Radiography

X-Ray Examination. This method of examination depends on the property of penetration of matter possessed by a radiation from an electrically excited Crookes' tube. This radiation has been proved to lie outside the spectrum, and has been named X-ray.

It may, for purposes other than those required by the expert, be looked upon as a source of light which has the property of penetrating the tissues to a greater or less extent according to their density, and the shadows cast by it can be recorded on a photographic plate, or may be viewed with the naked eye by means of a screen composed of a thin layer of barium platinocyanide, a substance which becomes highly fluorescent in the presence of this radiation.

One or the other of these methods is used for the recognition of pathologic conditions existing in the human tissues.

The fluorescent screen appears at first sight to be an easy way of recognizing abnormalities. Its value in the examination of the thorax, where the movements of the heart, lungs, and diaphragm have to be observed, is undoubtedly very great; but as an accurate means of recognizing any abnormality, it is untrustworthy. For instance, it is possible to fail to recognize simple transverse fracture of the tibia by its means. Its use is therefore to be deprecated in cases where great accuracy is necessary, and it is safer and better to make use of the more certain method, the photographic plate.

A further objection to the use of the screen is that the constant exposure of the hands and other parts of the body of the observer may result in an intractable, dangerous and chronic dermatitis.

By using a photographic plate the danger of dermatitis can be avoided, since it is not necessary to expose the hands at all; and at the same time greater accuracy is ensured and a permanent record is obtained.

Although examination by radiography is a somewhat tedious procedure in comparison with direct observation by the fluorescent screen, yet it is less difficult if the photographic side of this method is approached in a proper and businesslike manner.

Interpretation of Radiograms. A successful result in X-ray examination involves a clear understanding of the meaning of the radiogram produced. Even with the most accurate knowledge of anatomy, it is difficult to interpret X-ray shadows; for a radiogram is only a shadow, and the outline of the part thus demonstrated is liable to great variation. For example, in the case of injury to bone, it is always possible to secure strong and accurate X-ray shadows of the part, and no error ought to be made in diagnosis, yet errors of this kind are not uncommon.

To avoid such mistakes, it is imperative that the quality of the radiogram secured should be the best possible. For instance, in the examination of the ankle-joint and the bones of the foot, a radiogram which is flat, indistinct, and altogether wanting in detail, is of no value, while a radiogram of good quality of the same ankle-joint and foot, is of value. The interpretation of the latter is easy, while that of the former would be almost impossible, and certainly inaccurate.

The usual practice in securing radiograms is to place the subject in a position considered likely to give the best results, and then roughly, almost at random, to place the tube in some unknown relation to the part of the body under examination. The resulting shadow is often of no value because it is wanting in detail and depth. One method of avoiding this fault is to produce stereoscopic views of the part examined.

Two views having been secured in stereoscopic register, and placed in a stereoscope, the part can be viewed in relief. Theoretically, then, by this means one is able to view the parts of the body opaque to the X-rays as they would appear to the naked eye. In practice, however, this method, though it may prove of value in exceptional circumstances, is laborious. Moreover, though the parts may be made to appear in relief, they are not really as one would see them with the naked eye, but are still X-ray shadows.

A more practical method is to ensure that in all cases radiograms of any part of the body be absolutely comparable with one another by taking care to maintain the same relationship between the X-ray tube and the part under examination. For example, in making an examination of the ankle-joint, the limb is placed in a prescribed position, and the anode of the X-ray tube, that is, the actual source of the X-ray, is brought into accurate relationship to the tip of the internal malleolus by a simple mechanical contrivance, the details of which need not be dealt with here. This relationship between the tube and the ankle can always be reproduced, and therefore the shadow of a normal ankle-joint can always be obtained under the same conditions for comparison with the radiogram of the suspected ankle.

In this way, not only is the surgeon able to select the view of the part which will have the depth and detail necessary for proper interpretation, but, the shadow being familiar, he can more easily recognize any abnormality.

A radiogram secured under the conditions usually adopted, shows definite and known anatomic relationship between the bones and the X-ray tube, namely, with the anode of the tube directly opposite the tip of the internal malleolus.

To render this method of examination more perfect, there has been devised a system of radiography containing a definition of the relationships between the tube and the various parts of the body which have been found to give the most useful views, and also radiograms of the normal appearances of each part at the ages respectively of 5, 15, and 25 years.

By using this system the surgeon can secure a radiogram of any part of the body, of the requisite standard in quality, while he has at hand a normal radiogram of that part for comparison with the abnormal.

Having secured a radiogram of good quality, it is necessary for the purpose of interpretation that it should be viewed in a suitable light. The best for the purpose is a bright light shaded with opal in a dark room. The negative may be viewed at its best while still wet. Considerable loss of detail follows the taking of prints, which for this reason may greatly detract from the value of the radiogram.

It is a mistake to suppose that X-ray examination in the diagnosis of diseases can replace the older and well-tried clinical methods of investigation; it is merely a useful means of acquiring knowledge which, in conjunction with accurate clinical investigation, leads to a more accurate diagnosis and prognosis, and is often most useful by suggesting a more suitable line of treatment. It must be remembered that this method of investigation has been in use only a comparatively short time. In some diseases no definite statement is yet possible that may not prove in the future to be misleading.

At present the therapeutic use of the X-ray is rightly falling into the hands of the dermatologist and the medical clinician. In surgery, outside of the conditions mentioned above, its use is limited to lupus, keloid, epithelioma, sarcoma and carcinoma, both before and after operation.