COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 27281 RC78 .P93 1 91 8 Roentgen technic di fW^% . i Columbia Winihtv^itp in tf)e dtp of j^eto gorfe \*B ^ciiool of Mental anb 0tal burger? i^eference S^ibrarp Property of COLUMBIA UNIVERSITY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/roentgentechnicdOOprin ROENTGEN TECHNIC EOENTGEN TECIINIC (DIAGNOSTIC) BY NORMAN C. PRINCE, M.D. ATTENDING EOENTGENOLOGIST TO THE OMAHA FREE DENTAL DISPENSARY FOR CHILDREN; ASSOCIATE EOENTGENOLOGIST TO THE DOUGLAS COUNTY HOSPITAL, BISHOP CLARKSON MEMORIAL HOSPITAL, SWED- ISH IMMANUEL HOSPITAL, ST. JOSEPH'S HOSPI- TAL, AND FORD HOSPITAL, OMAHA, NEBE. WITH SEVENTY-ONE ORIGINAL ILLUSTRATIONS SECOND EDITION ST. LOUIS C. V. MOSBY COMPANY 1918 Copyright, 1917, 1918, by C. V. Mosby Company Press of C. V. Mosby Company St. Louis PKEFACE TO FIRST EDITION Tliis small volume lias been iDiepared particularly for those general practitioners who have seen fit to install x-ray equipments along with the numerous other appa- ratus necessary in helping them to best care for those who come under their observation. There has been very little written in English, dealing exclusively with roent- gen technic and it has seemed to the author, after hav- ing talked with many physicians, that such a publication is sorely needed. It is so common to have one's attention drawn to a case where a physician is doing so-called gastrointestinal diagnosis by means of the roentgen ray, his entire pro- ceeding consisting of an opaque meal followed by one plate taken with the clothing on, that one is led to be- lieve that such a procedure is not due to negligence on the part of the physician, nor used for show only, but that it is due wholly and entirely to ignorance — the phy- sician knowing nothing else to do. One also is brought face to face every day with the man who is taking bone plates one way only, and thereby at no time rendering a diagnosis of any value. But why should one wonder at these gross errors when one takes into consideration the preparation given the neophyte by the x-ray salesman? His machine is set up, a few plates hurriedly exposed and developed, all of which looks easy, and then he is left to his own resources. The consequence is, from the begin- ning he is working in the dark, never knoA\ing the ivhy and the ivlierefore of any process. It is needless to say, from the fact that this book deals exclusively with roentgen technic from a diagnostic standpoint, that nothing has been said regarding inter- pretation. So much has been and is being written upon 10 PREFACE this brancli of the subject by the masters that it is not for me to touch uj^on. It has been assumed tliat all read- ers of this volume are using interrupterless transformers ; the coil, therefore, has not been given any consideration, as it has been abandoned almost universally for the former type of aj^paratus. The author wishes to express his gratitude to his col- leagues, Doctors Tyler and Kuegie, for information and suggestions tendered. N. C. P. PREFACE TO SECOND EDITION The exhaustion of the first edition within a period of ten months has rendered it necessary to x)repare a neAV edition, and has enabled the author to make a few addi- tions and the necessary corrections in the text that were overlooked in preparing the first edition. The favorable reception given this book by the reviewers and the pro- fession has been most gratifying. N. C. P. CONTENTS PAGE CHAPTER I. General Principles 17 CHAPTER II. X-RAY Tubes 24 CHAPTER III. Operation of Machine 27 CHAPTER IV. General Examination Routine .31 CHAPTER V. Positions and Exposures 39 CHAPTER VI. Sinus Injection 105 CHAPTER VII. Location of Foreign Bodies 106 CHAPTER VIII. Dark Room Procedures 109 11 ILLrSTRATIOXS FIG. PAGE 1. Pathway of current from line to tube . 22 2. Old style gas tube 24 3. Coolidge tube 25 4. Gas tube connected to transformer 29 5. The advantage of taking a fracture in both planes 32 6. A. Wlien tube is centered exactly over fracture. B. When tilted to one side 33 7. Plate changing tunnels for stereoscopy 34 8. Tilting side of Kelly tube stand .35 9. Shifting side of Kelly tube stand 35 10. Change in position of tube -when taking stereoscopic plates ... 36 11. Set of Hickey cones and diaphragms ' 37 12. Lead markers on adhesive strips 38 13. Posteroanterior wrist and hand position 41 14. Lateral wrist position 41 15. Anteroposterior elbow position . 43 16. Lateral elbow position 43 17. Anteroposterior ankle position 45 18. Lateral ankle and lateral tarsus positions 45 19. Lateral ankle and lateral tarsus positions 47 20. Anteroposterior tarsus position 47 21. Anteroposterior knee position 49 22. Lateral knee position 49 23. Anteroposterior hip position 51 24. Anteroposterior pelvis position 53 25. Anteroposterior shoulder position 55 26. Lateral cervical spine position . 57 27. Anteroposterior cervical spine position 57 28. Anteroposterior dorsal spine position 59 29. Oblique dorsal spine position 59 30. Anteroposterior lumbar spine position 61 31. Oblique lumbar spine position 61 32. Clavicle position 63 33. Scapula position 65 34. Kidney position ; . 69 35. Bladder position on dorsum 69 36. Kidney position 72 37. Bladder position on dorsum 73 38. Prone bladder position 73 39. Chest position 77 13 14 ILLUSTRATIONS FIG. PAGE 40. Lateral lioad position 78 41. luferosuperior head position 79 42. Posteroanterior head position 80 4:'>. Mastoid position '. . . . 82 44. Mandible position 83 45. Position in taking upper teeth 85 46. Position in taking lower teeth 85 47. Gall bladder position 87 48. Position for esophagus 89 49. Prone stomach position 92 50. Oblique stomach position 93 51. Standing stomach position • , . 93 52. Showing serial plate apparatus ready for use 95 53. Showing serial j)late apparatus tilted upward when not in use . 96 54. Diagram showing relative distance between object and jslate . . 107 55. Plate, cassette and envelope rack shelf in dark room 110 56. Ventilating shafts in dark room walls Ill 57. A print drying on a ferrotype after squeegeeing 122 58. Showing camera mounted on permanent stand for lantern slide making 124 59. Rear of camera showing centering squares on ground glass . . 125 60. Simple method of arrangement for making lantern slides from illustrations 126 61. A negative 127 62. A positive 128 63. Manner in which envelopes are marked for filing 131 64. Case record book 132 65. Cross index card 134 66. Floor plan No. 1 137 67. Floor plan No. 2 137 68. Floor plan No. 3 137 69. Floor plan No. 4 138 70. Floor plan No. 5 138 71. Flour plan No. 6 139 ROENTGEN TECHNIC (Diagnostic) ROENTGEN TECHNIC CHAPTER I GENERAL PRINCIPLES X-rays are certain rays of unknown number which are produced when a high tension current is forced through a specially constructed vacuum tube. These rays when jorocluced will theoretically penetrate all substances, some with greater ease than others. The general rule is that the greater the atomic weight, the less the ease of pene- tration. The following list of common substances is given in order of their ease of penetrability: 1. Air. 2. Celluloid. 3. Aluminum. 4. Cardboard. 5. Wood. 6. Flesh. 1, Rubber. 8. Barium or bismuth. 9. Bone — teeth. 10. Steel. 11. Lead. When centering x-rays on an object, these varying de- grees of penetration take place; but in order to profit by them, there must be some way whereby they may be perceived. Two methods have been devised; namely, the fluorescent screen and the sensitized plate. 17 18 EOENTGEX TECHNIC The Fluorescent Screen The fluorescent screen is notliing more tlian an ordi- nary jDiece of cardl)oard coated with a combination of chemicals which have the peculiar propert}^ of fluorescing when exposed to the x-rays, the same as a match will fluoresce in the dark when rubbed between moist fingers. Of course, this fluorescence can not be seen except in dark- ness, and tlien only when the pui)ils of the eyes have di- lated to their fullest, which will take from ten to twenty minutes. When the rays are generated, this screen Avill glow; and Avlien the excitation of the tube has ceased, it will stoj). Some makes of screens have what is known as a lag, that is, fluorescence continues for some few sec- onds after the discontinuance of the energy in the tube. Unless the operator is shifting from one area to another very rapidly, this will have no detrimental effect. There are also two distinct colors in an illuminated screen, one having a greenish cast, the other black and white. One is jorobably as good as the other, the preference depend- ing largely upon the operator. If the tube is excited, thereby causing the screen to fluoresce, and some object is interposed between the tube and the screen, naturally the x-rays do not reach the screen in as unhindered a state as they do when no object interferes; therefore, as x-rays to all practical purjDoses only travel in straight lines, the portion of the screen that is covered by the interfering object will not fluoresce to as great a degree as the areas not so covered, and one is thereby enabled to discern the shajDe of the ol^ject. The fluorescence w411 be hindered directly according to the difficulty of the rays in passing through the object. As an example, if a number of objects, say a lumd with a bullet supported upon the palm, is interposed between an excited tube and a screen, the image will show the bullet practically black, as no rays are j)enetrating it, and there- GENERAL PRIlSrCIPLES 19 fore the screen is not fluorescing at this point. Next, the bones are seen as a sort of a grayish black because some little amount of the rays is coming through and causing a slight fluorescence. Next, the flesh is seen surrounding the bones. This is a very light gray color because a large part of the rays is coming through the flesh and causing the screen to light up; and lastly, the air surrounding the hand is no hindrance to the rays, and the entire action is thrown on the screen which is fully illuminated. The Sensitized Plate The sensitized plate or film is briefly a piece of clear glass or celluloid coated Avitli certain chemicals in a gela- tine solution which has been allowed to dry (dry plate). The coating, film, or emulsion^ as it is called, is i^repared from a number of substances, the main one being some salt__of_silyer which isniixed with liciuid gelatine ; and after having gone through a process of heating and wash- ing, this substance is ready to be spread very thinly and evenly on the supporting medium and set away to dry. During the latter part of the process of preparation, the emulsion takes on a property whereby if it is exposed to tlie rays of the solar_s,pectrum, except red, and then put into a solution of certain reducing chemicals, the silver will turn black; whereas if it is not so exposed and put into the solution, it A\dll remain its original color, a very light creamy yellow. All the rays of the spectrmii act on the silver except red, the ultra-violet probably ex- erting the greater part of the change. The x-rays possess this same power, and, therefore, when an unexposed plate is placed near an excited x-fay tube and then put into the developing solution, it will be found to have undergone the change and will turn black instead of remaining its original creamy color. Now, if . some object, say a bullet, is interposed between the plate 20 EOENTGEX TECHNIC and the tube, it is easy to see that the part of the plate covered, as it were, by the bullet will not receive as niiTcli, if any, of the rays as the jDarts not so covered. The sur- face so covered by the bullet will remain creamy, while the surrounding parts that get the full effect of the rays will turn black. In this way it is possible to distinguish that a bullet was on the plate at the time of exposure. Therefore, if the same illustration is taken as was used for the fluorescent screen, the same end is accomplished, except the colors are reversed. On the screen it was seen that the bullet remained black because the x-rays could not get through to fluoresce the screen, but on the plate it is seen that the bullet remains creamy for the same reason, the rays can not get through to allow the silver to be acted upon and it therefore remains its original color. An intensifying screen is a piece of cardboard coated over with certain chemicals somewhat the same as a fluorescent screen. The chemicals used, however, are dif- ferent so that one can not be used satisfactorily in the other's stead as has been tried and demonstrated. This screen is very sensitive to x-rays, and for this reason is used in connection with plate work to shorten the time of exposure. The coated side of the screen is placed in contact with the film side of the plate, either in a spe- cially constructed holder for this purpose called a cas- sette, or in the ordinary loading envelope. The latter method is rarely used, as the surface of the screen is very easily marred, and if scratched or splattered with chemicals, is forever useless, these defects showing on all plates subsequently taken with it. If the minutest quantity of rays strikes the screen, it will act by lighting up. This, in turn, affects the plate at this point and the image is made. "Without an intensi- fying screen, one has to liave enough rays to properly af- fect the silver in the plate to make the desired impres- sion. Intensifying screens seem to respond particularly GENEKAL PRINCIPLES 21 well to soft rays, therefore, in using these screens, a me- dium soft tube should be employed. The great difficulty in their use is in overexposing the plates. The latitude of error is very narrow ; the plate must be exposed just right or a poor negative will result, w^hereas, with the plain plate, a slight over- or underexposure will not be notice- able. For producing the rays to reproduce some object on a sensitized plate, there are three main things one has to t ake in t o consid eration; namely, ainount~of voltage used, number of milliaH pere?]of"currentpan^^^ tlieanode of the tube to the pTafer Tor all practical pur- poses the voltage varies from 55,000 to 70,000 £ind the milliamperage from 35 to 140. It is roughly estimated that 10,000 volts will, span a gap (air space) of one inch, therefore, if there is a gap of 5^2 inches which the cur- rent will span, but no farther, it can be assumed that the current is approximately 55,000 volts, and with a 7 inch gap, 70,000 volts. In the positive side of the circuit there is usually set what is known as a milliammeter, a gauge for register- ing the number of milliamperes (one-thousandth part of an ampere) passing through the tube. This milliampere reading depends, if a gas tube is used, upon the degree of vacuum in the tube, but if a Coolidge tube is employed, a different principle is' involved, this device depending on the degree of heat in a small tungsten filament which is placed in the circuit within the tube. In the gas bulb, the greater the vacuum the lower the milliamperage, and the harder the tube. In the Coolidge tube, the greater the heat in the filament the more electrons are set free and this in turn allows more milliamperes to pass,' and we therefore have a softer tube. In Fig. 1 a schematic sketch has been made of the current so as to make the course in the production of x-rays more easily understood. The electrical current is seen to travel in a circle, the 22 EOEISTTGEN TECHNIC SYHCURONOUS YAOTOR Fig. 1. — Pathway of current from line to tube. GEISTERAL, PRIjS^CIPLES 23 outgoing wire being the positive ( + ) and the incoming, the negative ( — ). It accomplishes its work while travel- ing the circle, the whole thing being kno^m as the circuit. From the source of supply, the current (alternating as- sumed) is taken two wa^^s; namel}^, (a) to the motor and (b) to the tube via the transformer. The current that goes to the motor does not enter into the production of the x-rays, but is simply for excitation of the motor which in turn causes the rectifying wheel or switch to revolve. The supply or incoming current is small, usually 220 volts. When this emerges from the coil or transformer, it has been raised in voltage, or 'Sstepped up" as it is termed, so that it is now a high tension current, whereas before this raising process it was of low tension. As it flows through the rapidly revolving rectifying wheel it is changed into a direct current Avhich is necessary for the successful operation of an x-ray tube. If the current is not prevented, it will flow through the tube and back to the source, thus completing the circuit. At points C and D (Fig. 4) there are rods so arranged that their ends can be placed at varying distances from each other. If these points are brought very close together, the current will take this, the easiest route, not going aroimd by the Avay of the tube. This is what is known as the spark gap. CHAPTER II X-RAY TUBES X-ray tubes are of two general classes; namely, gas tubes and Coolidge tubes, and operate upon two distinct principles. The gas tube (Fig. 2) is a glass bulb with the air ex- hausted to a certain point, nearly a complete vacuum. Fig. 2. — Old style gas tube. It is equipped with a regulating chamber so that a small quantity of air can be let in which will, of course, reduce the vacuum. AVith such a tube the current which travels through it of necessity must pass through this partial vacuum. It has been determined that the nearer a per- fect vacuum in a tube, the harder it is to force an elec- trical current through it, but when forced through a high vacuum, hard rays are given forth, and they are more penetrating and less likely to burn than the soft ones. 24 %. )V_e^A.^1(y^Ws, Y'U-^I-C X-RAY TUBES 25 Conversely the less perfect the vacuum or the more air in the tube, the easier to force the current through, and soft rays are produced. It is easy to see that if the vacuum or resistance in the tube is greater than the spark gap resistance, the current will take the easier route and jump the gap. If the gap is now increased to such a point that the current will pass through the tube in pref- erence to the gap, the tube is said to be backing up a parallel spark gap of so many inches. If, however, it is desired that the tube back up so many inches and no more, just enough air should be admitted so that it will not jump that distance. The tube is then as desired. Fig. 3. — Coolidge tube. The Coolidge tube (Fig. 3) is operated upon an entirely different principle. It is pumped to an almost perfect vacuum which remains the same constantly. At the neg- ative end of the tube is a sinall tungsten filament within the pumped bulb. This is lighted by means of an at- tachment to an ordinary light socket. It, however, will take only approximately 12 volts so that the current which usually is of 110 volts capacity must be cut down to the required 12 volts. This is accomplished by a small 26 KOENTGEN TECHNIC apiDaratus knoAvn as a step-down transformer. Tlie in- tensity of this light can be increased or diminished at the will of the operator b,y means of a little instrnment known as the filament control. When the filament is bnrning its maximum of current or is at its brightest, the tube will take the most current, the same as would the gas tube when it had the maximum of air in it. In either instance the tube is spoken of as a soft tube. Conversely when the filament is burning low or as in the case of a gas tube, when the air is at its lowest, then the tube is hard. The intensity of the x-rays is in inverse proportion to tlie scpiare of the distance. If the exposure for a certain IDart is three seconds Avitli ten inches between the plate and the anode, the time of exposure required for in- creased distances will be as follows : Distance Time Distance Time Distance Time in in in in in in inches seconds inches seconds inches seconds 10 3 17 8.67 24 17.28 11 3.63 18 9.72 25 18.75 12 4.32 19 10.83 26 20.28 13 5.07 20 12 27 21.87 14 5.88 21 13.23 28 23.52 15 6.75 22 14.52 29 25.23 16 7.68 23 15.87 30 27. CHAPTER III OPEEATION OF MACHINE After the installation of the eqnipment, the first thing for the beginner to do is to test out his tubes so that he may know what setting he wants when different parts come up for roentgenographing. First, after starting the motor (assuming he has an interrupterless transformer) and setting the polarity switch as indicated, he lights the filament in the Coolidge tube, if such is to be used, set- ting the control at a point about one-half way of the scale. The spark gap is set about 4^/2 inches, and the rheostat placed on about the 20tli button or about two- thirds out. The final or x-ray switch is now closed and if the gap is not spanned by the current, the control is re- duced or sent backwards a few points and the procedure repeated. If the spark jumps the gap the filament light is increased and so on until such a point is reached that the current is such that it will constantly spit across the gap, the milliamperage being noted. If it is in the neigh- borhood of 35, let it stand. If lower, increase the control button. This w^ill require a change in the filament again. By manipulating the rheostat and the control button of the filament, one can finally get an output that will re- cord a certain number of milliamperes with a certain backup spark. When once 35 milliamperes backing up 5I/2 inches has been found, note it on paper. Now set tube so that it will carry 75 milliamperes with a 6 inch gap as also the following: 90 ma. backing up a 6 inch gap. 40 ' '' 6I/2 '' " IQ ' " 6I/2 '' '' 100 ' " 6I/2 " " 140 ' <' 6I/2 " " 60 ' I i I " 41/2 " " 27 60 4 13/20 41/2 35 4 3/20 51/2 75 4 12/20 6 90 4 8/20 6 60 4 3/20 61/2 70 4 4/20 61/2 100 4 6/20 61/2 140 4 4/20 61/2 28 ROENTGEN TECHXIC After these have all been set down on paper one will have something like the following: MILLIAMPEEES COOLIDGE CONTROL SPARK GAP RHEOSTAT CONTROL BUTTON 24 22 25 26 25 26 27 28 The gap can now be opened to its fullest caiDacitj^, and unless some new combination is to be used, it need never be closed again, for with a given Cooliclge tube, one will always get an exact duplication if the same formula is followed. If a gas tube is used, a different procedure is employed. The rheostat is set on the iirst button and the spark gap placed at say, 6 inches. The x-ray switch is now closed. The meter will probably read somewhere between 20 and 30 milliamperes. Now the rheostat can be thrown over several buttons until the spark gap is spanned. It is then reduced one button and the milli- amperage noted. If this is too hard a tube, it can be low- ered by sending a small amount of current through the regulating chamber. This is accomplished either by con- necting the cliaml)er to a cord connected to a movable reel placed on the front of the transformer, the reel being capable of being drawn close to the negative i)ost ; or by means of a stiff Avire attached to the chamber, the end of which can be brought in close proximity to the nega- tive end. (Fig. 4.) The current normally goes from A to B directly tlirough the tul)e. If the tube is to be re- duced or softened, cord F is connected to the regulating- chamber at G, and E is brought close to D, which is done by tension on a string. The rheostat is put on the first button and the final switch is closed. This sends the cur- rent through the regulating chamber G back to D in- stead of through B. Somotiiiics a Avire is used from G OPEKATIOX OF MACHIXE 29 to B. The current then passes from A to B via G instead of A to B. When the wire is not in use, it is tilted up- wards so that it will not get in the circuit. AVhen gas tubes are to he used, several should he employed, each having a different backup gap as it is not only very an- noying but soon ruins a gas tube to be continually chang- ing its vacuum. When using the fluoroscope, usually about 2 ma. are employed, the penetration being regulated by the fila- Fig. 4. — Gas .tube connected to transformer. ment when using the Coolidge or by the third wire with the gas tube. On all the latest fluoroscopes there is a little device whereby the operator can control the gas tube in the apparatus simply by pulling a string the same as on the transformer when regulating for picture work. This approximates the wire connected to the reg- ulating chamber and the negative post, thereby reduc- ing the tube. As soon as the tube is reduced sufficiently, the string is released and the two points fly apart. This 30 eoentge:n" technic can be done Avliile the machine is in operation as the niilliamperage is so low (2 ma.) that the rednction is more or less gradual. If this were done with a roent- genographic tube running with, say 40 ma., the reduction would be so rapid even in a fractional part of a sec- ond that the tube would be worthless from over reduc- tion. It would be so soft that it would have no penetra- tion. CHAPTER IV GENERAL EXAMINATION ROUTINE When a patient is submitted for x-ray examination, first take a complete history. The following is a good general chart: No. Name Address Past history, Present sickness or accident, Physical findings, Clinical diagnosis, Roentgenological diagnosis, Date, Charge, Size plate, Referred by, This is made a convenient size to file alphabetically. After the history is taken, the patient goes to the dress- ing room and bares the part to be examined. If a spinal, gastrointestinal, chest, or genitourinary examination is to be made, all the clothing is removed, and if a female, a white washable gown is slipped on. The patient is then placed on the table and a complete physical exam- ination is made, all points being noted on the chart. The x-ray examination is then proceeded with. In the taking of any roentgenogram, there are three things that must always be remembered; namely, 1. Have the tube centered as nearly over the lesion as possible. 2. Place the part to be taken as near the plate as is convenient. 3. Have the rays strike the plate at right angles un- less the part can be shown to better advantage otherwise, 31 32 r.OEXTGEX TECHXIC and the accompanying distortion does not make any ma- terial difference. Taking these np in their order, (1) it will be seen in the accompanying illnstration that it is possible to make, for instance, a fracture appear different from what it really is by not being particular in this regard (Fig. 6). Fig. 3. — The advantage of taking a fracture in both planes. GEHSTERAL EXAMIl^ATION ROUTINE 33 A B Fig. 6. — A. When tube is centered exactly over fracture. B. When tilted to one side. 34 PvOextge:n^ technic (2) The nearer an object is to the plate the clearer it ^^'ill appear and the nearer to its normal size, whereas, if removed to an}^ considerable distance, it will appear hazy and very much magnified. (3) If the tube is not placed so that the rays strike the plate at right angles, overlying parts will be thrown out of their true rela- tionship and other parts will be distorted as to their size and shape. In all extremity work, views should be taken in two directions, that is, anteroposteriorly and laterally. If this is not done very faulty diagnoses may be made. A transverse fracture with the lower fragment lying pos- teriorly to the upper, will in a large majority of cases Fig. 7. — Plate changing tunnels for stereoscopy. not show the misplacement if taken anteroposteriorly, but if a plate is taken laterally, the faulty jDosition will be easil}^ seen. (Fig. 5.) Two iDlates are not only more expensive but are not so convenient to handle as one, and therefore a single plate large enough to take in both views is used, the half not under exposure being cov- ered by a sheet of 1/16 inch lead. A pencil mark should be made on the envelope where the lead stops so that one may know where to edge it when making the other ex- posure. If it is impossible to get a lateral view of a part as, for instance, the shoulder and hip, the stereo- scopic method should be employed. This is accomplished by the use of two plates and by shifting the tube. A thin box, the proper size to hold the covered plate, is placed under the part (Fig. 7) and the patient instructed GENERAL EXAMINATION ROUTINE 35 Fig. 8. — Tilting side of Kelly tube stand. Fig. 9. — Shifting side of Kelly tube stand. 36 EOEXTGEN TECHNIC that two plates are about to be taken and not to move until the sign is given. The tube is centered exactly over the part to be taken and by a si^ecial device on all stands locked at this point, the tube is allowed to move Fig. 10. — Change in position of tuljc when taking stcrt-oscopic plates. GENERAL EXAMINATION" EOUTINE 37 botli ways one and one-quarter inches. This 2Y2 inches, as will be seen later, is the approximate distance between the two pupils of the eyes. It is also necessary to tilt the tube by a special tilting device so that the direct rays are at both extremes pointing to the center. (See Figs. 8 and 9.) A plate is slipped into the box and tube placed in posi- tion A (Fig. 10) and the exposure made. This plate is then removed and placed in a safe place and another slipped into the box in the same relative position, all this Fig. 11. — Set of liickey cones and diaphragms. time the patient should remain absolutely quiet. The tube is now shifted to position B and the exposure made, both plates having the same time. When taking the plates to the dark room, number them No. 1 and No. 2 in the order they were exposed. This will be found use- ful when placing them in the stereoscope. If No. 1 is placed on the left side and No. 2 on the right, the stereo- scopic effect will be obtained almost at once. The chang- ing boxes should be four in number. Two capable of holding 8 by 10 inch envelopes and two for the 11 by 14 inch size; one of each size having the opening on the 38 PiOElNTGEI^ TECHNIC end and tlie other on the side. They are made of Avood, the top being of either cellnloid, alnminnm, cardboard, or thin Avood, all of which offer little resistance to the rays. If wood is used, it should be free from knots and as thin as consistent Avith the weight that is put upon it. One small point that is aa^cII to remember Avith this Fig. 12. — Lead markers on adhesive strips. stereoscopic Avork is that the black and orange euA^elopes in Avhicli the plates are enclosed are ahvays somcAA^liat larger than the plate. This is done, of course, to facili- tate loading them. When placing the tAvo plates in the box, they should be .shaken into one corner or the other and placed in corresponding i:)ositions at each exposure. It makes no difference Avliich corner just so they occupy the same in the box. CHAPTER V POSITIONS AND EXPOSUEES x\ll of the following exposure times are given for reg- nlar Paragon or Seed plates and Cramer plates. If Cra- mer's are used with the technic calling for Paragon or Seed's, increase the time 25 per cent as the former are about that much slower. Detail in all will be about the same. If an intensifying screen is to be used, divide the time given about one-eighth. Intensifying screens do not act well with regular Paragon plates. If it is de- sired to use this make with screens, get the ''screen" plate, which is made especially for this class of work. Cramer's and Seed's plates seem to work as well with or without, the time being shortened as above stated. In the following list of exposure times, two technics are used in some instances. It might be well to try them both out, selecting that which seems to give the best plates. Some prefer the one while some like the other. With the first, it is noticed that Paragon or Seed's are used and with the second, Cramer's. All times are given on a basis of an adult about 5 feet 10 inches tall and weighing about 160 pounds. Give a little more or less according to weight. Eecently a new plate has been placed upon the market (Diagnostic). This the author has found to be very fast, ha\dng four times the speed of the Cramer and twice that of the Paragon when used directly. With a screen its speed is not so marked. 39 40 ROENTGEN TECHNIC Size of Plate. Diaphragm. Position. Name of Plate. Kumier of Exposures. SparTc Gap. Milliamperage. Distance. Time. Part. — Hand and Wrist 8x10, or ei/oxSi/o. Laige. Center over part de- sired. Paragon or Seed's. Two. Anteroposterior and lateral. 5V2 inches. 35 ma. 18 inches. Anteroposterior ]{^ sec- ond, lateral Y2 sec- ond. Cramer 's. Two. Anteroposterior and lateral. 41/4 inches. 60 ma. 22 inches. Anteroposterior IV2 sec- onds, lateral 2 sec- onds. POSITIONS AND EXPOSURES 41 Fig. 13. — Posteroanterior wrist and hand position. ^' ■■ ■ i ,1 ■ 1 1 ^^m^B=-TT-:H|| , ■■■■«• - • t*lb 1 1 Fig. 14. — I,ateral wrist position. 4v; ROENTGEN TECHNIC Size of Plate. Diaphragm. Position. Name of Plate. Ninnier of Exposures. Sparlc Gap. Milliamperage. Distance. Time. Part. — Elbow 8x10. Large. Center between con- dyles. Paragon or Seed's. Two. Anteroposterior and lateral. 51/^ inches. 35 ma. IS inches. Anteroposterior, % sec- ond; lateral, % sec- ond. Cramer 's. Anteroposterior and lat- eral. 4% inches. 60 ma. 22 inches. Anteroposterior, 3 sec- onds; lateral, 2i/^ sec- onds. POSITIONS AiSTD EXPOSURES 43 Fig. 15. — Anteroposterior elbow position. — ■ !*.■«, , 1 ' - ->^^ j j r Fig. 16. — Lateral elbow position. 44 TvOEXTGEN TECIIXIC Size of Plate. DiMphragm. Position. Name of Plate. Numlier of Exposures. SparTc Gap. Milliamperage. Distance. Time. Part.— Ankle 8x10. Large. Througli mallGoli. Paragon, or Seed's. Two. Anteroposterior, and lateral. 514 inches, .35 ma. IS inches. Anteropos t e r i r, l^o seconds ; lateral, 1 second. Cramer 's. Two. Anteroposterior, and lateral. 41/^ inches. 60 ma. 22 inches. Anteroposterior, .3 sec- onds; lateral, 2i/4 sec- onds. POSITIOXS AXD EXPOSURES 45 Fig. 17. — Anteroposterior ankle position. Fig. 18. — Lateral ankle and lateral tarsus positions. 46 EOEXTGEN" TECHjSTIC Part. — root Size of Plate. SxlO. (3) Diaphragm. Large. Fosition. First a stereoscopic set should be taken with the foot on its external side. This should take in all the foot and ankle joint. One plate (8x10) should now be taken anteroposteriorly, the patient lying on the back with the knee drawn up so that the plantar surface is resting firmly on the plate. The tub© should now be brought down so that the principle rays are centered over the tarsus, tilting the tube so that the rays point a little toward the heel. In order to bring out the tarsus well in this position, the toes will have to be somewhat overexposed. If only the toes or metatarsal bones are desired, the exposure will nec- essarily be somewhat shorter. (Figs. 19 and 20.) Name of Plate. Number of Exposures. Sparlc Gap. MilUamperage. Distance. Time. Paragon or Seed's. Three. 5% inches. 35 ma. 18 inches. Anteroposterior, 1% seconds ; lateral, 1 second. Cramer 's. Three. 4% inches. 60 ma. 22 inches. Anteroposterioi', 3 sec- onds; lateral, 2 sec- onds. POSITIOI^S AND EXPOSURES 47 Fig. 19. — Lateral ankle and lateral tarsus positions. Fig. 20. — Anteroposterior tarsus position. 48 EOEXTGEX TECHXIC Part. — Knee Size of Plate. 10x12. Diaphragm. Large. Position. Place patient on back, with the center of the plate at a point about 2 inches below the patella (Fig. 21) ; also one exposure with patient lying on affected side with plate centered over same point (Fig. 22). Name of Plate. Number of Exposures. Sparl; Gap. Millia mp e rag e. Distance. Time. Paragon or Seed's. Two. oMi inches. 35 ma. 18 inches. Anteropos terior, 1% seconds; lateral, 1% seconds. Cramer 's Two. 41^ inches. 60 ma. 22 inches. Anteroposterior, 3 sec- onds; lateral, 2i/^ sec- onds. POSITIONS AND EXPOSURES 49 Fig. 21. — Anteroposterior knee position. ;^.^, ':';'"", ■■". ' - . • . i^/jW- ij 1' 1 f Fig. 22. — I,ateral knee position. 50 ROENTGEN TECHNIC Part. — Hip Size of Plate. 8x10. Diaphragm. Large with cone. Fositiaii. Place tip of thumb over highest point of iliac crest, tip of mid- dle finger over great trochanter and with the tip of the first finger form a triangle. At this point, center the principal rays. Bring the cone in contact with the skin without compression. (Fig. 2.3.) Name of Plate. Numier of Exposures. SparJc Gap. Milliamperage. Distance. Time. Paragon or Seed's. Two. Stereoscopical. 6 inches (without screen). 90 ma. (without screen). Contact, or as near 20 inches as possible. 1 second (without screen). Cramer's. Two. Stereoscopical. 41/^ inches (with screen). 60 ma. (with screen). Contact, or as near 20 inches as possible. 3 seconds (with screen). POSITIONS AND EXPOSURES 51 IHHI ■ 1 |^l^|,n-i. .^B^^^^^B^B M ^^L ^1 1 d Fig. 23. — Anteroposterior hip position. 52 EOENTGEN TECI-INIC Part. — Pelvis Size of Plate. 11x14. Diaphragm. Large or none (see below). Position. The patient is placed on the back with the plate extending cross- wise at the point midway from the upper and lower edge site of the femoral head, as shown in Fig. 24. (To find the femoral head, place the tip of the thumb on the highest point of the iliac crest, the tip of the middle finger on the greater trochanter and with the tip of the index finger, form a triangle, the point over which the index finger rests is the approximate site of the femoral head.) Name of Plate. Ntimher of Exposures. SparJc S^ap. Milliamperage. Distance. Time. (without Paragon, or Seed's. Two. Stereoscopical. 6 inches (without screen). 90 ma. screen). 20 inches. (If a dia- phragm is used, the distance will have to be increased to 27 inches.) 1 second at 20 inches without screen, or is/io seconds at 27 inches without screen. Cramer 's. Two. Stereoscopical. 4% inches (with screen) . 60 ma. (with screen). 20 inches. (If a dia- phragm is used, the distance will have to be increased to 27 inches.) 3 seconds with screen at 20 inches, or S^/^ seconds with screen at 27 inches. POSITIONS AND EXPOSURES 53 Fig. 24. — Anteroposterior pelvis position. 54 EOEiSTTGEN TECH:N'IC Part. — Shoulder Size of Plate. 8x10. (Two stereoscopieal.) Diaphragm. Large. Position. Center rays a little internal and sligktly above axilla (Fig. 25). This examination should always be made stereoscopically, as it is impossible to get two way plates satisfactorily. The stereo- scopic box or plate holder is placed under the affected shoulder and a book or other object about twice the thickness of the box is placed under the opposite side. This throws the shoulder to be taken well down on the holder, thereby insuring good detail. Name of Plate. Numher of Exposures. SparTc Gap. Milliamperage. Distance. Time. Paragon or Seed's. Two. 5V2 inches. 35 ma. 18 inches. 21^ seconds. Cramer 's. Two. 4:^2 inches. 60 ma. 22 inches. 4 seconds. POSITIONS AND EXPOSURES 55 Fig. 25. — Anteroposterior shoulder position. 56 EOEXTGEjS!' technic Part. — Neck Sise of Plate. 5x7. (2) 8x10. (1) Diaphragm. Large and medium. Position. A lateral view should first be taken. This is best done by having the patient sit in a chair with the tube tilted on its side (Fig. 26). Use the medium size Hickey cone, allowing it to rest on the patient's shoulder. In fact it should exert some pressure so that the shoulder is forced downward as far as possible. The plate (5x7) is held by an assistant against the opposite side of the neck, pressing it well down onto the shoulder, but at the same time not getting it too far from the neck. The patient is asked to sit in an attitude of dejec- tion with shoulders drooped to their fullest extent. Unless this is done, the seventh cervical will not be reached. This plate shows the lateral view of all the cervieals. In the anteroposterior position, the patient should be lying on the flat of the back, the head just off the table (see Fig. 27). An 8x10 plate is placed under the neck, extending up to the occipital protuberance. The rays are directed about 2 inches above the episternal notch. This will take in all the cervical vertebrae except the upper two or three. The third position is to obtain these upper two or three bones from an anteroposterior view. The patient is on the back with the head resting on the table. The plate (5x7) is placed well up under the occiput. The mouth is opened to its fullest extent (about two inches), and a cork placed between the teeth. The small diaphragm is used, the rays being centered over the open mouth. This plate will show the first and second vertebras very plainly. Name of Plate. Numter of Exposures. Sparh Gap. Milliamperage. Distance. Time. Paragon or Seed's. Three. Two anteropos- terior; one lateral. 51/^ inches. 35 ma. 18 inches. Anteroposterior, 3 sec- onds; lateral, 2i/4 sec- onds. Cramer 's. Three. Two anteropos- terior, one lateral. 4l% inches. 60 ma. 22 inches. Anteroposterior, 4 sec- onds; lateral, o% sec- onds. POSITIONS AND EXPOSURES 57 Fig. 26. — Lateral cervical spine position. Fig. 27. — Anteroposterior cervical spine position. 58 ROENTGEN" TECHNIC Part. — Dorsal Spine Size of Plate. 11x14. (3) Dia.pliragm. Large. Fosition. The upper end of the plate should be on a level with the seventh cervical running lengthwise down the spine with the body cen- tered on it evenly from side to side. The principal rays should be directed over its center. This gives an anteroposterior view of the whole dorsal region (Fig. 28). For an oblique view, lay the patient on the face, rotating him a quarter turn upward one side or the other, placing the plate a little posterior from the center of the body (Fig. 29). Eaise the arms strongly above the head. It relieves the strain somewhat to support the raised hip and shoulder by means of sand bags. If the true lateral posture is desired, the patient is laid squarely on the side with the arms extended well above the head. The plate is placed in position, remembering that the spine occupies a point about two-thirds back from the chest wall in front. In all these exposures it should be remembered that the patient should be directed to take a deep breath and maintain it dur- ing the time of exposure. Name of Plate. Numher of Exposures. Sparlc Gap. Milliamperage. Distance. Tvme. Paragon or Seed 's. Three. 51/^ inches. 35 ma. Anteroposterior, 36 in- ches ; oblique and lat- eral, 30 inches. Anteroposterior, 10 sec- onds; oblique, 9 sec- onds ; and lateral, 9 seconds. Cramer's (with screen). Three. 41/^ inches. 60 ma. A.nteroposterior, 36 in- ches; oblique and lat- eral, 30 inches. Anteroposterior, 6 sec- onds ; oblique, 5 sec- onds; lateral, 5 sec- onds. POSITIONS AND EXPOSURES 59 :^ , 1 V -* J IH^k'. ' 1 ^: .' li i'vl" »^^~iwiniK Fig. 28. — Anteroposterior dorsal spine position. Fig. 29. — Oblique dorsal spine position. 60 ROENTGEN TECHNIC Part. — Lumbar Spine Size of Plate. 11x14. (2) Diaphragm. Large with large size Hickey compression cone. Position. Place the patient on the back with the plate well v:p to the mammillary line (Fig. 30). The cone is centered over the epi- gastrium having the upper edge just overlapping the costal arch. Compression is now made at the same time, tilting the tube so that the cone fits snugly into the epigastrium. The patient is instructed to take a full breath and hold it until the exposure is completed. The oblique view is made the same as in the dorsal spine, except that the plate and tube are moved downward so as to take in the lumbar vertebrae instead of the dorsal (Fig. 31). (See dorsal spine technic.) Name of Plate. Numier of Exposures. Sparlc Gap. Milliamperage. Distance. Time. Paragon or Seed's. Two. 51/^ inches. 35 ma. Contact (about IS inch- es). 5 seconds (without screen). Cramer 's. Two. 41/^ inches. 60 ma. 22 inches. 3 seconds (with screen). POSITIONS AND EXPOSURES 61 Fig. 30. — Anteroposterior lumbar spine position. Fig. 31.— Oblique lumbar spine position. 62 ROEXTGEX TECHXIC Part. — Clavicle Sise of Plate. 8x10, if one is to be taken; 11x14, for both. Diaphragm. Large. Position. Place plate under clavicular region, having placed patient on chest (Fig. 32). The long way of the plate should run from side to side and should extend well out to the shoulder joint and high enough up so that the upper margin extends well up onto the neck. If one plate of both are to be taken, an 11x14 should be placed crosswise of the upper chest, the upper edge extend- ing' well up above the level of the clavicles. The tube should be centered over the spinous process of the second or third dorsal vertebra. The same instructions regarding the holding of the breath should be given as in the lumbar spine, for if there is any respiratory movement it will ruin the effect. Name of Plate. Number of Exposures. Sparlc Gap. Milliamperage. Distance. Time. Paragon or Seed's. One. 5yo inches. 60 ma. 24 inches. 1 second. Cramer 's. One. 41/^ inches. 60 ma. 24 inches. 21/4 seconds. POSITIONS AND EXPOSURES Fig. 32. — Clavicle position. 64 ROENTGEN TECHNIC Part. — Scapula Size of Plate. 10x12. Diaphragm. Large. Position. Place the patient the same as for taking the shoulder except the arm on the affected side should be raised above the head (Fig. 33). This throws the scapula toward the side of the chest. The plate is placed under the scapular region, the upper edge extending well above the shoulder lever, the inner edge extend- ing to the spine. The tube is centered about two inches below the clavicle a little outside the mammillary line. Name of Plate. Paragon or Seed's. Cramer's. Numier of Exposures. One. One. SparTc Gap. 5% inches. 4i/^ inches. Milliamperage. 80 ma. 60 ma. Distance. 18 inches. 22 inches. Time. 1 second. 2 seconds. POSITIONS AND EXPOSURES 65 Fig. 33. — Scapula position. 66 KOENTGEN TECHNIC Part. — Sternum Size of Plate. 11x14. Diaphragm. Large. Position. This is the most difficult bone in the body to reproduce success- fully. It is very rarely seen well done. The patient must he placed in the oblique position, that is, being laid on the face and then turned upward one-quarter turn. A deep inspiration must be taken and held. The plate is placed so that it will extend out anteriorly beyond the chest wall and well up on the neck. The tube is centered over its center. (Fig. 29.) Some operators iind they can do better work by placing the patient flat on the chest with the plate under the entire sternum extending well up onto the neck, directing the rays obliquely through the chest at a point about lialf way between the spine and the axillary line. The author has not had as good success with this as with the preceding position, but has seen some beautiful work done by others. It is well worth a trial. Name of Plate. Paragon or Seed's. Cramer's. Number of Exposures. One. One. SparJc Gap. 51/2 inches. 6^2 inches. Milliamperage. 60 ma. 80 ma. Distance. 24 inches. 24 inches. Time. 1% seconds. 11/4 secoilds. POSITIONS AND EXPOSURES 67 Part.- — Ribs Size of Plate. 11x14. Diaphragm. Large. Position. Place the patient in the best position suited to bring the sup- posed fracture nearest the plate. This is usually oblique, either on the face or on the back whichever seems best. Center tube so principal rays will fall directly over painful area. In- struct patient to hold breath while making exposure. It is al- ways advisable to place a lead marker over the suspected lesion (a lead letter stuck to the center of a piece of adhesive plaster placed over the area is good). This will identify the exact area on the finished plate. Name of Plate. Numlier of Exposures. Sparlc Gap. MilUamperagc. Distance. Time. Paragon or Seed's. One. 6 inches. 60 ma. 24 inches. 1 second. Cramer 's. One. 41/^ inches. 60 ma. 22 inches. 2 seconds. 68 ROENTGEN TECHNIC Part. — ^Urinary Tract This examination is not complete until the entire tract has been taken, that is, both kidneys, both ureters, and the bladder. It has been demonstrated many times that a stone in one kidney may give pain only in the bladder, and vice versa; also a stone in one kidney may give all sj-mptoms seemingly in the opposite. It is therefore very incomplete to examine only one part with the possible lesion being situated in another. Size of Plate. One, 11x14; one, 8x10. Diaphragm. Large with large size Hickey cone. A copious water enema should always precede this examina- tion taken in the recumbent position ; thus clearing the colon of all feces and gas. Position. The 11x14 plate is used first, taking in both kidneys and both ureters close to their termination in the bladder. The patient is j)laced on the back, the shoulders and knees being raised and supported, and the plate being placed lengthwise, running from the eighth rib behind downward. (See Figs. 34 and 35.) The tube with large cone attached is now set down so that the upper edge of the cone just overlaps the costal arch. The tube is tilted a little so^ that the cone will conform a little better to the slant of the abdomen, and compression is made, bringing the sjjine close to the plate. The other plate takes in the lower ends of both ureters and the bladder. An 8x10 plate is used. This is so placed that the upper edge is about on a level with a line dropped from the navel. The lower edge of the large Hickey cone which is used is placed so that it just overlaps the pubic arch and the cone tilted slightly so that the rays are thrown slightly into the pelvis, that is, the ui^jjer edge is dropped slightly in the abdomen. (Fig. 35.) Compression is made, the knees having been lowered but the shoulders still being raised and supported. At the time of both these exposures, the breath should be held. Name of Plate. Number of Exposures. SparJ; Gap. Milliamperage. Distance. Time. Paragon or Seed's. Two. 5V2 inches. 35 ma. Contact, cone. About 22 inches. Kidney, 5 seconds (without screen ) . Bladder, 4 seconds (without screen). Cramer 's. Two. 41/^ inches. 60 ma. Contact, cone. About 22 inches. Kidney, 3 seconds (with screen). Blad- der, 2% seconds (with screen). POSITIONS AND EXPOSURES 69 Fig. 34. — Kidney position. Fig. 35. — Bladder position on dorsum. 70 ROENTGEN TECHNIC Pyloroentgenography Tliis is a branch of the roentgenological examination of the urinary tract that is nsed by some workers, very frequently. It consists in placing in the kidnej'S and ureters, a contrast substance so that they may be shown the same as the stomach is when filled with bismuth mixture. There are several methods employed: 1. Metal stylet enclosed in ureteral catheter. 2. Catheter impregnated with bismuth. 3. Specially prepared ureteral catheters, known as x- ray catheters. 4. Silver solution injection. (Collargol 10 per cent, Cargentos 20 per cent.) 5. Thorium solution injection, 15 per cent. The patient is examined cystoscopically, using an in- strument rigged for double catheterization. After both catheters are in their respective ureters, the protruding ends are attached to a graduated glass cylinder holding 150 c.c, and the solution is alloAved to run in under a very low pressure, the container only being raised a short distance above the patient. Pressure such as may be applied by a syringe should never be used as danger of forcing the solution out into the kidney substance or even of rupturing the pelvis becomes very possible. Up- on the first sign of distress being evidenced by the pa- tient, the flow is immediately shut off and the catheters removed. The amount injected for both kidneys and ureters should never exceed 15 c.c. The folate having previously been placed in joosition, the tube is centered over its center which Avill be about the navel, and after instructing the patient to hold an inspiration, the ex- posure is made. Tins will, if properly performed, show the pelves and calices filled, as well as both ureters. POSITIONS AND EXPOSURES 71 This reveals a very good idea of the size of both kidneys, their position, and the course and length of both ureters. One will be able to rule out, among other things, ne- phroptosis and ureteral kinks. If a stone is in the ureter, the solution will probably not pass it, but stop as soon as the obstacle is met, the ureter filling from there down. An opaque injection should never be done until a thor- ough examination of the entire tract has been made, ruling out calculi, which of course would be obscured by the opaque media used. If nephroptosis is suspected, it is advisable to take a plate not only in the prone posi- tion but also standing if the condition of the patient warrants it. It is sometimes desirable to demonstrate the presence or absence of vesical diverticula. This is best accomplished by filling the bladder by means of an ordinary rubber catheter attached to a glass cylinder containing a contrast solution, composed of either of the following mixtures: Barium sulphate 3 oz. 01. amydalse dulcis 15 oz, Or Silver iodide 2% Use about 16 oz. All or as much as can be comfortably borne is injected, and then after turning the patient once on the face and back again to distribute the solution, the exposure is made. 72 EOEITTGEN" TECHNIC Fig. 36. — Kidney position. Part. — Kidneys, Ureters, and Bladder. (Injected.) Size of Plate. 14x17, 11x14, and 8x10. Diaphragm. Large, with large Hickey cone. Position. One plate should be taken with the patient on the back, the l^late being placed so that it extends well under the ribs poster- iorly. The 14x17 plate should be used without diaphragm or cone, the entire tract being obtained. Another plate (11x14) should now be j^laeed so that its upper edge extends well under the posterior ribs and using the large size cone and diaphragm, the tube is tilted so that it fits into the anterior abdominal wall under the costal arch. (See urinary tract examination.) Two 8x10 plates are used in examining the injected bladder. With the first, the patient is placed on the back, the plate and tube being located the same as for the bladder examination. With the second, it is well to place the patient on the face, putting the plate so that its lower edge is below the pubic arch about two inches. The tube with large cone and diaphragm is tilted so that the principal rays strike about the anal opening. (See Figs. 36, ?,7 and 38.) Name of Plate. Numier of Exposures. Sparic Gap. Milliamperagc. Distance. Time. Paragon or Seed's. Three. 51/^ inches. 35 ma. 30 inches (14x17). Contact (11x14, and 8x 10). Kidney, 5 seconds (without screen). Bladder, 4 seconds (without screen). With 14x17 at 30 inches, 9 seconds. Cramer 's. Three. 41/^ inches. 60 ma. Same. Kidney, 3 seconds (with screen). Bladder, 2% seconds (with screen). With 14x17 at 30 inches, 5.8 sec- onds (with screen). POSITIONS AND EXPOSURES 73 Fig. 37. — Bladder position on dorsum. Fig. 38. — Prone bladder position. 74 EOENTGEX TECHXIC Chest Examination Tlie clothing having been removed, the patient is taken into the fluoroscopic room and viewed through the ver- tical instrument. First, the two apices are observed by forming the diaj^hragm aperture into a horizontal slit about 2Y2 l^y 8 inches. The patient is asked to take several deep inspirations followed by a cough. By this means can be ascertained whether either apex fails to fill well or ''light up" as it is conmionly phrased. Fol- lowing this the aperture is changed to a vertical slit somewhere about 3 by 10 inches. Both hila are now ex- amined to note any thickening, or other abnormality. At this time the heart is gone over hurriedly, more par- ticularly to ascertain the presence or absence of aortic aneurysm. The shape and size are also noted. Follow- ing this, both complementary sjDaces (the lung tissue ex- tending down between the arch of the diaphragm and the ribs) are observed for cloudiness, the patient being instructed to breathe deeply several times so that the excursion of the diaphragm can be seen on both sides. The patient is now turned a quarter turn to the left. The heart is now seen at the operator's right and the spine to the left with the clear jDosterior mediastinum between. It should be noted whether this sjoace is as clear as usual or whether it is encroached upon by glands or enlarged aorta. After this the diaphragm is opened to its fullest, the patient is brought to face the operator, and the chest as a whole is viewed, all the while the pa- tient breathing deeply. If anything of interest is seen, such as areas of consolidation, cavity formation, etc., it is closed down upon and observed more in detail. This detail is at its best only partial, for plates are the only satisfactory method of regist(^ring pulmonary detail, the fluoroscope showing practically only movement and cer- tain gross pathologj^ POSITIONS AND EXPOSURES 75 The patient is now reversed with back to screen and jDractically the same routine is gone over with. The case is now ready for the roentgenogram. In doing chest fluoroscopy it is well to have the tube particularly soft. There is no necessity for excessive penetration, the lung being of such a spongy character, and the wealth of detail thereby produced is an exten- sive help in differentiating the various types of pathol- ogv met with. 76 ROENTGEN TECHNIO Part. — Chest Size of Plate. 14x17. Diaphragm. None. Position. Patient lies on chest, face straight ahead, with forehead rest- ing on table. The upper border of the plate should be well up un- der the chin. Hands and arms at side with palms up. A deep inspiration is taken and the exposure made. (Fig. 39.) Name of Plate. Niimier of Exposures. SparJc Gap. Milliamperage. Distance. Time. Paragon or Seed's. One. Some workers prefer that the chest always be taken stereoscopi- cally. This is a mat- ter of preference. 5\'o, inches. 60 ma. 30 inches. 1% seconds. Cramer 's. One. 5^/^ inches. 60 ma. 24 inches. IV2 seconds. POSITIOisrS A'^D EXPOSURES 77 ^^_'i3i^'J^'k ij 1 ■ -'■-■ / "1 •a ,^, .^ ! ^ ^^^1 1 Fig. 39. — Chest position. 78 EOEXTGEN" TECHNIC Fig. 40. — Lateral head position. Part. — Head Size of Plate. 8x10, or 10x12. Diaphragm. Large. Position. In looking for fractures of the iDase or vault, it will only be necessary to take stereoscopic plates with the head first on one side and then on the other, but if the sinuses are in question, to this must be added an anteroposterior and an inferoposterior. All hairpins and ornaments should be removed, allowing the hair to fall loosely. If looking for a suspected fracture, lay the head with the injured side down next the plate, resting it upon the stereoscopic box. The patient lies on the side with the arm next the table placed behind him. Tliis brings the chest against the table and not only allows the head to remain nearer the tal)le but insures a more steady position. (See Fig. 40.) A stereoscopic set is now taken as heretofore described, the long way of the plate being placed from before backward. "When the accessory sinuses are desired, two plates are required. With the first the patient is placed face downward with the chin rest- ing on an 8x10 running from above downward. The head is so placed that while the chin rests on the plate, the tip of the nose is about one-half inch distant from it. A large Hickey cone is used and is brought down so that it envelops the head, the principal rays being directed through the malar promi- nences. By assuming this position, the petrous portions of the temporals are thrown downward so that they do not obstruct POSITIONS AND EXPOSURES 79 1 W^ ■V "^V^^v m L". _ 1 Fig. 41. — Inferosuperior head position. the antra of Highniore. By using this position, one is enabled to compare as to density, both frontals, both antra, anterior and posterior ethmoids on both sides, and both mastoids to a lim- ited degree; tliis, however, not being the best position for mas- toids. Besides the sinuses this position shows not only the general conformation of the face but certain minor things like the nasal septum, and parts- of the turbinates. The lower jaw, especially the anterior portion containing the central and lateral incisor teeth, comes out quite clearly. If now with one lateral view the sphenoid cells are seen to- be clear, all has been done that is necessary; but if this area looks cloudy, an infero- superior view should be obtained. For this the patient is placed on the back with the head hang- ing over the end of the table as far as possible (Fig. 41). A stool is now placed under the crown of the head with an 8x10 plate interposed. This plate should be parallel to a plane drawn through the external auditory meatus and the superciliary ridge! The tube with the small Hickey cone is placed so that the end of the cone comes under the chin, the principal rays striking the plate at right angles. This will show the butterfly- shaped sphenoid bone with the sphenoid cells in the center. Both sides can now be compared- for any difference in their density. The anteroposterior head position is shown in Fig. 42. Tliere is another method that is very satisfactory in demon- strating the sphenoid cells. It is obtained as follows : Seat the patient in a chair facing the side of the table, the 80 EOE]SrTGE:N" TECHNIC Fig. 42. — Posteroanterior head position. table having been raised so that it is about on a level with the episteinal notch. Its surface is now tilted upwards toward the jjatient, or, if this is not convenient, a wedge is placed so that the thin side is to the patient and the cassette is placed thereon. The patient now extends the neck and the chin forward to their utmost, letting the chin rest on the cassette. The tube with the small cone is now brought down near the dome with the principal rays entering at a point about half way between the vertex and the superciliary ridge, directed in a plane that will strike the plate as near a right angle as possible. This will show the sphenoid with its enclosed cells very nicely. If the case is one for general diagnosis of some indefinite head lesion, stereoscopic plates should be taken from both sides. In case the frontal bone itself is in question, it should be placed directly in contact with the envelope so as to bring out as much detail as possible. The head is the only part of the body where a stereoscopic view must be taken from both sides, and it is only from the fact that the head is so thick that the side away from the plate is not distinct enough to make out the detail necessary. In a lateral stereoscopic view of the head, the half of the head nearest the plate shows up with great distinctness while the far side is very hazy. By reversing the process, both sides are brought out with the maximum of detail. POSITIONS AjSTD exposures 81 Name of Plate. Numher of Exposures. SparTc Gap. Milliamperage. Distance. Time. Paragon or Seed's only. Fracture of vault: Two, stereoscopical. Sinuses: Two, one lateral, one anteroposterior. (One, below upward, if necessary.) Indefinite pathology: Four, double stereoscopi- cal. 61/^ inches. 40 ma. Anteroposterior, 20 inches; lateral, IS inches. Anteroposterior, 5 seconds, lateral, 2 seconds. 82 EOENTGEN TECHNIC ■ 9^^^^^^H ^■H^BBHK ^^^\^«»> » f 1 ^ Fig. 43. — Mastoid position. Part. — Mastoids Size of Plate. 5x7. Diaphragm. Small. Small Hickey cone. Position. In mastoid work a plate should always be taken of both sides, so that they can be compared when finished. The patient is laid on one side with the arm next the table placed behind the body, the same as was suggested in the lateral head position. The head rests on a wedge, the base of which is raised from the table about 4 inches, the thin edge being placed under the neck and the thick side under the side of the head. This throws the head at an angle of about 30 degrees from the horizontal (Fig. 43). The plate is now placed with the mastoid in the center, the ear being turned forward so as not to overlap the cells. The tube is centered a little below and posterior to the parietal eminence so that the central rays mil strike the process as it lays on the plate. This, of course, will cause the rays to strike the plate at an angle of about 60 degrees, but what distortion there is makes no difference as both sides are taken the same way and arc thus in proportion. Name of Plate. Number of Exposures. Sparlc Gap. Milliamperage. Distance. Timie. Paragon or Seed's only. Two. Gi/^ inches. 40 ma. Cone almost in contact. 21/i seconds. POSITIONS AND EXPOSURES 83 Fig. 44. — Mandible position. Part. — Lower Jaw Size of Plate. 5x7. Diaphragm. Medium with a medium Hiekey cone. Position. The patient is placed in the same position as for a mastoid plate except the wedge is reversed, that is, the thick edge is placed under the neck, letting the head fall over it (Fig. 44). It is necessary that the neck be stretched to its fullest extent. This is imperative for by so doing the side of the jaw not wanted and farthest from the plate will be thrown out of range of the rays. The tube and cone are tilted so that the principal rays will strike directly on the jaw against the plate, being cen- tered just in front of the larynx. This, of course, throws the rays at an angle to the plate of about 60 degrees which causes some distortion, but a satisfactory plate results. Name of Plate. Number of Exposures. Sparlc Gap. Milliamperage. Distance. Time. Paragon or Seed's only. One. 4% inches. 60 ma. About 22 inches. ?j to 4 seconds. 84 EOEKTGEN TECHNIC Part. — Teeth Sise of Plate. Dental film 11/4x1% (negative). Diapliragm.. Small with small Hickey cone. Position. The film is placed inside the jaw opposite the tooth to be taken so that the tooth and alveolar process are interposed between •it and the rays. The tube is now tilted so that the principal rays will strike the film at right angles. This is very im- portant, for, if not done, the aj^ices of the roots, the most im- portant part, will not get on the film, the teeth appearing very long, extending all the way across the film. If the rays strike the film properly, the tooth will be seen normal in size. Always be sure that the film edge is about on a level with the chew- ing edge of the tooth, this will insure the apex on the film with sufficient bone tissue surrounding it to be satisfactory. The patient should be made to hold the films with the finger or thumb if possible. (See Figs. 45 and 46.) Numlter of Exposrtres. Usually three teeth side by side can be taken on one film. It requires ten films to include all of the teeth. Sparlv Gap. 4i^ inches. Milliamperage. 60 ma. Distaoice. Almost cone contact. Time. % second for uppers ; trifle less for lowers as the cone can be placed closer, usually about i/^ second. POSITIONS AND EXPOSURES 85 Fig. 45. — Position in taking upper teeth. Fig. 46. — Position in taking lower teeth. 86 ROENTGEN TECHNIC Part. — Gall Bladder Size of Plate. 8x10. Diaphragm. Medium with medium Hiekey coue. Position. The plate is so placed that its center is directly under a point on the right costal arch at the junction of the middle with the inner third. The patient is rotated a little to the right, bring- ing the right side close to the plate (Fig. 47). The cone is brought down so that its upper edge lies below the last rib at a point about equal distance from the spinous processes and the axillary line. The tube is tilted slightly upward and inward. The patient is instructed to take a deep inspiration and hold it during the exposure. Name of Plate. Number of Exposures. SparJc Gap. ^[iUiamperage. Distance. Time. Paragon or Seed 's. 4 to 6. 51/4 inches. 35 ma. Almost cone contact. 11/4 to 3 seconds (with screen). Average, 2 seconds. Cramer 's. 4 to 6. 414 inches. 60 ma. Almost cone contact. 2 seconds (with screen). POSITIONS AND EXPOSURES 87 ii ■ t 1 i - 1 i 1 _ J Fig. 47. — Gall bladder position. Oe PvOEI^]-TGEN TECHNIC Examination of the Esophagus This examination is made to determine stenosis re- sulting from malignancy, chemical action (lye, phenol, etc.), spasm, pressure from the outside, possibly from enlarged or malignant mediastinal glands, aneurysm of aorta, and spinal disease, Fluoroscope. — The patient is ]Dlaced in the ohlique posi- tion ; viz., turned a quarter turn to the right, just enough to allow the posterior mediastinum to show clearly. In order to view the wall of the esophagus properly, it should be coated with a mixture somewhat more ad- hesive than the ordinary buttermilk mixture. Hirsch, of New York, in a recent connnunication recommended the following: A teaspoonful of mucilage of acacia is stirred up with a heaping tablespoonful of bismuth subcarbonate. Stirring should con- tinue for ten minutes or until the mixture assumes a syrupy consistency. A teaspoonful of this is sufficient to cover the entire tract and it remains long enough to view the tube with some deliberation. Peristaltic waves can be seen, ex- ternal points of pressure can be noted and irregularities in the contour can be shown. Normally, the tract is clear in a few minutes, if, however, any lesion exists, the coat- ing will remain considerably longer. After taking plenty of time to view the coated tract (giving more mixture if necessary), turning the patient a quarter turn not only to the right but also to the left and straight forward, one plate or a stereoscopic set is taken preferably mth the patient standing in the right oblique position, al- though if necessary it can be done lying in the same position as for an oblique view of the stomach. (See gas- trointestinal technic.) POSITIONS AND EXPOSURES 89 Fig. 48. — Position for esophagus. Part. — Esophagus Size of Plate. 11x14. Diaphragm. Large with large Hickey cone. Position. Oblique (quarter turn). Eight breast to plate. Preferably standing, but not necessarily so. The patient is jDlaced in the position to be assumed, and is directed to take a fresh swallow of the contrast mixture so as to be sure to have some in the tube at the time of exposure. The patient is told to hold the breath, and the exposure is made. (See Fig. 48.) Name of Plate. Milliamperage. SparTc Gap. Distance. Time. Paragon or Seed's. 60 ma. 514 inches. 24 inches. 1 second. CVamer 's. 80 ma. 5^2 inches. 30 inches. 1% seconds. 90 EOENTGElSr TECHNIC Gastrointestinal Examination Tlie patient, having fasted for at least eight hours, l^resents himself and is prepared the same as for a chest examination, that is, all the clothing is removed, and a kimono slipjoed on. (If a male, only the clothing to the waist line need he taken off, the jDants being slipped down when the exposures are made.) He is now taken into the roentgenographic room where plates are made of the gall bladder. This is very essential as a routine in all gastrointestinal examinations trying to show gall stones, for it can not be done after the contrast meal has been given for fear of any stones that might be present being covered by the opaque media. (See gall bladder examination.) The opaque or contrast meal is now pre- pared. There are various mixtures used. Of the opaque ingredients bismuth subnitrate, bismuth subcarbonate, or bismuth oxychloride in 2 ounce doses, or barium sul- phate 5 ounces are the most common. On account of the difficulty in obtaining chemically pure bismuth salts, barium sulphate is the safest preparation besides being considerably less expensive. It does not obstruct the ra^^s quite as well as bismuth, but if given in large enough doses, is very satisfactory. Various vehicles in which to suspend the contrast substance have been used ; name- ly, cream of wheat, farina, potato pap, mucilage of acacia, malted milk, gruel, corn meal mush, buttermilk, and va- rious other things. Any one of them is satisfactory ; but for routine office work, the buttermilk, either as obtained from the drug store soda fountain or prepared by one of the various buttermilk tablets on the market, is ac- ceptable. Sixteen ounces are required. One meal should be adopted and maintained as a standard, for switching from one to another will lead to trouble, all of them giv- ing varying results, such as filling of the stomach and duodenum, emptying time, etc. POSITIONS AND EXPOSURES 91 Having prepared the meal, it is placed within easy reach, and a hurried examination is made of the chest, just to rule out any gross pathology that may have gone unnoticed. The patient is now placed in the oblique position the same as for viewing the posterior medias- tinum, the container holding the contrast mixture is held in the patient's left hand and he is directed to take a few swallows. The meal is now viewed by the aid of the vertical aperture as it passes from the mouth to the cardia. This, in a rough way, determines whether there is any marked stenosis or spasm of the esophagus. After this has been determined, the stomach is viewed, notic- ing any irregularities such as notches, hourglass contrac- tions or marked filling defects. The patient is now turned forward and the rest of the meal is directed to be taken. When the full amount has been ingested, the stomach is viewed as a whole, noting its shape, size and position. If peristalsis does not take place after a few moments, the patient is allowed to sit down for ten or fifteen minutes, after which waves will probably be no- ticed traveling from the cardia downward, especially on the greater curvature. The number, depth, and rapidity of these will be noted, as well as the pylorus and first part of the duodenum. A normal duodenum in its first part (cap) will be plainly visible as a sort of a triangular body with its base joining the pyloric sphincter which will be noticed as a narrowing. If there seems to be a sluggishness in the filling of the duodenal cap, a little pressure in the prepyloric region will, if normal, fill it out and will probably reveal the descending (second) portion, which is finally lost behind the antrum of the stomach as it approaches the ligament of Treit. The en- tire organ should be palpated to ascertain freedom of movement, filling defects or notches. "When all data ob- tainable have been elicited, the patient is taken into the roentgenographic room and plates of the stomach made. 92 eoentge:^ technic Part. — Stomacli and Duodenal Cap Sise of Plate. 11x14. Diaphragvi. Large. Position. From the fact that the cap, first portion of the duodenum, fills best in the prone position, from one to three plates are made with the patient lying on the face (Fig. 49). The plate (11x14) is placed under the belly lengthwise, estimating the position of the stomach from what has been seen with the fluoroscope. (It usually is from four to five inches higher when lying than when standing). After tliese have been taken, the patient is turned a quarter turn so that he is lying slightly on the right side, the plate having been slipped under previously. This not only brings the very important pylorus and cap near the plate but it shows the stomach in a different position. This is called the oblique position (Fig. 50) and by some is thought very impor- tant. The standing posture is now assumed (Fig. 51). The tube is tilted so that the rays pass parallel to the floor. The table is tilted to the vertical position supporting the plate, and the patient interposed. The stomach now, of course, will be in the same position as when viewed with the vertical fluoro- scope, and the height of the plate will be determined accord- iiigl^y- The patient must be instructed to stand very close to the table mth the hands resting on the edge, else due to un- steadiness on the feet, movement will take place. Before each gastrointestinal exposure is made, the breath must be held. Fig. 49.— Prone stomach position. POSITIONS AND EXPOSURES 93 Fig. SO. — Oblique stomach position. Fig. SI. — Standing stomach position. 94 EOEXTGEX TECHiSTIC Xante of Plate. Paragon or Seed's. Number of Exposures. 3 to 6. Spark Gap. — Si~e of Patient. — r Prone, Syi in. (without screen) Small i Oblique, 6;'2 in. (without screen) I Standing, 6^ in. (without screen) r Prone, 6^ in. (without screen) Medium ■{ Oblique, 6J/2 in. (without screen) I Standing, 6^ in. (without screen) I Prone, 7 in. (without screen) Large ^ Oblique, 7 in. (without screen) I Standing, 7 in. (without screen) Milliamperagc. — I Prone, 90 ma. (without screen) Small -; Oblique, 90 ma. (without screen) I Standing, 90 ma. (without screen) {Prone, 100 ma. (without screen) Oblique, 100 ma. (without screen) Standing, 100 ma. (without screen) {Prone, 120 ma. (without screen) Oblique, 120 ma. (without screen) Standing, 120 ma. (without screen) Large Distance. — • Time. — Small Medium Large Lying and standing, 22 in. Oblique, 24 in. {Prone, Va sec. (without screen) Oblique, J4 sec. (without screen) Standing, Yz sec. (without screen) {Prone, J4 sec. (without screen) Oblique, 1 sec. (without screen) Standing, 3/J sec. (without screen) Prone, % sec. (without screen) Oblique, lYz sec. (without screen) Standing, 1 sec. (without screen) Cramer's. 3 to 6. Prone, 6J/2 in. (with screen) Oblique, 6J/2 in. (with screen) Standing, 6]/^ in. (with screen) Prone, 6Y2 in. (with screen) Oblique, 6Y2 in. (with screen) Standing, 6Y2 in. (with screen) Prone, 7 in. (with screen) Oblique, 7 in. (with screen) Standing, 7 in. (with screen) Prone, 90 ma. (with screen) Oblique, 90 ma. (with screen) Standing, 90 ma. (with screen) Prone, 100 ma. (with screen) Oblique, 100 ma. (with screen) Standing, 100 ma. (with screen) Prone, 120 ma. (with screen) Oblique, 120 ma. (with screen) Standing, 120 ma. (with screen) Same Prone, Vs sec. (with screen) Oblique, % sec. (with screen) Standing, Y2 sec. (with screen) Prone, Y2 sec. (with screen) Oblique, 1 sec. (with screen) Standing, J4 sec. (with screen) Prone, Ji sec. (with screen) Oblique, lYi sec. (with screen) Standing, 1 sec. (with screen) Serial Roentgenography Very frequently it is advisable to have several views of the antrum of the stomach, the pyloric sphincter, and the duodenal cap, so that a complete cycle may be viewed. With this in inind, the author's colleague. Doctor A. F. Tyler, and the author designed and put in operation a table which accomplishes this in a very satisfactory POSITIONS AiSTD EXPOSURES 95 inaiinor. (See Figs. 52 and 53.) It is made to hold a 14x17 plate, obtaining sixteen views on same, which meas- ure 314 by 414 inches each. After the usual plates are taken, this apparatus is laid upon the roentgenographic table, the patient being placed on it face do^^mward and 96 ROENTGEN TECHNIC the exposures made in rapid succession ; the whole opera- tion consuming about one minute or less. At times, this is a great help in clearing up some obscure point. The box in which the plate holder pla^^s, measures 29 by 35 by 211/2 inches, inside measurements. The holder is one taken from a Kelley-Koett table with two handles at- tached to one side. This runs forward and backward, as Fig. 53. — Showing serial plate apparatus tilted upward when not in use. POSITIONS AND EXPOSURES 97 well as from side to side, somewhat the same as a tube in a horizontal flnoroscope, there being a track running in both directions. The back and both ends are enclosed, leaving the front open. The top is lined with one-eighth inch lead having a square opening in the center 3V2 by 4^ inches. On the front edge of the top, there are two spring snaps opposite the two handles. When the plate holder is in position, it can be moved the required dis- tance, 4^ inches, and stopped. On the handles, Avliich are circular steel rods, there are lugs every 3^/2 inches. The holder is started from one end, after having been pushed into the back of the box and moved four spaces, each 414 inches, it is then pulled out to the first lug, 3^/2 inches and returned in another four spaces or inter- vals. This is repeated until all sixteen spaces are cov- ered. In order to locate the sphincter over the center of the given space, the patient is first placed face downward on the horizontal fluoroscope, the duodenum and pylorus located, and a small cross with a skin pencil made, the intersection being over the sphincter. After this, the patient is laid face downward on the table; a steel rod bent to a right angle is set into a socket placed on the back side of the table which has an adjustable line hang- ing from its tip with a plumb bob on the end. It was determined in the placing of this socket and in figuring the length of the horizontal arm, that the plumb bob would fall squarely over the center of the opening so when the patient is in position and his body adjusted so that the plumb points squarely over the intersection of the cross, it is known that the pylorus too is squarely over the opening. The rod is now removed and the tube with the small diaphragm and cone are centered oVer the cross. Following this the patient is directed to return at the end of six hours (fasting) so that the emptying time yy EOEXTGEX TECHXIC may be ascertained flnoroscopically. (Eepeated exam- inations have slioAvn that a normal stomach should be entirely empty at this time if given buttermilk mixture.) If the stomach is not emjoty at this time, the cause, if possible, should be learned, a i^late being taken not only to record it, but to lend any possible aid in ascertaining the delay. The plate will also show how far the head of the meal has advanced, how much still remains in the ileum, etc. Twenty-four hours following the ingestion of the meal (18 hours following last observation) the pa- tient presents himself again, having been given permis- sion to take food, if desired, but no enema or laxative having been allowed. (If the stomach is not enixDty at six hours, it is desirable to observe the case every few hours if convenient until emj^tying has taken jilace and a note made of it.) At this time, the colon should nor- mally be filled as viewed by the fluoroscope. It should be determined by palpation whether the colon is freely movable; whether any adliesions are present, either to surrounding parts or from one part of the gut to an- other; whether the ai)j)endix shows (it does at this time in about 75 per cent of cases) and if so, whether it is freely movable, bound down in the j)elvis or, jDossibly up behind the cecum (retrocecal), whether it is tender to pressure; whether there is an elongated sigmoid loop, how much ptosis is present, if any, and whether the cecum or ascending colon are beginning to empty or not and anything further that may help in reaching a cor- rect diagnosis. A plate is taken at this time, especially so if the appendix is visible. The case may from now on be followed by means of the fluoroscope only (unless something of interest presents itself which should be permanently recorded on a plate). The horizontal ap- paratus is used at any one of these observations if any further information can be obtained, as for instance, a transverse colon that sags doAvn into the pelvis and can POSITIONS AND EXPOSURES 99 not be raised in the standing jDosition, may come np readily if the i^atient is placed on the back. Adhesions at this point can sometimes only be demonstrated in this manner. From now on the case is nsually nothing more than determining Avhether a colon stasis exists, and if so, of how many hours. Most authorities give from 36 to 48 hours as the time the patient should be entirely free from the whole meal. If the pathology is thought from the first to be located wholly in the intestines with the jDossible exception of an involved appendix, an opaque enema should be adminis- tered (the bowel having been previousl}^ emptied by a two quart Avater enema). Here it may be stated that in the author's opinion there is only one proper position to have a patient assume in taking an enema to fill the colon; that is, first, place him on the left side and insert the tube, having the container raised about three feet. The liquid is now allowed to flow into the bowel until about half of it is taken; he is now turned over so that he is lying flat on the face, and the remainder is given. If this method is carried out, there will usually be no griping and little desire to expel the fluid. He is now turned onto the back, the tube having been removed; and after the knees have been drawn up, the abdomen is lightly kneaded so as to insure a thorough distribution of the liquid. The enema is prepared in various ways, two coimiion and satisfactory methods being as follows : To one quart of heavy buttermilk add 5 ounces of one of the bismuth salts or 8 ounces of barium sulphate. This is placed in an ordinary irrigating can and warmed by placing the can in a sink or pail of hot water and agitating the con- tents, either with the hand or with a long-handled spoon. This also keeps the heavy powder from settling to the bottom and thereby clogging the outlet tube. The sec- ond and probably the better w^ay is as follows: To 32 100 ROENTGEN TECHNIC ounces of warm water add 7V2 ounces of barium sul- jDliate, and 15 ounces of kaolin. This after being well stirred is injected. Following the injection, the patient is viewed fluoroscopically. The same things are noted as seen subsequent to a meal from above with the excep- tion that the ap]3endix rarely shows when the contrast mixture is given from below. Ileocecal incontinence should also be looked for as this is the only method by which it may be demonstrated. It is sometimes advis- able, especially if malignancy is suspected, to watch the enema injected b}^ means of the horizontal instrument. This will reveal any point or points of hesitation, etc., which may be exceedingly helpful. The different parts of the gastrointestinal tract should never be examined separately, a meal should alwa^^s accompany, and care- ful observations be made of it until it is wholly expelled. Kuegle Technic There has been an exposure table worked out by an- other of the author's colleagues, Doctor F. H. Kuegle, which probably puts exposures on a more exact basis than any other that has been observed by the author. With it, especially in bone work, a medium spark gap is used together Avith a small number of milliamperes and long exposures. In the author's opinion, the great- est disadvantage is the long time with its greater pos- sibilities for movement. On the other hand, the great wealth of detail that can be secured if quiet is main- tained is very pleasing. By this method all parts are measured, a certain time being allowed each centimeter. With the ordinary exposure table one is told to give a certain amount of time to a knee in an adult weighing approximately 160 pounds. It is well known that knees in 160 pound men vary, and the roentgenologist must use his own judgment; that is, a little less time must be POSITIONS AND EXPOSURES 101 given in the case of a tall, thin man, and a little more for a short stout man. By using the Kuegle method this personal element is done away Avith, there is a set time for each part. The following is submitted as approximately correct in using both Paragon and Cramer plates: All Bone Work Centimeters in thickness Time, in seconds Paragon Cramer 4 % 1 5 1 IV2 6 1% 21/4 7 IVa 8 2% 4 9 3 5 10 4 6 11 51/2 71/2 12 7 8 1/2 13 8 91/2 14 9 11 15 10 12 Vo 16 11 14 17 12 141/2 18 13 16 19 14 171/2 20 15 19 21 16 201/2 22 17 22 23 18 231/2 24 19 25 25 20 26 26 Milliamperes, 20. Spark gap, 5^/4 inches. Distance, 24 inches. 21 27 Gastrointestinal Tract (Only) Time, in seconds Paragon Cramer (Without screen) (Screen) Small (prone) ¥2 - 1/4 Medium (prone) Vs Vs Large (prone) Milliamperes, 65-70. 1% V2 Spark gap, 6i/i-6i4 inches. Distance, 24 inches, 102 EOEXTGEX TECHNIG Chest (Only) Time, in seconds Paragon Cramer (Without screen) (Without screen) Small 14 34 Medium % 1 Large 1 I14 Milliamperes, 80. Spark gap, oyi-oVo inches. Distance, 30 inches. A slow teclmic has recently been adopted by the author preferably used in conjunction with the hydrogen tube, employed, however, very satisfactorily with the Coolidge. A fine focus tube is essential and 35 milliamperes is the maximum employed. For most of the ex^^osures made of the bony system the use of the plate direct is satisfactory, but in certain instances intensification must be used by means of the screen. The author has found it more satisfactory with this technic to use two screens ^\\\\\ films. Both are mounted in the cassette and the film is xolaced between. This is so thin that the effect of both screens is regis- tered. From exioeriments the author is of the opinion that there is no material increase in the speed by using this method, the main advantage arising from the fact that all mottling is done away Avith, this having been the great disadvantage with the single screen in the past. In the following exposure table the author has stated the time in milliampere seconds. Tliis is nothing more than the product of the milliamperes passing through the tube and the time given in seconds ; as, for instance, in the anteroposterior exposure of the knee with 20 mil- liamperes passing through the tube (wliieh is kept as neai'ly constant as possible) and backing up a 4-inch siDark gap, to register the required 80 milliampere sec- onds, one will have to expose 4 seconds. In other words, 20 milliampei-es for one second, or 4 seconds for 80 mil- POSITIONS AXD EXPOSURES iUo liampere seconds. One will note that there are only four settings used ; namely, 3%-incli gap using 20 milliamperes. 4- inch gap using 20 milliamperes. 41/2-iiich gap using 25 milliamperes. 5- inch gap using 35 milliamperes. Practically all of the bony system is done by the 4-inch gap and 20 milhamperes. In the stomach and colon work, a 41/^-inch gap and 25 milliamperes are used. If the sub- ject is very large, or when the peristalsis is excessively active so that one Avould be led to believe that in one second's time movement would be shown, the method given elsewhere should be used. In the ordinary subject, however, the 25 milliamperes for one second A\ith the double screen gives a very satisfactory roentgenogram. The only place where the tube is at all taxed is in the chest work Avhere it is necessary to use 35 milliamperes. The author, after having used this milliamperage Avith a single hydrogen tube now for over six months, including a large number of chest cases, fails to note any injurious pitting of the focal face and, therefore, concludes that the occasional chest examination as compared vith the other work recpiiring only 20 milliamperes is not harmful to the tube. PART POSITION SP. GAP MILLI. DISTANCE PLATE (inches) SEC. (inches) II and A. P. 31/2 221/2 22 Direct Lat. 31/2 30 22 Direct Wrist A. P. 31/2 221/3 22 Direct Lat. 31/2 30 22 Direct Elbow A. P. 31/2 45 22 Direct Lat. 31/2 52 22 Direct Shoulder 4 50 24 Direct Foot A. P. 31/2 22% 22 Direct Lat. 31/2 30 " 22 Direct Anlde ■ A. P. 4 50 22 Direct Lat. 4 40 22 Direct Knee A. P. 4 80 22 Direct Lat. 4 60 22 Direct 104 ROEISTTGEN TECHNIC PART POSITION SP. GAP MILLI. DISTANCE PLATE (inches) SEC. (inches) Uip 4 80 (Contact large cone) Direct Pelvis 4 70 24 (Screens with film) Cervical spine A. P. 4 50 24 Direct Lat. 4 40 24 Direct Dorsal spine A. P. 4 60 24 ( Screens with Lat. 4 40 25 film) Lumhar spine A. P. 4 40 22 (Screens with film) Lat 4 80 (Compression large cone) ( Screens with film) Kidneys 4 40-60 (Compression cone) (Screens with film) Bladder • 4 60 (Compression cone) (Screens with film) Chest 5 35-50 28 Direct Stomach 41/2 25 22 (Screens with film) Head A. P. 4 60-80 22 (Screens with Lat. 4 37-50 22 film) Sphenoids iiifero- 4 60 (Contact (Screens with superior small cone) film) Gall bladder 4 60 23 ( Screens with film) Heart 41/2 10 28 ( Screens with film) Teeth upper molars 4 17 Direct upper bicuspids and cuspids 4 15 Direct lowers 4 10 Direct Mandible 4 50 20 Direct Mastoids 4 50 22 (Screens with film) CHAPTER VI SmUS INJECTION Sometimes it is desirable to determine the course and origin of a sinus, usually leading from some focus in a bone, as possibly an old bone abscess with sequestrum formation, an old Pott's disease, or tuberculosis of the sacroiliac joint, a discharging pulmonary empyema, or even an unremoved bullet or other foreign substance. When this procedure seems necessary, the sinus is in- jected with Beck's bismuth paste which is put up by Parke, Davis & Company. It comes in collapsible tubes with a cap having a long snout. This is inserted in the sinus opening and held firmly by a wad of cotton about the opening. An assistant now makes pressure on the tube, injecting as much as the patient can stand com- fortably or until it begins to come out around the cotton. A small piece of adhesive plaster with a lead marker in its center is now pasted over the opening not only to lo- cate the opening on the plate but also to stop the bis- muth from coming out during the rest of the procedure. Stereoscopic plates are now taken which, when placed in the stereoscope, will show the entire tract from one end to the other. Doctor Beck, in a recent article deal- ing with this subject, called attention to the importance of placing the bismuth injection container in a hot water bath before injecting so as to insure its easy accessibility into all recesses and cavities of the tract. 105 CHAPTER VII LOCATION OF FOEEIGN BODIES There have been innumerable methods and devices reconmiended for the localization of foreign bodies, all of which in their place are good. Only tAvo will be de- scribed here as they are perfectly adequate and require no additional apjoaratus. When one can take plates in two directions as in a forearm or ankle, it is hardly nec- essary to look further; stereoscojDic plates are also very satisfactory, but to be a little more accurate, both of the following methods should be used, one to check the other. Plate Method It is Avell always to fluoroscope the part first to get some idea of the location of the foreign body; one is sometimes greatly surprised to find it many inches from its suspected location. This region is then placed over a plate of adequate size. The tube is set as for taking a stereoscoj)ic set of plates, and the first exposure made. The tube is then moved as in the stereoscopic method (21/2 inches) without tilting, however, and the plate re- maining in the same position, another exposure is made as before. It will be seen on developing the plate that the object sought shows in two different positions, caused by the moving of the tube. It is now comparatively easy to figure geometrically the distance of the object from the plate. (See Fig. 54.) The distance from the anode to the plate is known, say 18 inches, and is represented by BC. The distance from DG is known, 2l^ inches. 106 LOCATION OF FOREIGN BODIES 107 D-^ B -^ G A — c — ^ r Fig. 54. The distance between the objects at the different ex- posures is measured, and found to be 1/2 inch and is rep- resented by the line EF; thus the formula, Let X equal the distance of the foreign body from the plate, it being represented by A. Let X equal BC X EF DG + EF X will equal BC(18") X EF(.5) or 9" DG(2.5") + EF(.5) or 3" X equals 9 or 3" 3 A is 3" from C, or the plate. 108 r.OEXTGEX TECHXIC The Fluoroscope Method This method is practically the same as the preceding, usmg the fluoroscope instead of the plate. The horizon- tal aiDparatus is used. The distance from the anode to the surface of the table is knoAvn. say IS inches. AMien the member in question has been placed on the table and the screen put in position, the distance from the table to the screen surface is obtained by means of a rule kept near by. This is added to the already known IS inches which gives the total distance from tlie anode to the screen. The tube box is now moved so that the anode will be exactly under the object to be located, it liaving already been located and diaphragmed down upon. A mark should now be made with a blue ijencil on the screen and also on the flesh (for further reference). The tube is now moved a knoAvn distance one Avay from the vertical, say 4 inches. This, of course, must be absolutely kno\\Ti, and can be determined by notches cut in the side of the table or by large brass-headed tacks being driven about 2 inches apart. After tlici' tnlie is thus moved it 'will be seen that the olj.ject is observe y^ vVs.^vv.vv.'- - >J..sv>.VvVv.'vS'^'-vSV>. '^^^v-v^^v-^»^^'vVVv^^.v.^v^.M..vv^^.vv^.^■v->.^ . M>^>,^i^ ^■^V'-.^V^'-^^^:^ t7y: ^xV^S>tJ^V,SV< VVvV\VV^>>N.VvV-!^vVV^».'<-.VVSVV.V-.v^^ •O" ^^^ ^^^^vV^vv^v'^^v^v^vv^^^^^^^^^^^vv^vv^^^^^ ( f^svvssvsw^x ^ '^^^v-^vvvx^vv-^'^Vs^.o ^^Uorfl^UyfU. ■x«.«..<- « t -<^ ^3C-/ va.l^e 1 TXooin De&K O 2g' 'li'io^o.-t Fig. 67. — Floor plan No. 2. ire.t.e.-pf/oyx, -Tfoonx \ Tr/i^afc / KUf.c Fig. 68. — Floor plan No. 3. 138 EOENTGEN TECHlSriC /loo m - H Pes A X)yess- O ToUH -n.,.,.J. D^sK Tfoertiatn 2^ JV^ic/o./. Fig. 69. — Floor plan No. 4. 5: f y3 fosc o-£ ic rXOO ITK I rcuoroScof»><- CoTn.lt t nc^ I K / ^ Jp: 32' '/f"^-'/' Fig. 70. — Floor plan No. S. ,/. CONVENIENT FLOOR PLANS 139 55 "PAotoyrd^Ai / ' 'J)resSir\q I Dressing ' © Coti.c h. ^ ^ I '~Pa. St «._ye T