fixed to a filing envelope. The film itself should be kept in this envelope. This arrangement provides for a most trustworthy identi- fication of those films on which the projected captions are only moderately legible. In addition, this plan is time saving as com- pared with writing the identifications on the outside of each envelope. 51. Technical assistance.—a. When close coordination with other members of an examining team is required and when several hundred individuals are to be examined in a day, it is recommended that the X-ray team consist of at least six assistants, in addition to the roentgenologist. The activities of these assistants might be as follows : (1) Secretary and f ling clerk (No. 1).—The duties of this assistant would include general secretarial work such as recording interpreta- tions, filing records, and handling correspondence. (2) Captioning stenographer (No. 2).—The duties of this assistant would be similar to those of assistant No. 1. In particular though, he would record the data as reported by each individual, developing thereby the identifying captions. It is estimated that the roentgen- ography of 200 individuals (400 exposures) can be accomplished within a period of 4 hours. If this number were admitted in a steady line, this assistant might be borrowed from other activities of the examination center for such a period of time. (3) X-ray machine operator {No. 3).—This assistant must be a well-qualified X-ray technician. His duties should include not only 73 TM 8-275 51 MEDICAL DEPARTMEXT the handling of the controls of the machine but he must bear respon- sibilities for proper maintenance of the equipment and for obtaining satisfactory roentgenographic densities. He should be familiar with a kilovoltage penetration technique and vary the settings of the auto- transformer according to the measurements of the chest, as reported to him by No. 4 assistant, (4) Positioning assistant {No. 4-) ■—This man should likewise be a well-qualified X-ray technician. He should be a “pinch hitter” in case of disability of No. 3 assistant. When coordinating with the entire team, his duties should consist of properly positioning the indi- vidual and the X-ray tube. As the individual advances toward the fluoroscopic screen, he should measure the diameter of his chest (at the nipple level) and announce this measurement to the X-ray ma- chine operator. He should then carefully position the individual in front of the plane of the screen or cassette panel, with his chest lean- ing forward (so as to expose the apices). He must insure symmetri- cal approximation of the chest and rotate the upper extremities so as to clear the scapulae as much as possible. The cassette or screen should be raised high, extending the chin of the candidate, and then the focal spot of the X-ray tube should be alined to the center of the field, shifting either way from the center for stereoscopy. Routinely, the long axis of the X-ray tube should be perpendicular to the floor, with the cathode end up, so as to provide for the greatest radiographic intensity through the apices and through the captions. Before the exposures are made, No. 4 assistant should step away from the tube and behind a lead screen so as to avoid unnecessary X-radiation exposure (the accumulation of minimal leakages which are to be expected even through modern ray-proof housings). (5) Film handler {No. 5).—This assistant should obtain the caption of each candidate as he advances toward the radiographic unit. He should remove any caption already present (as described in par. 50b) and replace it with the one pertaining to the individual. While the candidate is being positioned by assistant No. 4, he should prepare (he film for the first exposure. If automatic shifting is not provided, it will be necessary manually to change the film between the two exposures. A lead screen should be provided and located adjacent to the film holder so as to protect this assistant against unnecessary X-radiation and yet permit him to be sufficiently close to the film holder so as to arrange for changing of the film (within reasonable time limits of holding one’s breath). This assistant should also accom- plish a liaison between the exposure room and the processing room 74 TM 8-275 51-52 MILITARY ROENTGENOLOGY and between the processing room and viewing room or office. With the roll type of film many of these services become unnecessary. (6) Film processor {No. 6).—This assistant will be responsible for loading and unloading all films as well as processing them. He must expedite all phases of the processing, avoiding unnecessary delay particularly during fixation and washing, so that films can reach the roentgenologist within one-half to three-quarters of an hour following the actual exposure. h. It is apparent that with considerable rush of activities the services of an additional assistant may be necessary, particularly for coordina- tion between the processing room and the exposure room or the office. With lesser activity the number described above may be superfluous. The duties of assistants Nos. 1 and 2 may be consolidated as well as those of Nos. 3, 4, and 5, whereby a team of three assistants plus the roentgenologist may function without difficulty. 52. Technical factors,—a. It is not possible to present definite factors which may be trusted for use with any and all X-ray ma- chines. The following outline is therefore presented merely as a guide. These factors have been found suitable when the wave form of the high-tension circuit is of average quality. It must be realized that where distortion of wave form is encountered, somewhat greater exposures will be required. When the wave form is of the highest quality, exposures as great as those listed will not be necessary. Fac- tors other than wave form may also be involved, for example, variations in rnilliammeter recordings, variations in X-ray tube performances, etc. b. It will be noted that relatively high kilovoltage values are sug- gested. There are several reasons for this policy: (1) it serves to counteract an otherwise excessive contrast; by doing this, it provides for visualizing the peripheries of the lungs in the regions of the rib cross-overs without overexposing the hilar thirds. (2) It provides for reduction of exposure time, thereby minimizing the adverse effects of motion. (3) It provides for exposures with radiographic density which re- quire considerably less heat units than those which would be required if lower kilovoltages and higher milliampere-second factors were used, thus actually reducing, relatively, the punishment upon the X-ray tube. However, in addition to considering heat unit requirements, insulation tolerances of the shockproof cables, the X-ray tube envelope, its terminals, and those of the high-tension transformer must be respected. At the present time, a kilovoltage of 90 should not be exceeded. 75 TM 8-375 52 MEDICAL DEPARTMENT c. In order to provide for sufficient contrast where secondary fog would otherwise obscure the detail, it is advisable for chests having a measurement of 25 centimeters or more to place a wafer grid in front of the fluoroscopic screen. The standard portable grid (item No. 96070) serves well for this purpose. With this grid, it is merely necessary to increase the milliampere-second value to twice that which would be used without it. This compensatory increase is considerably less than that which would be required for a moving grid having the same ratio (5 to 1) or for grids in which the lead strips are thicker than those of the Army wafer grid. However, even the double milli- ampere-second value means considerable increase in X-ray tube punish- ment. Special consideration of tube capacity must be given. After accomplishing the exposures on a large-chested individual, it is ad- visable to allow 1 or 2 minutes before proceeding with further ex- posures. It must be emphasized that the Army wafer grid has been constructed to a definite radius, 36 inches (though it is usable with distances as great as 48 inches), and for this reason it is important to place the top side of the grid toward the patient while the film side of the grid is toward the fluoroscopic screen. Table I.—Photoroentgen technique Thickness (cm) Kvp With grid Without grid Ma. Time Ma. Time 16 72 200 Ms 200 Mo 17 74 200 H 200 Mo 18 76 200 H 200 Mo 19_ 78 200 M 200 Mo 20 80 200 % 200 Mo 21 82 200 Ms 200 Mo 22 84 200 Ms 200 Mo 23 i 86 200. % 200 Mo 24 88 200 H 200 Mo 25 90 200 Ms 200 Mo 26 90 200 H 200 Mo 27 90 200 Mo 200 Mo 28 90 200 Mo 200 Mo 21L 90 200 % 200 Ms 30 90 200 M 200 Ms 76 TM 8-275 53 MILITARY ROENTGENOLOGY Section YII DIAGNOSTIC ASPECTS 1 General 53 Nontuberculous conditions 54 Tuberculous lesions 55 Confusing evidence 56 Paragraph 53. General.—a. There must be a scientific evaluation of roent- gen findings. Mere search for typical pictures of pathology will lead to too many mistakes—failure to recognize important lesions; errors due to exaggeration of the unimportant. Very conspicuous lesions may be unimportant whereas relatively inconspicuous changes may be cause for rejection or for treatment. Interpretations must depend upon an orderly sequence of analyses: consideration of the soft tissues, the bony thorax, the pleurae, the diaphragm, the lung parenchyma, the hilar lymph nodes, the cardiac silhouette, and finally, the trachea and mediastinum. Tangible roentgen criteria significant of changes in any of these must be tabulated, at least mentally, and diagnoses must be based upon deductive reasonings substantiated by factual evidence. h. The range of diagnostic possibilities is protean. These are well known to qualified roentgenologists. Reference texts should be con- sulted liberally. Today, roentgenological details are too voluminous to incorporate in any one manual. Since pulmonary tuberculosis is the particular problem with which the Army is concerned during times of mobilization and demobilization, this discussion will be mainly concerned with the criteria of this disease. Keference is directed to the several Army Regulations and circular letters and in particular to MR 1-9, Standards of Physical Examination during Mobilization; AR 40-100, Standards of Miscellaneous Physical Examination; AR 40-105, Standards of Physical Examination for Entrance into the Regular Army, National Guard, and Organized Reserves. c. The roentgenologist must come to a definite decision relative to the immediate handling of each case. It is realized that follow-up studies are not infrequently indicated for crystallizing opinions as to definite diagnosis. However, candidates for the service cannot be studied as hospital cases. The roentgenologist is simply required to list definite X-ray findings and render an expression as to whether the findings are insufficient to disqualify; whether they should dis- qualify—indefinitely or “for the present.” As a consultant, the roent- 1 Roentgenological studies of chest as accomplished prior to admission or discharge. 77 TM 8-275 53-54 MEDICAL DEPARTMENT genologist is entitled to know any pertinent details relative to the individual’s background such as history of past diseases, his previous occupation, and contacts. He may wish to know of present physical findings and he is entitled to delay the rendering of the report until any such information has been obtained. (I. Though it is not the duty of the roentgenologist actually to clas- sify the individual, the official classification is here listed. Detailed description of the several classes is found in sections XXI. XXII. XXIII. XXIV, and XXV, volume three, Selective Service Regulations. (1) Glass I ( lass I A: Available; fit for general military service. Class Mi: Available; fit only for limited military service. Class I—C: Member of land or naval forces of United States. Class I D: Student fit for general military service; available not later than July 1, 1941. Class I-E: Student fit only for limited military service; avail- able not later than July 1, 1941. (2) Glass II. Class II-A: Man necessary in his civilian activity. (3) Glass III Class I II-A : Man with dependents. (4) Glass IV. Class 1V-A ; Man who has completed service. Class IV-B: Official deferred by law. ('lass IV-C: Nondeclarant alien. ('lass IV-D: Minister of religion or divinity student. Class TV-E: Conscientious objector available only for civilian work of national importance. Class IV-F: Physically, mentally, or morally unfit. 54. Nontuberculous conditions.—a. In general, any condition which may reasonably be expected to inhibit the activities required in military life or serve as an excuse from performing an assignment should be considered basis for disqualification. Moreover, rejection should be recommended where the findings indicate a lesion or condi- tion which may be aggravated by military service or be cited as basis of claim for a pension. 78 TM 8-275 54 MILITARY ROENTGENOLOGY b. As examples of such unacceptable findings the following non- tuberculous conditions are cited in regulations: (1) Tumors of the soft tissues of such size and location as to inter- fere with the wearing of the uniform or military equipment, or any malignant tumor. Figure 45.—Erosion of sternum by malignant tumor. (Interest was directed to the sternum in this case but routinely the thoracic cage should be studied for invasive or metastatic lesions.) 451112°—42 6 79 TM 8-275 54 MEDICAL DEPARTMENT (2) Anomalies of the thorax such as Sprengel’s deformity or dysostosis of the clavicles. Minor degrees of such may be recognized as class I-B provided they do not prevent the registrant from suc- cessfully following a useful vocation in civil life. Figure 46.—Dysostosis of clavicles. (Note triangular configuration of thorax; absence of clavicles ; prominent spines of the scapulae. Some of these individuals can easily handle Army equipment because of compensatory muscular developments.) so TM 8-275 54 MILITARY ROENTGENOLOGY Figure 47.—Sprengel's deformity. (Note elevation and rotation of left scapula ; fixation to cervical spine (by way of omohyoid process) ; curvature of spine (compensatory) and other anomalies—in this case, spina bifida involving lower cervical and upper thoracic vertebrae.) 81 TM 8-275 54 MEDICAL DEPARTMENT (3) Ununited fractures of the ribs, infections of the ribs (such as actinomycosis), or deformities of such degree as to interfere with physical activities (lesser degrees of such may be classified as I-B). Figure 48.—Ununited fractures. (Note residual fracture gaps, eighth, ninth, and tenth ribs, left.) 82 TM 8-275 54 MILITARY ROENTGENOLOGY (4) Herniation or eventration of the diaphragm. Figure 49.—Eventration of diaphragm. (Note elevation of entire left dome; air contained in stomach beneath.) 83 TM 8-275 54 MEDICAL DEPARTMENT Figure 50.—Herniation of diaphragm. (Note relatively normal position of peripheral portions of left dome and sacculation in mesial portion.) 84 TM 8-275 54 MILITARY ROENTGENOLOGY (5) Spontaneous pneumothorax. Figure 51.—Pneumothorax. (Note absence of pulmonary markings in superior and lateral aspects of left thorax and demarcation of lung boundaries.) 85 TM 8-275 54 MEDICAL DEPARTMENT (6) Empyema or unhealed sinuses of the chest Figure 52.—Empyema. (This case is included in order to emphasize the dimensions which may be attained by a walled-off pocket. These may be located in basal, parietal, or interlobar positions. Evidence of free fluid would be disqualifying, though it is less likely that such cases would be physically active.) 86 TM 8-275 54 MILITARY ROENTGENOLOGY (7) Evidence of acute pleural inflammations or chronic pleural thickenings of such degree as to obscure the pulmonary markings over a considerable portion of the lungs such as a volume comparable to the right upper lobe. Figure 53. Acute pleurisy. (These cases do not always present roentgen evidence. Per- tinent criteria may include contraction of ribs ; elevation of dome of diaphragm (involved side) ; localized densities of such degree that pulmonary markings may be discernible through them and possibly evidence of fluid in the diaphragmatic sulcus—all of which criteria can be seen in this case.) 87 TM 8-275 54 MEDICAL DEPARTMENT Figure 54.—Thickened pleura, residual to chronic process. (The degree of thickening shown in tills case is sufficient to disqualify because dormant inflammatory processes may be concealed.) 88 TM 8-275 54 MILITARY ROENTGENOLOGY (8) Tumors of the pleurae. Figukb 55.—Tumor of pleura. (Note multiloculation and complete margination of mass.) 89 TM 8-275 54 MEDICAL DEPARTMENT (9) Pulmonary emphysema with impairment of function or definite cystic disease of the lung. Figure 56.—Emphysema, both bases. (Note flattening of domes of diaphragm ; expansion of Intercostal spaces; increased radiographic densities; and honeycomb structure of lung parenchyma. Lateral studies of these cases will oftentimes reveal an increased anterior-posterior diameter of the thorax and conspicuous pneumatization anterior to the outline of the heart. This particular case also shows a fibrin ball over the mesial aspect of the right dome.) 90 TM 8-275 54 MILITARY ROENTGENOLOGY (10) Silicosis of so-called second degree or more severe, as mani- fested roentgenological ly by disseminated nodular densities in addition to the strandlike densities and enlarged lymph nodes. Fkjuke 57.—Pneumokoniosis, second degree. (Note conspicuous pulmonary markings through all zones of both lungs ; disseminated nodular densities in addition to enlarged hilar lymphatics. This particular case shows marked emphysema at the bases.) 91 TM 8-275 54 MEDICAL DEPARTMENT (11) Chronic bronchitis with emphysema, bronchiectasis. Figure 58.—Bronchiectasis and compensatory emphysema. (Note conspicuous pulmonary markings through hilar and midzones of lower lobes—most frequent locations for bronchiectasis ; “Swiss cheese” pattern through these areas. The lateral aspect of the right lower lobe shows moderate emphysema. The paranasal sinuses should be studied in cases such as this one, where there is evidence of chronic lower lobe bronchitis.) 92 TM 8-275 54 MILITARY ROENTGENOLOGY (12) Foreign body in the lung. Figure 59.—Foreign body in lung. (Note outline of pin in lingular portion of left uppe lobe. Metallic foreign bodies may remain for long periods of time without excitim tissue reactions, whereas irritating oils such as contained in peanuts will produce ; marked reaction with abscess formation.) 93 TM 8-275 54 MEDICAL DEPARTMENT (13) Acute inflammatory lesions of the lung such as bronchitis (may classify as I-B), lobar- or broncho-pneumonia (may classify as I-B), abscess, etc. Figure 60.—Vincent's pneumonitis. (Marked inflammatory changes such as demonstrated in this case may occur in mycotic infections or in infections by Vincent's organisms without there being extreme physical depletion.) 94 TM 8-275 54 MILITARY ROENTGENOLOGY Figure 61.- Mycosis of lung. (The roentgen criteria may very closely simulate those concerned with reinfection tuberculosis but considering the degree of involvement, the patient is likely to be in better physical condition if the lesions are due to fungus. More- over, except in the case of the ray fungus (actinomycosis), fungus lesions may become moderately advanced without there being any conspicuous nodular lesions.) 431112° 42 7 95 TM 8-375 54 MEDICAL DEPARTMENT (14) Tumors of the lung or mediastinum. Figure 62.—Neoplasm of mediastinum. (These lesions are usually globular in outline, sharply marginated. They may attain considerable size without there being any appreciable symptoms.) 96 TM 8-275 54 MILITARY ROENTGENOLOGY Figure 63.—Bronchogenic carcinoma of lung. (Note evidence of atelectasis in addition to “sun ray” infiltration density of tumor.) 97 TM 8-375 54 MEDICAL DEPARTMENT (15) Abnormalities in the configuration or diameters of the heart in proportion to the diameters of the thorax. These cases warrant additional studies such as teleroentgenographic projections onto large films and fluoroscopic studies, if possible. Figure 64.—Enlargement of right ventricle. (Note increase in oblique diameter of heart and in this case residua of pulmonary infractions (left auxiliary region and right base).) 98 TM 8-275 54 MILITARY ROENTGENOLOGY Figure 65.—Enlargement of left ventricle. (Note increase in transverse diameter of cardiac silhouette, apex of heart being deviated to left and downward.) 99 TM 8-275 54 MEDICAL DEPARTMENT Figure 66.—Coarctation of aorta. (Note pulsation erosions—scalloping along inferior borders of ribs ; inconspicuous knob of aorta. Some of these cases will also show a conspicuous left ventricle (increase in the transverse diameter of the cardiac silhouette) and in most of the cases the systolic blood pressure is greatly increased.) 100 TM 8-275 55 MILITARY ROENTGENOLOGY 55. Tuberculous lesions.—a. Two phases of pulmonary tuber- culosis are recognized : the primary or initial phase and the reinfection phase. Because of a different type of bodily reaction to the first versus the second bacterial invasions, certain roentgen characteristics defi- nitely distinguish these two phases. b. The average prognosis of the primary phase of tuberculosis is quite different from that of the reinfection phase. Unless extensive, a primary lesion usually involutes with calcification and substantial fibrosis. The calcification occurs after necrosis of tissue. Evidence of it simply indicates considerable reaction on the part of the in- dividual and a protective fibrosis is usually found concurrently with it. After retrogression, recurrent activities of these lesions are rea- sonably unlikely. The type of reaction to a reinfection lesion is usu- ally quite different. Here, fibrosis ordinarily occurs before autolysis, and calcification of the lesion and the type of fibrosis may be oidy partially protective. Moreover, the mere fact of reinfection signifies inability on the part of the individual to resist the second invasion or extension of a process. Though overwhelming infection or the depletion of bodily reserves may be responsible, further reactivation of reinfection lesions is to be considered as not unlikely. The in- cidence of breakdown of these lesions is dependent upon the care and the type of existence of the individual, but the relatively poor prog- nosis of reinfection cases as compared with those of the primary phase might be emphasized by the fact that approximately 30 percent of reinfection lesions require further hospital care following an apparent cure, while no more than 4 percent of primary lesions have shown breakdown, within the age groups of military personnel. g. The primary phase is characterized by lymph node involvement; it may include one or more pneumonic consolidations. The involved lymph nodes may be located in the cervical region or they may be located in the intermediary zones of the lungs, but they are usually to be found in the hilar regions or in the vertebral gutters. Pneu- monic processes are usually located in the hilar or intermediary thirds of the lung fields, though occasionally they are found in the very periphery of the lungs. There may be several pneumonic processes and, in fact, actual miliary lesions may be developed in the primary phase. d. In contradistinction, the reinfection phase is characterized by an infiltrative process which is essentially concerned with the lung paren- chyma or with the bronchi and the peribronchial lymph channels. This phase is usually manifested, therefore, by strandlike densities which extend according to bronchial arborizations and which are 101 TM 8-275 55 MEDICAL DEPARTMENT therefore likely to be found in the peripheral third of the lungs. Par ticularly, if this type of lesion is found in the apices or in the retro Figure 67.-—Pulmonary tuberculosis, primary phase. (Note enlarged paracervical and hilar lymph nodes on right side. The dimensions of these lymph nodes plus the fact that there is no evidence of fibrosis or calcification signify activity of the process, though the indi- vidual may be fairly active, simply feeling slightly under par.) clavicular regions, it is most likely that they are manifestations of the reinfection phase. 102 TM 8-275 55 MILITARY ROENTGENOLOGY e. Any evidence of activity of a primary lesion is cause for rejection. Activity may be manifested by a soft tissue density outlining a pneu- monic consolidation or by the outline of enlarged lymph nodes. In Figukb 68.—Pneumonic consolidation, primary phase. (Note localized consolidation, right lower lobe. The infection has not yet extended to the lymph nodes in this case. The patient had been steadily active; he was a medical interne whose tuberculin skin tests had been negative until after the finding of this lesion.) either case, mere stipplings of calcific density should be considered as indication of an unstable lesion and therefore cause for rejection temporarily. Likewise, lesions which consist of a central calcific 103 TM 8-275 55 MEDICAL DEPARTMENT density having a periphery of lesser tissue densities (perifocal reac- tion) should he considered uncertain as to healing and therefore the individual should be disqualified at least temporarily. Actual cavi- tation might be found during the primary phase; such evidence Figure 69.—Involuting lesion in lymph nodes. (The number of lesions visualized in this case would not be sufficient to disqualify the individual, but the dimensions of the one or two large lymph nodes in the left hilum and the stippled character of the calcification signify incomplete involution of the process and for this reason the individual should be rejected.) should be considered indicative of activity and therefore disquali- fying. Calcific lesions which are homogenously dense and sharply circumscribed might be acceptable provided their dimensions are not too great and there are not too many of them. In order to pro- vide for uniformity of decisions, arbitrary limits are cited as follows: 104 MILITARY ROENTGENOLOGY TM 8-275 55 there may be as many as 15 of these lesions, 5 being located within lymph nodes and 10 in the lung parenchyma. Those located in the lymph nodes must not be of dimensions greater than 1.5 centimeters. Figdke 70.—Involuting lesion in parenchyma. (Note residual consolidation in lateral aspect of left lower lobe. Large film studies revealed a central calcification with a peripheral fading of the density. Such lesions may continue to retrogress, provided suitable rest and nourishment are supplied, or these lesions may suddenly progress into an extensive reinfection type of tuberculosis. Therefore, these findings should serve to disqualify for the present.) Of those located in the lung parenchyma, no more than one may he as large as 1 centimeter in greatest dimension while the others must not be greater than 0.5 centimeter in greatest dimension. These measure- 105 TM 8-275 55 MEDICAL DEPARTMENT nients may be estimated on the basis of studies made by reduction roentgenography (that is, using the miniature films), but the measure- ments pertain to actual size as they would be projected teleroent- genographically onto 14- by 17-inch films. These studies should be Figure 71.—Disqualifying single primary lesion. The character of the reaction processes in this case appears to be substantial but because of the dimensions of the lesion, this case should be disqualified. accomplished wherever there is uncertainty because of the factors of distorted proportions and the reduction inherent to the miniature film procedure. /. Any evidence of a reinfection lesion must be considered basis for disqualification. Later acceptance of an individual having very minimal lesions might be possible, provided after a period of 6 months 106 TM 8-275 55 MILITARY ROENTGENOLOGY there is found to be neither progression nor regression of the lesion. Such final acceptances must be limited to a very small percentage of these cases for the extent of these lesions must not exceed in dimen- sions a volume of lung parenchyma such that, when projected onto Figure 72.—Multiple primary lesions. Though the lesions in this case appear to he healed because of there being more than 15, the individual should not he accepted. a standard 14- by 17-inch roentgenogram, the involvement will be con- fined to an area no greater than 5 square centimeters. Reinfection lesions are characterized by strandlike densities. Lymph node en- 107 TM 8-275 55 MEDICAL DEPARTMENT largements are not a part of their picture. Their pattern may appear merely as exaggeration of the normal pulmonary markings or as nodulations and definite consolidations. Misinterpretation of promi- Piguee 73.—Pulmonary tuberculosis, reinfection phase, minimal. Note the calcific density in the right hilum. This likely represents the primary lesion. The infiltrate in the lateral aspect of the right upper lobe is the beginning reinfection lesion. When projected onto a 14- by 17-inch film, this particular lesion measured approximately 5 square centi- . meters—the maximum area dimensions permitting reconsideration after a period of 6 months. nent pulmonary markings, due to underexposure of the roentgeno- gram or to movements of the pulmonary vessels, must not be confused with tuberculous processes. In contradistinction, reinfection lesions 108 TM 8-275 55 MILITARY ROENTGENOLOGY are generally localized; the fuzzy markings which depict them are not usually distributed uniformly throughout the entire lung fields, ex- cept in extreme degrees which would be readily recognized. Rein- fection lesions usually follow one or another bronchial distribution Figukb 74.—Typical reinfection lesion. Note the location of the infiltrates—the peripheral aspect of the upper lobe, the infraclavicular region. The fuzzy pattern of this infiltrate suggests activity and the extent of involvement compels disqualification without reservation. and therefore, even in their earliest stages, they should be identified after glancing over other portions of the lung fields and noting the more delicate pattern of the normal lung as compared with the coarsened and fuzzy pattern of an involved portion. 109 TM 8-275 55 MEDICAL DEPARTMENT Figuke 75.—Very early stage of reinfection tuberculosis. (This study emphasizes the im- portance of certain inconspicuous lesions. Note very delicate arborization in axillary portion of right lung. This should have been noted if care had been taken to follow a definite sequence of analysis. The contraction of the ribs in the region of the lesion would have been noticed an then, doubtless, significance would have been placed in the delicate arborization of pulmonary markings found in the peripheral third of the right middle lung zone. Note rapidity of break-down during succeeding 8 months as visualized in figure 76.) 110 TM 8-375 55 MILITARY ROENTGENOLOGY Figure 76.—Reinfection tuberculosis, moderately advanced. (This study shows how ram- pantly an active tuberculous process may progress under conditions of military life.) (See fig. 75.) 431112° 42 8 ill TM 8-275 55 MEDICAL DEPARTMENT g. Cavitation may occur either during the primary phase or dur- ing the reinfection phase. Regardless of the size of any cavities, they should be considered cause for rejection. However, rather than misin- Figuke 77.—Cavitation in pulmonary tuberculosis. (Note that complete encirclement of this cavity is evident by a definite wall. The location of the cavity is characteristic, being in the peripheral third of an upper lobe. The absence of a fluid level and the thin wall depict the cavity as of tuberculous nature.) terpret superimposed pulmonary markings which may present the appearance of cavitation, it is always important thoroughly to visual- ize a cavity by obtaining projections from various angles; utilizing 112 TM 8-275 55 MILITARY ROENTGENOLOGY obliques, laterals, and stereoscopic studies, and films of standard dimension, if necessary. h. Mere evidence of a pleural cap (that is, thickening of the pleura over the apex of either lung) or of diaphragmatic tentings should Figure 78.—Apical caps. (The heterogeneous densities which cap the apical portions of both upper lobes are partly due to thickened pleurae. Whereas such evidence alone is of no importance, an underlying infiltrate as found in the left upper lobe of this case (both above and below the left clavicle) is basis for disqualification.) not be considered cause for rejection unless there are found, extending from either of them, definite parenchymal lesions. Then, evaluation of the findings should be based upon identification of the phase of the disease process. Widespread pleural thickenings might be considered 113 TM 8-275 55 MEDICAL DEPARTMENT Figure 79.—Diaphragmatic tentings and calcification of pleura. (Mere evidence of strands extending from the diaphragm or of calcifications in the pleurae such as visualized in this case should not serve to disqualify. However, careful search should be made for any walled-off pockets or for evidence of adhesions to the pericardium, which findings should disqualify.) 114 TM 8-375 55 MILITARY ROENTGENOLOGY cause for rejection, provided their etiology is not attributable to a nontuberculous episode and provided the thickenings of the interlobar septa or of the diaphragmatic or parietal coverings are such as pos- sibly to obscure a focus of dormant infection. Calcifications in the Figuee 80.—Obliteration of diaphragmatic sulcus. (This case shows considerable pleural thickening. Studies should be made to rule out the possibility of free fluid or walled-off pockets of inflammatory media. If there is no such evidence, these findings should not disqualify.) pleurae are not considered to be of the same degree of importance as calcifications in the lung parenchyma or lymph nodes. Unless pa- renchymal lesions are found extending from them, acceptance or rejec- tion of such cases should be based upon the extent of the pleural involvement as above described. Obliteration of the diaphragmatic 115 TM 8-275 55 MEDICAL DEPARTMENT sulci because of pleural thickening may not be of serious importance or basis for rejection. In such cases a twofold assurance should be established: assurance that ample margin of vital air capacity remains; and assurance that there are no concealed pockets or empyema (that is, dormant or active inflammatory media). i. The above descriptions have been limited to more or less border- line cases where some doubt might exist as to whether an individual should be accepted or disqualified. Moderately advanced or far advanced lesions of reinfection tuberculosis would likely prevent any individual from being sufficiently active that he would be examined for service in the Army and in the case of those already in the serv- ice, the diagnosis would doubtless have been established during earlier stages. At least, these more developed processes would readily be recognized and there should be no doubt as to proper handling of them. Miliary lesions, whether they present evidence of instability or of having healed, must be considered disqualifying. With con- siderations of responsibilities on the part of the Government, not only prognosis and the probabilities of break-down must be considered but also the possibilities of claims being made later merely because of the presence of lesions which are likely to become known to the individual. j. In general, a disqualification which is based upon a diagnosis of a reinfection phase of tuberculosis will usually be permanently effective, whereas a disqualification which is based upon a diagnosis of an unstable primary lesion provides for later reexamination and possibly later acceptance. It must be emphasized that the clinical aspects of any doubtful cases must be considered. The criteria listed pertain to cases where explanations cannot be based upon pyogenic pneumonic processes or a background of other infections. Table II emphasizes acceptable versus unacceptable criteria. 116 TM 8-275 55 MILITARY ROENTGENOLOGY Table II Phase Acceptable Unacceptable Primary Definitely active (1) Pneumonic consolidation, isolated or few (usu- ally located in hilar or mid zones; pos- sibly lobar or miliary). (2) Enlarged lymph nodes (usually located in hilum; possibly para- tracheal, midlung zones, or cervical). (3) Cavitation. (1) Residual parenchymal consolidation (possi- bly showing central calcific density but a periphery of lesser densities fading into those of normal paren- chyma) . (2) Stippling of calcific den- sities (either in paren- chymal lesions or in lymph nodes). (1) Parenchymal nodula- tions, multiple, more than ten in number, or if the diameter of any one is greater than 1.0 centimeter or if more than one is larger than 0.5 centi- meter. (2) Lymph node densities, multiple, more than five in number or if a diameter of any one is greater than 1.5 centimeters. Unstable Stable (1) Parenchymal nodulation (usually calcific in den- sity), provided there are no more than ten such and provided no more than one of these has a diameter as great as 1.0 centimeter, the others having no larger diameter than 0.5 cen- timeter. (2) Residual lymph node densities (calcific), pro- vided there are no more than five such and provided their diameters are no greater than 1.5 centi- meters. (3) Pleura] cap, without un- derlying parenchymal lesion of significance. 117 TM 8-275 55 MEDICAL DEPARTMENT Table II—Continued Phase Acceptable Unacceptable Primary—Con. Stable—Con (4) Diaphragmatic tenting without overlying parenchymal lesions of significance. Reinfection Definitely active (1) Hazy, strandlike, and diffusely nodular den- sities in the lung par- enchyma. Unstable. . (2) Bronchopneumonic or lobar consolidations. (3) Cavitations. (4) Pleural effusion. (5) Pneumohydrothorax. (1) More or less sharply de- marcated strandlike den- sities infiltrating a volume of lung parenchyma which when projected onto a standard 14- by 17-inch roentgenogram would measure more than 5 square centimeters. (2) Pleural thickenings of such degree as possibly to obscure a dormant infec- tion. Sharply demarcated strand- Questionable sta- Sharply demarcated strand- bility. like densities infiltrating a like densities, as just de- volume of lung pareuchy- scribed, but involving less ma which when projected volume of lung parenchy- onto a standard 14- by 17- ma. Such cases should inch roentgenogram would be restudied after an in- measure less than 5 square terval of 6 months. centimeters and which has shown no progression or regression in size or ap- pearance after an interval of 6 months. 118 TM 8-275 56 MILITARY ROENTGENOLOGY’ 56. Confusing1 evidence.—a. Particularly when studying films directly rather than stereoscopically, a number of normal densities may serve to obliterate important detail of pathology. Occasionally these densities have been misinterpreted and reported as actual pa- Figure 81.—Cervical rib, right thology—a very serious error not only because the services of the indi- vidual may thereby be lost to the Government but also because such errors may impose a psychic shock upon the individual unneces- sarily. Intelligent identification of the densities in the upper por- tions of the thorax is especially important since lesions of tuberculosis are so characteristically located in the apices of the lungs. no TM 8-275 56 MEDICAL DEPARTMENT h. In case the head is insufficiently extended during the exposure, there may be superimposition of the densities of the chin or cheeks upon the upper lung fields: if the head is overextended, the density of the occiput will be superimposed. These relations would prevail Kiguke 82.—Conspicuous nock folds. (In this particular case a tuberculous infiltrate was almost overshadowed by the fold in the left para tracheal regions.) particularly if the focal spot of the X-ray tube is alined to a high level with respect to the chest. c. The densities of cervical ribs or of neck folds may likewise lead to confusion. 120 TM 8-275 56 MILITARY ROENTGENOLOGY d. As previously emphasized, mere thickening of the pleura over the apices (pleural cap) should not by itself be considered basis for rejection. Post mortem studies have indicated a very substantial degree of fibrosis in most of these lesions. Occasionally, there are Figdkk 83,—Azygos septum. (Note crescentic outline of azygos septum. These septations are always located in the apical portion of the right thorax. They occur in approximately 10 percent of individuals and must not be misinterpreted as a tuberculous infiltrate.) associated with them definite parenchymal lesions which may not be clearly discernible because of the density of the pleural cap itself. Therefore, particular search must be made for underlying paren- chymal lesions in all such cases. e. The septatiou produced by the azygos vein is not infrequently visualized and occasionally the innominate or subclavian vessels may 121 TM 8-275 56 MEDICAL DEPARTMENT cast a shadow. These densities are likely to be more conspicuous on the miniature film than on the standard 14- by 17-inch film because of the relatively short focal screen distance (resulting in magnified distortion) and the subsequent photographic reduction (resulting in Kiguuk 84.—Visualization of subclavian vessel. (Note ribbonlike density in left apex outlined by arrow markings. When there happens to be sufficient contrast provided by air space about the greater vessels, they are visualized as in this case.) sharpening of the detail). These densities must not be misinter- preted. as tuberculous infiltrates. /. Particularly if a pocket of air surrounds a soft tissue tumor such as a papilloma or even a normal nipple during the exposure, a con- spicuous density may be produced, presenting the appearance of a pneumonic consolidation. g. A bifid rib may produce an outline which might be interpreted as cavitation. 122 TM 8-275 56 MILITARY ROENTGENOLOGY h. Calcifications in costal cartilages or in the pleurae may be erroneously interpreted as calcifications within lymph nodes or in the lung parenchyma. i. When located in the region of the arch of the aorta, enlarged lymph nodes may not be recognized. In the postero-anterior projec- Fiuube S5.—Superficial papilloma presenting appearance of pneumonic consolidation. (Note spherical density in left lower thorax. Lateral projections established the fact that this density was produced by a superficial papilloma.) tion they may present the appearance of a distorted or widened “knob.” Considering the age of most candidates for the service, it would be rare that arteriosclerosis should be encountered or that rotation of the arch might be explained on any other basis. There- fore, oblique and lateral studies should be made on all such cases, in order to provide for the separation of the mediastinal densities and 123 TM 8-375 56 MEDICAL DEPARTMENT to visualize more clearly any enlarged lymph nodes which might be located in the hilar regions proper or in the vertebral gutters or the retrosternal regions. j. Apparent tentings of the diaphragm may actually represent strands of pleural septa, particularly as concerned with the inferior Figure 86.—Bifid rib. (Note abnormal appearance of anterior portion of left third rib. Occasionally, these bifurcations are interpreted as cavities.) accessory lobes (which are present to some extent in 40 to 50 percent of individuals). k. Platelike atelectases are occasionally seen. They may present the appearance of a tuberculous infiltrate. They should be con- sidered where the densities are of a crescentic or flattened pattern— 124 TM 8-375 56 MILITARY ROENTGENOLOGY versus the more arborized pattern of the tuberculous infiltrate. Such cases warrant reexaminations following a period of deep breathing. If these studies reveal a reduction in their size or a disappearance of the densities, the individual should not be disqualified. Occasionally, Figure 87.—Calcification of costal cartilages. (These calcifications should be recognized because of their alineinent to the borders or the axes of the ribs.) these localized atelectases are produced because of compression phe- nomena due to large bullae or blebs. In such cases they should be made more conspicuous after deep breathing and the individual should be disqualified. 125 TM 8-275 56 MEDICAL DEPARTMENT Figure 88.—Retrosternal lymph node. (In the postero-anterior projection, the outline of this lymph node is partially superimposed upon the density of the aorta.) 12G TM 8-275 56 MILITARY ROENTGENOLOGY Fiauuifl 89.—Retrosternal, oblique study. (Note distinct visualization of two enlarged lymph nodes provided by this study.) (See fig. 88.) 431112° 42 0 127 TM 8-275 56 MEDICAL DEPARTMENT Figure 90.—Septation of inferior accessory lobe. (The strands indicated by the arrows are not infrequently interpreted as pleural adhesions but they should be recognized as septa associated with the inferior accessory lobe.) 128 TM 8-275 56 MILITARY ROENTGENOLOGY Figure 91.—Platelike atelectasis. (Note compressed strand extending horizontally across left mid-lung zone and absence of regional infiltration.) 129 TM 8-275 56 MEDICAL DEPARTMENT I. The outline of a cross section of a bronchus may present the appearance of a cavity. Figuke 92.—Cross section of large bronchus. (Note circular outline in paraspinal region of right seventh interspace. These configurations should be recognized as cross sections of a bronchus. They are easily identified by stereoscopic studies or by making compara- tive studies, varying the relative position of the focal spot.) 130 TM 8-375 56 MILITARY ROENTGENOLOGY Figure 93.—Prominent trunk of pulmonary artery. (Due to contrast of air in front ot the trunk of the left pulmonary artery, this vessel may be conspicuously visualized and in some cases falsely presents the appearance of an enlarged lymph node.) 131 TM 8-275 57 MEDICAL DEPARTMENT Section VIII ROENTGEN THERAPY 1 General 57 Dangers 58 Types of lesions warranting this treatment 5D Collateral treatment - 60 Dosage calibration 61 Paragraph 57. General.—a. Relatively long wave length X-ray therapy may be indicated for certain infections and dermatoses which may he encountered in the field of combat. One should not expect to be encumbered with the treatment of neoplasms in the forward zone. Therefore, as far as the requirements of the mol tile surgical hos- pital or the evacuation hospital are concerned, high kilovoltage and high filtration X-ray therapy need not be provided. h. The regulation of the high-tension transformer included with item No. 96085 and the design of its autotransformer provide for kilovoltages as high as 100 with a milliamperage load of 4. It has been found that the shockproof cables of the first lot of these units do not tolerate more than 90 kvp. These particular shockproof cables can be identified by their having full-length outer metallic sheathings. Later constructions include shockproof cables of more substantial dielectric strength and these can easily tolerate a kilovoltage of 100 with the load of 4 milliamperes. These latter shockproof cables can be identified by the fact that outer metal sheathings cover only 9 inches of each of their extremities. Regardless of the fact that considerable reserve of dielectric strength is being provided with the latest type of cable, it is important that the radiologist bear in mind that the X-ray performance of this machine is by way of self-rectifica- tion. In case a load greater than 4 milliamperes is imposed, two maleffects would be incurred: added punishment would be imposed upon the target of the X-ray tube; and the difference between the useful voltage and the inverse voltage would be increased, thereby subjecting the shockproof cables to potentials considerably greater than 100 kvp for each unused half cycle. In the same way, exces- sively high potentials would be imposed by disregarding the limit of 100 kvp, useful voltage, and permitting higher settings. Thus it is important that the limits, 100 kvp and 4 ma„ are not exceeded. However, these capacities may be tolerated continuously. 1 As provided with the standard X-ray machine unit, item No. 96085. 132 TM 8-275 58 MILITARY ROENTGENOLOGY 58. Dangers.—a. Three phases of danger are to be considered with respect to this type of X-ray therapy: (1) X-radiation dangers as far as the technicians and attendants are concerned. (2) X-radiation dangers as far as the patient is concerned. (3) Electrical dangers for those in contact and break-down of the equipment. b. The maleffects of X-radiation are described in the National Bureau of Standards Handbook HB-20, and TM 8-240. It must be emphasized that when operating with kilovoltages as used for X-ray therapy the X-rays concerned with the primary beam are much more penetrating and much greater in quantity than are those used for roentgenography and that, moreover, the shorter wave lengths of the therapy range are productive of considerably more secondary radiation, which is injurious to those who receive repeated exposures. The X-ray technician who is delegated to perform these duties should be instructed to operate the unit at the greatest possible distance from the primary beam and from the patient (see fig. 94), and at all times the primary beam should be directed either downward or in a direction away from the operator. Similar consideration should be given to other attendants in a ward as well as to nearby patients. It is real- ized that lead protective panels will not often be available but should they be, their protection should be utilized. It is important that fre- quent blood counts be made of technicians engaged in this type of work. These examinations should be accomplished at least once a month and they should include both a red cell count and a white cell count. c. Though the quality of the X-rays as developed with a kilovoltage of 100 is considered to be of short wave length as compared with the wave length utilized for roentgenography, nevertheless these wave lengths are relatively long as compared with the usual X-ray wave length utilized in roentgenotherapy. It is impractical to use filters greater than 3 to 5 millimeters of aluminum. With no added filtra- tion and even with this amount of filter added, the wave lengths are of a quality such as to be the most destructive of any wave lengths used for X-ray therapy. It should be a very definite rule that the total dosage (summation dosage) must never exceed 400 r-. More- over, the treatment field should be limited to the utmost. All por- tions not requiring treatment should be protected, utilizing the limitations of lead diaphragms (as contained in the metal carbon which is used for packing the shockproof cables) or utilizing the protection of lead aprons or sheet lead which may be available. 133 TM 8-275 58 MEDICAL DEPARTMENT Figure 94.-—Roentgenotherapy as administered in the field. (Note protection given patient, except for limited areas where X-radiation is desired. Also note that protection to operator is accorded mainly by distance and his precautions as to positioning the X-ray tube properly.) 134 TM 8-275 58-59 MILITARY ROENTGENOLOGY When fields larger than 10 by 10 inches must be used, the summation dose should be limited to 300 r-. Before giving any X-ray therapy it is well to inquire of the patient and his records as to the type of treatment previously received. If previous X-ray therapy has been given or if solutions irritating to the tissues (such as, bichloride of mer- cury, Dakin’s solution, or tincture of iodine) have been used, X-radi- ation should be started with the utmost of caution or not at all. d. Even though this equipment is shockproof in design, several precautions must be exercised to provide for trust of the shockproof features. The ground wire, which is connected to a clip and adjacent to the wall plug, should be securely fastened to a metal housing such as is usually found at the wall receptacle, or to a water pipe or radiator. Electrical break-down is likely to take place in sites of strain such as produced by sharp angulations. Therefore, both for electrical security and preservation of the shockproof cables, precau- I ion should be exercised that all kinkings and sharp angulations are smoothed out or avoided. 59. Types of lesions warranting this treatment.—a. Long- wave length X-ray therapy of the type generated by this machine unit should be considered only for infections, dermatoses, and the most superficial (skin surface) neoplasms. h. Some of the infections which may be encountered in the zone of combat are gas gangrene, aerobic cellulitis, including erysipelas, subcutaneous abscesses, carbuncles, furuncles, lymphogranuloma venereum, lymphangitis, lymphadenitis, and even thrombophlebitis (only the acute stage should be treated with X-ray therapy). It should be realized that the more acute the process, the more respon- sive it is to X-ray therapy. Moreover, the more acute the process the less treatment dose will it tolerate. For very acute lesions, it is well to limit the dosage to 50 r- for any one seance and to repeat such treatments twice daily, in the early morning and in the late afternoon. For less acute lesions, it is well to consider 75 r- as the average single treatment dose and to treat once a day or at intervals of a few days. c. Before treating any dermatoses, a differential consideration should be given to the possibilities of parasites having been respon- sible. With the congestion of mobilizations, parasitic dermatoses can be expected to be of high incidence and X-ray therapy has no place in their treatment. Neither should X-radiation be used for treating chronic recurrent lesions such as psoriasis or chronic eczemas. Some of the dermatoses which might be considered for X-radiation therapy are acute folliculitis, pyogenic or mycotic sycoses, acute 135 TM 8-275 59 MEDICAL DEPARTMENT Figure 95.—X-radiation performance of average unit (item No. 96085), with considers lions of deliveries of X-radiation through various filters provided and at various practical focal skin distances. (The quality of X-radiation is thus also indicated in terms of half value layers. All these measurements were made in air without allowance for backseat ter.) 136 TM 8-275 59-60 MILITARY ROENTGENOLOGY dermatomycosis, acute eczemas presenting intolerable pruritus, and herpes (simplex and zoster). X-ray therapy can he expected quickly to alleviate the annoyance by any of these lesions and to involute these processes within a few days. It must be realized, though, that relatively large fields may be required and therefore particular pre- cautions must be taken in order to avoid an overdosage (which might produce not only local injury but depletion of blood cells). d. While it is not reasonable that superficial malignancies should be treated in the field, nevertheless they may be treated in the genera] hospitals with the use of this equipment. For them, it is most important that the treatment field be constricted to the minimum, for very large total dosage is required to get results. For basal cell carcinomas, the total dosage should be 4,000 to 6,000 r-; for squamous carcinomas, it should be 5,000 to 7,000 r-; while for adeno cystic carcinomas, it should be 6,000 to 8,000 r-. Pre-biopsy radiation to the extent of 1,500 to 2,500 r- should be applied (may be given at one time) and a biopsy should then be obtained. These treatments may be divided (particularly if the dimensions are larger than 2 centi- meters in diameter) but the total dosage should be administered within a time limit of 2 to 3 months. Drainage channels and regional lymph nodes should not be treated with this quality of radiation except inso- far as treatment of secondary infection might be considered. When such is evident, it is well to precede the treatment of the neoplasm itself by treating the infection. The regimen of this treatment is indicated in h above. 60. Collateral treatment.—Some degree of injury is always pro- duced by X-radiation, Benefits attributable to X-radiation are de- rived by way of injury to one or another tissue. This fact emphasizes the importance of providing supportive treatment. X-radiated skin will not tolerate bichloride solutions, tincture of iodine, or sirniliar irritating antiseptics. Even moderate and certainly excessive heat and sun radiation should not be superimposed. Icthyol ointment (10 percent) may well be tolerated, particularly in conjunction with X-ray therapy for the superficial infections. It may serve to restrict the flow of virulent organisms along sweat channels. For weeping sur- faces or where sweat is annoying, Dodd’s lotion may be beneficial. 1( consists of the following: Phenol 2 Glycerin 12 Zinc oxide 24 Lime water 240 137 TM 8-275 61-62 MEDICAL DEPARTMENT 61. Dosage calibration.—It lias not been possible to calibrate each individual X-ray machine unit. Average values are given in figure 95. It must be realized that the performance of the individual units vary as much as 10 percent plus or minus in relation to the values indicated. Section IX PROTECTION AGAINST X-RADIATION HAZARDS General 62 Primary versus secondary X-radiation 63 Exposures during fluoroscopy 64 Surgery with fluoroscopic visualization 65 Exposures incurred during photoroentgenography 66 Exposures during conventional roentgenography - 67 Protection features of field X-ray equipment 68 Limitation of protection by lead aprons and lead-impregnated gloves 63 Checking as to X-radiation exposures 70 Paragraph 62. General.—a. It is a widely known fact that a single large exposure to X-radiation or repeated small exposures to it may produce tissue injuries such as dermatitis, endothelial changes with the possi- bility of ulcer formations or neoplastic developments in the skin, de- struction of blood cells, inhibition of the hematopoetic system (with the production of an anemia or leucopenia), neoplastic changes of it (with the production of a leukemia), inhibition of glandular activities (in particular, of the reproductive glands), and actual deformations of a growing fetus. Besides these effects, there is substantial reason to believe that latent malconsequences may occur, these being con- cerned with genetic cellular function. This latter effect may prevent survival of tissue developments or it may lead to abnormalities of development—abnormalities in the individual and eventually in the race. These facts might be emphasized by quoting some of the statis- tical data obtained by Hickey and Hall. On the basis of a question- naire distributed to radiologists and radiation workers, it appeared that the incidence of sterility among them amounted to 36.6 percent, even though in most instances it was only the father in the family who was exposed to the X-radiation. Moreover, these investigators reported an increase in the incidence of abnormalities in the offsprings from 2.6 percent of those born prior to radiation contacts to 4.0 percent after such contacts. h. Very severe injuries to the superficial tissues and numerous deaths have occurred because of X-radiation exposures, particularly during the first two or three decades following the discovery of the X-ray. The dangers were then not realized; maleffects were due to 138 TM 8-375 62-63 MILITARY ROENTGENOLOGY ignorance as to the biological sequelae. The martyrs of those days were responsible for the incorporation of numerous protection fea- tures into the design and construction of equipment. Most of these provisions have been concerned with protection against the X-rays emitted from the X-ray tube itself—the primary X-rays. Ordinarily, too little consideration has been given to secondary radiation—the X-radiation which is emitted from table parts, the patient, and equip- ment in the exposure room. c. Considering all sources and types of X-radiation, a comprehen- sive evaluation of the threshold limits for the human (that is, the maxi- mum daily tolerance which may be incurred without the develop- ment of maleffects) is not available today. One might consider lim- its of exposure which could be tolerated by the superficial tissues of a portion of the body, the limits of tolerance to whole body radia- tion wherein not only the superficial tissues but also the blood- forming organs and blood cells become affected, or the maximum dos- age tolerated by the reproductive glands. A variety of investigations and experimental studies have beeu conducted by such authorities in X-i •adiation physics as Kaye, Taylor, Failla, Quimby, Heushaw, Packard, Scheele, and Cowie, and committee members have been selected by leading radiological societies to study this problem in the United States and in Europe. At intervals since 1921. rec- ommendations have been submitted by them. There has beeu some variation as to their interpretation and definition of the maximum daily tolerance dosage. However, it has always been considered to be of very small quantity and in more recent years there has been a definite tendency toward downward revision of this quan- tity. Depending upon the prospective, whether dealing with protec- tion for one or another tissue or for all tissues of the body, the maxi- mum daily tolerance dosage has been considered to be one or a few r-, 0.2 r-, 0.1 r-, or even as little as 0.02 r- per day. 63. Primary versus secondary X-radiation.—Short wave length X-radiation is to be most seriously considered as far as the deeper tissues are concerned. The superficial tissues bear the brunt of the longer wave length X-rays. Therefore, within the realms of fluoroscopy and conventional roentgenography, daily small exposures or any prolonged single exposure to X-rays of the primary beam must be avoided. Not infrequently, too much reliance is bestowed on the manufacturer and too much trust is given to the construction features of equipment. It is possible to eliminate exposures of the examiner lo the primary beam but it is not possible to eliminate entirely exposures by the secondary rays. 139 TM 8-275 64-67 MEDICAL DEPARTMENT 64. Exposures during- fluoroscopy.—'The Army roentgenolo- gist is responsible not only for providing protection to himself but he is also responsible for enforcing the maximum protection to the pa- tient, his roentgenographic technicians, and other assistants. No doubt, the greatest amount of punishment by X-radiation is received in the fluoroscopic room. There, during routine procedures, X-rays are being emitted from the table and from the patient and to a lesser extent from practically all objects in the room. Too often the radiol- ogist considers himself too rushed to bother with the ordinary precau- tions of putting on a lead apron or using a pair of lead-impregnated gloves. Too frequently his technician is allowed to stand close to the patient and the table without any protection whatsoever. Occasionally instructions are given that the technician subject his hands or portions of his body to very close proximity of the patient or even to the primary beam for such purposes as holding an enema tubing, syringe, or other instruments. There is seldom any substantial reason for having the technician thus exposed. When necessary, ample protection with lead gloves and a lead apron should be provided. 65. Surgery with fluoroscopic visualization.—In some insti- tutions, fractures are still being reduced under fluoroscopic observa- tion. Foreign bodies are being removed in the same manner. Such practices can only contribute to the large numbers of medical mar- tyrs in this field. There was excuse for the many catastrophes of Ibis sort in the early days of radiology, but there should be no excuse for repetitions of the mistakes made in those days, now that the treachery of X-radiation is understood. 66. Exposures incurred during photoroentgenography.— Careless practices are likely to appear at induction examining centers. Personnel are faced with a new problem—the handling of chest exam- inations of large numbers, requiring as many as 400 to 800 exposures within an 8-hour day. Mobile lead shields are provided and their proper use must be observed. The fact is recognized that considerable secondary radiation may be reflected from the walls of the room and that in certain positions the lead shields provide only false security. Moreover, personnel must be alert to the possibilities of careless ex- posures particularly by the technician who is charged with the positioning of the candidate and also the technician whose responsibility it is to exchange the films (see sec. VI). 67. Exposures during conventional roentgenography.— Lesser degrees of exposure are ordinarily encountered during conven- tional roentgenography. Occasionally, though, the technician care- 140 TM 8-375 67-68 MILITARY ROENTGENOLOGY lessly operates a timer or X-ray switch at a distance which is too close lo I lie patient and tlie X-ray tube. These practices must be avoided, and every effort should be made to utilize the full length of a timer cord or spacing of the control from the X-ray tube in order to allow the factor of distance to serve as one of the measures for protection. 68. Protection features of field X-ray equipment.—A num- ber of features have been incorporated in designing field X-ray equip- ment to provide for protection. Some of these features are as follows: a. For fluoroscopy, there is a fixed focal-fluoroscopic screen distance (66 centimeters). This feature in the table unit (item No. 96145) serves to obviate malalinements of the primary beam or changes in the coverage of it by the fluoroscopic screen as might apply in case the fluoroscopic screen were allowed to move independently in relation to the X-ray tube. Many have advocated the use of a bonnet type of fluoroscope which might be carried on the head of the operator, thereby providing for conducting these activities in a lighted room. This plan and others similar to it were rejected for the very reason that they would incur too great a hazard of X-ray exposure. h. The coverage of the fluoroscopic screen is 12 by 16 inches, thereby providing not only for a large fluoroscopic field but also for the maxi- mum practical protection with respect to secondary radiation adja- cent to the field of study. Many have recommended that in order to reduce the weight to a minimum and to facilitate the exchange of patients, the dimensions of the fluoroscopic screen should be 10 by 10 inches, as used in the World War. It was believed that the attributes of providing for protection against X-radiation outweighed the attributes of the smaller sized screen. c. For foreign body localization, marking of the skin surface is provided by a marker which can be manipulated beneath the fluoro- scopic screen but without exposing the hands of the operator to the primary beam. This is made possible because, with the method of localization which is used, the distance between the fluoroscopic image and the skin surface is subtracted and it is not necessary to position the fluoroscopic screen directly upon the skin surface. If it were neces- sary to position the fluoroscopic screen directly upon the skin surface, a perforation for admitting a skin marker would be required, as was the case with the equipment used in the World War. d. Stops are provided so as to limit the opening of the fluoroscopic shutters and thereby limit the maximum spread of the primary beam to the extent that at the level of the fluorscopic screen its area is con- fined to within 1 inch of the inside borders of the screen mounting. 141 TM 8-275 68 MEDICAL DEPARTMENT Thus, even with the most careless operation of the shutter controls, it is not possible to deliver a primary beam of such wide coverage as to permit escape of primary X-rays beyond the limits of the protection provided by the fluoroscopic screen and its lead protected glass (pro- tection equivalence of no less than 1.5 millimeters lead). e. The fluoroscopic screen and the X-ray tube are mounted on a C shaped support which is adjustable in the vertical plane, thereby pro- viding for varying the focal-skin distance and utilizing the greatest focal-skin distance possible for localizations—and the least part screen distance. This feature serves for minimizing X-radiation exposure upon the patient and reducing thereby secondary radiation from the tissues, while providing for the greatest degree of sharpness of detail for the fluoroscopic image. /. The X-ray tube housing is impregnated with opaque material to such an extent that except for the portal intended for the primary beam, protection of the equivalence of 1.5 millimeters of lead is provided. This degree of protection should be adequate to filter X-rays of wave length as short as those produced with the kilo- voltage of 100—the maximum kilovoltage provided with the unit. g. Through the portal provided for the primary beam, the combined inherent filtration is equivalent to that of 0.5 millimeter aluminum. This filtration consists of the wall of the insert tube (1 millimeter of pyrex glass), a thin layer of oil (1.5 millimeters), a 1.5-millimeter transparent bakelite wall, plus an added fixed filter of 0.25 millimeter aluminum. h. For fluoroscopy, in addition to the filtration just described, there is a second fixed filter of 0.5 millimeter aluminum. This filter is fixed into the housing of the fluoroscopic shutters. Thus, the total filtration during fluoroscopy is consistent with the stipulations con- tained in paragraph 2.03 of handbook HB-20 as compiled by the advisory committee on X-ray protection and published by the National Bureau of Standards. i. The shutter controls are contained in the vertical portion of the C-shaped supporting member, referred to above, thereby providing for distance between them and the primary beam and the sources of secondary radiation. This feature serves to minimize the exposure incurred by the examiner’s forearm and moreover it lessens the tendency for him to lean closely against the fluoroscopic screen whereby he would receive more extensive exposures to other portions of his body. j. The method of foreign body localization is such that only three short exposures for alinements are required. The localization pro- 142 TM 8-375 68 MILITARY ROENTGENOLOGY cedure can easily be accomplished within 80 to 45 seconds whereby even with the very shortest focal-skin distance (10 inches) a reason- able estimate of exposure incurred by the skin of the patient would be approximately 15 r-. The reading of the depth scale and the calibration scale can be made only while the X-ray exposure is inter- rupted, this feature being in contrast to so many methods which provide for reading of measurements with the assistance of the flu- orescence from the fluoroscopic screen. (The light intensity of the pilot lights should be kept at a minimum and they should emit dim yellow or faint red light in order to preserve the visual acuity of the operator to the utmost.) k. A limiting resistance is incorporated into the foot switch whereby the maximum milliamperage load is 5 milliamperes at 85 kvp. It is realized that well-qualified roentgenologists will prop- erly prepare their eyes by wearing dark goggles or by remaining in darkness for at least 5 to 10 minutes before starting fluoroscopy. They will thereby develop an acuity of vision not requiring excessive kilovoltages or high milliamperages and they will accomplish flu- oroscopy with kilovoltages of 65 to 80 and milliamperages of 2 to 4 (that is, fluoroscopy of extremities with 65 kvp and 2 to 3 ma.; fluoro- scopy of the chest at 70 kvp, and 2 to 3 ma.; that of the abdomen, 80 kvp and 3 to 4 ma.). The milliamperage limiting device has been incorporated for protection in case of heedless activities which might pertain to the stress of activities in the theater of operations. l. The fastest type of fluoroscopic screen is provided, thereby ob- viating the need for relatively great X-radiation exposures. m. The table top is a standard United States Army litter. It is constructed of materials of low atomic densities—canvas and alumi- num—rather than having a wide coverage of plywood or bakelite and metal framework. The secondary X-radiation emitted from the litter type of table top is considerably less than that emitted from conventional table tops and thus this source of secondary radiation is reduced and the radiologist is spared. n. A lead apron and a pair of lead-impregnated gloves are con- stituents in the chest which accommodates the control unit of the X-ray machine. Thus it is certain that at least one lead apron and one pair of gloves will be taken to every installation where the X-ray machine unit is to be operated. The United States Army does not suggest but it enforces the wearing of a lead apron and lead-impreg- nated gloves for this work. Samples of these items are tested at the Army Medical School and unless their quality is up to a standard, including the requirement that a single thickness of either provide 431112°—42 10 143 TM 8-275 68-70 MEDICAL DEPARTMENT for protection equivalent to 0.5 millimeter lead, these items are re- jected. The supporting straps of the aprons provide for suspension from one shoulder to the opposite hip, rather than the neck-band type, thus providing for the maximum of comfort in the wearing of these rather cumbersome garments. The standard gloves have a length of 37 centimeters rather than the somewhat shorter glove which is commonly used in many clinics. 69. Limitation of protection by lead aprons and lead- impregnated gloves.—It is important to realize that if one were to attempt to provide complete protection from the X-rays used in fluoroscopy, it would be necessary to incorporate lead or other opaque media of twice the thickness and weight ordinarily incorporated into lead-impregnated aprons or gloves. Such an addition would result in uncomfortable weight and impractical rigidity and it is believed that not a few radiologists would be annoyed by the use of them. Too many would discard them and expose themselves unduly. The lead apron is intended to protect against secondary radiation. No one should expose himself, even behind a lead apron, to the primary beam. Neither should the hands be subjected to the pri- mary beam, even though protected by lead-impregnated gloves. The amount of radiation which actually traverses an interposed portion of the body of a patient and. thereafter, a thickness of a lead-impreg- nated glove such as supplied to the United States Army would be minimal, and from all testings it appears that even after a strenuous day barely a threshold dosage of X-radiation would be incurred by the tissues of the hands; nevertheless, it must be recognized that some of the X-rays definitely do penetrate these protective gloves, and every effgrt should be made to accomplish manipulations by the gloved hand in a position peripheral to the actual limits of the primary beam. 70. Checking as to X-radiation exposures.—a. A quick anal- ysis of the escape of X-radiation into one or another portion of a room wherein fluoroscopy or other types of roentgenographic activity are conducted can be accomplished, when the room is darkened, by merely positioning a fluoroscopic screen toward the source of the radiation and by testing as to the penetration of the rays by placing an object of varying densities between their source and the fluoroscopic screen. Every roentgenologist should conduct such a survey with his equipment in order to put him on guard. A more quantitative in- dication would be that he and his assistants wear a dental film (with the emulsion side away from the body) having a lead number or metal object fixed to the outside of the film packet. Such a film should be 144 TM 8-275 MILITARY ROENTGENOLOGY processed after a week or so. If the metal object is visualized on a background of dense blackness, it can be realized that at least 2 r- have been received, which value over a period of 5 or 6 days must be con- sidered excessive. It should be routine practice that a platelet count and white blood cell count be obtained on all who operate X-ray equipment, at least once every 3 months. These studies should be FILM HANDLER PATIENT -X-RAY TUBE POSITIONING TECHNICIAN CONTROL OPERATOR LEAD SCREENS 10 PATIENT RUNS STEREOSCOPIC EXPOSURES 80-90 KV. P. NO GRID GRID 20 EXPOSURES“400 MA.S. 20 EXP0SURES-800MA.S. ® .0045 R 0 .010 R (2) .025 R (2) .050 R (3) (.001 R (3) .001 R (4) <.001 R 0 .001 R Figure 96.—Radiation exposures incurred by technicians. (The values listed represent average values obtained as a result of several testings. The X-radiation exposures will vary, depending u[)on the arrangement of the mobile lead shields and the positioning of the various items of X-ray equipment.) made immediately upon hearing of complaints such as easy fatig- ability or noting lack of application to duty by the personnel. h. In general, the same regard should be given to those who are constantly subjected to small quantities of X-radiation as would natu- rally be given to professional blood donors. Such individuals should have exercise in the open during at least two afternoons a week and they should see to it that their diet is well balanced, including green vegetables and meat. Liver, kidney, and heart should be fre- quent items in their menu. 145 TM 8-275 MEDICAL DEPARTMENT Examination Initial preparation Medium used Roentgen studies Subsequent consid ■ orations Barium sulphate (U. S. P.). tract: a. Esophagus No food nor fluids Thin meal; Fluoroscopy: Perhaps need for previous 8 hours. Barium, 1 part Use drinking lavage and aspira- (vol.). tube; patient lions followed by Water, 2 parts (recumbent reexamination. (vol.). and obliquely Thick paste; to left or prone). Barium, 6 parts Patient standing (vol.). or recumbent. Water, 1 part (vol.). ft. Stomach Quiet tract for 24 Barium, 1 part Fluoroscopy: Positional roentgen- hours—no earth- (vol.). Preliminary ography (or spot arsis; neither food Water, 2 parts swallow and films); 4- to 6-hour nor fluids for pre- (vol.). study of eso- study; thereafter vious 8 hours. 8 to 16 ounces total phagea! and fluids and food— volume during gastric relief; then 24-hour fluoroscopic fill- subsequent ad- study. ing. dition of vol- ume. C. Small bites- As above . As above (cold dis- Roentgen study tine. tilled water rec- ommended). 4 to 8 ounces total volume. every 15 minutes (4 such); then every half hour, as indicated. d. Obstructed Miller-Abbott or None Fluoroscopy and May inject (thru cases. similar tube for roentgenograph y: the tube) small suction drainage. Recumbent, lat- eral decubitus and upright. quantity (50 to 100 cc) thin barium. c. Colon . Repeated 1 percent Tepid thin barium Fluoroscopic con- Roentgenography saline enemata mixture: Barium trol of filling; re- following each (warm tap water) 8 ounces, water 2 examination after phase. In cases until clear return, quarts, acacia A evacuation; pos- of obstruction, 2 hours prior to ounce—all volu- sibly air injection give mineral oil the examination. metric. (under fluoro- 2 ounces b. i. d. No solids previous scopic control). and high enemata 12 hours. b. i. d.—until bar- ium has been eliminated. Gall bladder Fat-free diet: high Roen tgenography: 14 to 17 hours fol- carbohydrate in- recommend ene- take for previous lowing intake of rnata or pitressin day. Tetra-iodo- dye; again, 1 to 2 (unless contra-in- phenolphthalein hours following dicated), 8 to 15 (quantity in ac- fatty meal (yolks minutes and re- cordance with of 2 eggs and study. In case of weight) with fruit equal quantity vomiting or diar- juice, 14 to 16 hours of cream). rhoea, recommend prior to examina- paregoric, 1 to 2 tion. drams and repeat. Give double dose if single dose fails; possibly intra- venous dye. APPENDIX 146 TM 8-275 MILITARY ROENTGENOLOGY Examination Initial preparation Medium used Roentgen studies Subsequent consid- erations Urinary tract: a. K. U. B Repeated enemata may substitute licorice powder, 2 to 3 drams or cas- tor oil, 1 to 2 ounces, at least 20 hours prior to study. Pitressin (8 to 15 minutes) y2 hour prior to study—in cases of flatulence. None _ Roentgenography: Recumbent, A-P, oblique and oc- casionally erect. A-P and oblique films with ureteral catheters inserted (to study for cal- culi). h. Pyelography: (1) Intraven- As above; restrict Intravenous dye Recumbent studies: Films at 60 and 90 ous. fluids for at least 6 hours. (of reputable manufacture), fol- lowing “control” roentgenography. Make prelimi- nary skin test; have adrenalin ready. Preliminary film (control); 5 min- utes, 15 minutes, 30 minutes (patient erect), and 1 hour. minutes in cases with poor renal function. (2) Retrograde As above, no restric- tion of fluids. 5 to 12 percent so drum iodide or commercial dye (20 percent). Preferably, fluoro- scopic study of filling - retract catheters sacro- iliac level. Ro- entgenography: supine with 15° Trendelenberg; horizontal and 45° Fowler, plus deep inspiration, or sitting position 15-minute interval films following withdrawal of catheters until pelves emptied (patient in Fow- 1 e r position or erect). c. Cystography. Enemata; bladder lavage (1 percent warm saline). 2 to 5 percent so- dium iodide—200 to 300 cc. Roentgenography— before and after voiding: A-P,P-A and obliques. Possibly oxygen in- jection studies. d. Urethrog- raphy. Catheterization and irrigation of blad- der. 5 to 12 percent sodi- um iodide—in- jected during ex- posure. Roentgen ography: Patient in semi- Fowler or true Fowler position. Encephalography Sodium amytol, gr. Air, 120 to 140 cc Stereoscopic roent- Ice cap to head; (ventriculogia- 1 H to 3, night be- (by replacement) genography: P-A, salicyates,codeine phy). fore and morning of examination; morphine sul- phate, gr. % to gr. —for adults (chil- dren proportion- ately less); no breakfast. —40 to 50 cc for vent riculo g- raphy; air must be filtered. A-P, and laterals —vertical and re- cumbent. and caffeine as needed; fluids and food as tolerated. 147 TM 8-275 MEDICAL DEPARTMENT Examination Initial preparation Medium used Roentgen studies Subsequent consid- erations Myelography Sodium amytol, gr. to 3, night be- fore and morning of examination. Oxygen (or filtered air), 50 ce or io- dized oil (20 to 40 percent iodine content), 2 to 6 ec. Roentgenography: A-P and lateral stereoscopic films —must be made immediately after injection, if oxy- gen (or air) is used. Fluoroscopic obser- vations—patient in modified Tren- delenberg and semi-Fowler posi- tions. Needle as- piration of resid- ual oil. 24-hour roentgenography. Bronchography (1 Sodium amytol, gr. Iodized oil (20 to 40 Installation of oil No food or liquids lobe or single 1 Vi to 3, night be- percent iodine under fluoroscopic for 2 to 4 hours lung study at a fore; morphine sul- content)—10 to control. Film (until cough re- time). phate, gr. % to M with scopolamine, gr. Hso, morning of examination. Cocaine spray (5 percent to phar- ynx and larynx; 10 percent to Pyri- form sinuses); in- tranasal tube. Have barbiturate for intravenous in- jection in readiness to counteract co- cainism. 30 ce. studies: P-A ster- eoscopic, obliques and laterals. flex is regained); encourage cough to remove oil. 148 TM 8-275 INDEX Paragraph Page Anomalies of thorax 54 78 Aorta, coarctation 54 78 Aprons, lead, limitation of protection 69 144 Biplane marker 34 54 Calcifications: Acceptable limits 55 101 Found in primary phase 55 101 Occurring in costal cartilages ; 56 119 Occurring in pleurae 55 101 Significance of stipplings 55 101 Chassis unit, mobile 22 26 Chest: Diagnostic possibilities 53 77 Nontuberculous conditions — 54 78 Sequence of analysis 53 77 Classification of individual 53 77 Dermatoses, treatment 59 135 Deteriorating supplies 6 6 Form used 7 6 Diaphragm: Eventration 54 78 Herniation 54 78 Electrical generator 20 22 Empyema 54 78 Expendable supplies 5 5 Form used 7 6 Field X-ray equipment: Design 16 19 Protection features 68 141 Supply catalog listings 17 20 Film— Chest 18 21 Dryer 19 21 Loading bench 19 21 Loading bin 19 21 Processing unit: Auxiliary wash section, cascade design 24 31 Heating and cooling capacities 24 31 Portability 24 31 Section for small hospitals 24 31 Time requirements for processing 49 72 Two-section, for large hospitals 24 31 Water circulation capacity 24 31 149 TM 8-275 INDEX Films: Paragraph Page Captions 50 72 Consumption 10 12 Filing 49 72 Illegal sale 10 12 Life 24, 41. 48 31,63,71 Miniature film 42 65 Fluoroscopy, exposure dangers 64, 65 140 Forms 7 6 Foreign body localization; Body, general; Accuracy of method 32, 33 53, 54 Description of equipment 27, 28 44, 45 Geometric analysis of method 31 51 In lung 54 78 Procedure 29, 30 46, 49 Eye: Accuracy of method 39 62 Description of equipment 35, 36 55, 56 Intraocular versus extraocular positions 40 63 Procedure 37, 38 58, 59 Gloves, lead, limitation of protection 69 144 Grid unit, portable 23 29 H azards, X-radiation; Blood cell depletion 62 138 Checking exposures 70 144 Endothelial changes .• 62 138 Genetic changes 62 138 Neoplastic changes 62 138 Skin damage 62 138 Sterility effects 62 138 Ulcer formations 62 138 Heart, abnormalities in configuration 54 78 Infections, treatment 59 135 Intensifying screens, illegal sales 11 13 Lungs: Abscess 54 78 Acute inflammatory lesions 54 78 Bronchiectasis 54 78 Bronchitis 54 78 Cystic disease 54 78 Emphysema 54 78 Foreign body in 54 78 Outline of bronchus 56 119 Platelike atelectasis 56 119 Pneumothorax 54 78 Silicosis 54 78 Tuberculous lesions 55 101 Tumors 54 78 150 TM 8-275 INDEX Lymph nodes: Paragraph Pago Acceptable calcifications 55 101 Appearing as arch of aorta 56 116 Enlarged and primary phase of tuberculosis 55 101 Machine, X-ray, portable or mobile 21, 22 24, 26 Memorandum receipts 6 '1 Miliary lesions 55" 101 Neoplasms, treatment 57, 59 132, 135 Nondeteriorating supplies 6 6 Form used 7 6 Nonexpendable supplies 5 o Form used 7 6 Nonstandard items 4 3 Form used 7 6 Periodic estimates 8 11 Photofluorography 42 65 Photoroentgenography 42 65 Camera unit 45 6S Exposure dangers 66 140 Film requirements 45 03 Film shifting 45 63 Fluoroscopic screen 45 63 Lense requirements 45 63 Stereoscopic projection 45 X-ray machine capacity required 46 70 X-ray tube capacity required 47 70 Pleurae: Acute inflammation 54 78 Chronic inflammation 54 78 Empyema 54 78 Pleural cap 55, 56 101, 11!) Septation for asygos vein 56 119 Tentings of diaphragm 55, 56 101, 1 19 Thickenings at base 55 101 Tumors 54 78 Pleural cap 55 101 Pneumothorax 54 78 Primary X-radiation, dangers of exposure 63 139 Property: Accountability 42 16 Responsibility 2’ 12 2’ 19 Credits 13- 14 46, 18 Handling 9 11 Transfer 44 18 Purpose and scope 4 1 Reports: Based on probabilities 55 101 Credits 13 J(i Localization of foreign bodies 39> 38 49, 59 151 TM 8-275 INDEX Reports—Continued. Paragraph Page Periodic estimates 8 11 Property 7 6 Roentgenological 53, 56 77, 119 Requisitions 3 2 Forms used 7 6 Initiating 7 6 Ribs, confusing densities produced by 56 119 Infections 54 78 Ununited fractures 54 78 Roentgenographic examination: Economic importance 41 63 Equipment needs at induction center 44 67 Legal aspect 41 63 Methods 42 65 Policy 41 63 Reduction method 42 65 Reporting 55 101 Requirement of film life 41 63 Space requirements at induction centers 43 65 Technical assistants required 51 73 Technical factors 52 75 Roentgenography, exposure dangers 67 140 Scope and purpose 1 ] Secondary X-radiation, dangers of exposure 63 139 Standard items 3, 4 2, 3 Stereoscopic viewing: Importance 42, 56 65, 119 Provisions 44, 46, 49, 52 67, 70, 72, 75 Supplies. (See Deteriorating supplies; Expendable supplies; Nonexpendable supplies.) Table, X-ray, emergency 21, 25 24, 39 Adaptations 21, 25 24, 39 Design 25 39 Foreign body localization 25, 27, 28 39,44,45 Packing arrangements 25 39 Tent, darkroom: Expected uses 26 42 Two-purpose adaptation .. 26 42 Theater of operations, handling of supplies 15 19 Therapy, roentgen: Collateral treatment 60 137 Dangers 58 133 133, Dosage 58, 59, 61 135, 138 Extent 57 132 Wave length relationship 57 132 Tolerance, X-radiation, maximum dosage 62 138 152 TM 8-275 INDEX Tuberculosis: Paragraph Page Cavitation 55 101 Miliary lesions 55 101 Phases 55 101 Primary phase 55 101 Reinfection phase 55 101 Reporting 55 1.01 Tumors: Lung 54 78 Mediastinal 54 78 Pleural 54 78 Soft tissue, superficial _ _ 54. 56 78, 119 [A. G. 062.11 (10-9-41).] By ORDER OF THE SECRETARY OF War : G. C. MARSHALL, Chief of Staff. Official : E. S. ADAMS, Major General, The Adjutant General. Distribution : X. (For explanation of symbols see FM 21-6.) 153 U. S. GOVERNMENT PRINTING OFFICE: 1942 For sale by the Superintendent oi Documents, Washington, D. C.