to remember, in considering radiographs,
that they are not simple shadow pictures
or simple silhouettes, but records of den-
sity, the shadings being indicative of
atomic weight.
In the radiograph of the hand, which I
thow you, the bones having greater density
than the flesh, offer more obstruction to
the passage of the ray ; the flesh being of
lower specific gravity than the bones, of-
fers still less resistance to the ray; so that
in the radiograph of the hand we have a
record of the density of the compact bone
as distinguished from the cancellous tis-
sue, a differentiation between the bones
and the flesh and a differentiation be^
tween the finger-nails and the pulp of the
finger. It is important to remember that
the bulk of the X-rays proceed from a
fixed point on the anode, and that they
proceed from that point in straight lines,
and are not subject to deviation by any
procedure that we know of at the present
time. With this fact in mind, it is evi-
dent that the bodies which are close to
the photographic plate will be defined
more sharply than bodies at some distance
from the plate. It is also obvious that
if the target of the tube is placed too near
the plate the rays will be so divergent as to
cause distortion. A similar distortion is
seen, oftentimes, in kodak pictures, where
the nearness of the feet to the camera
causes them to assume grotesque propor-
tions. A technically good X-ray negative
should possess the greatest possible sharp-
ness in the differentiation of density and
should possess the minimum amount of
distortion. Contrast in thin parts of
the body, such as the hand, arm or foot,
is easily secured. When radiographs
are made through the denser parts of the
body, as the hip, the contrast between the
soft tissues and the bones is often slight.
This lack of contrast is now recognized
to be partially due to a fogging of the
plate from the secondary X-rays which
are induced in the body, and also from the
•secondary rays (sometimes called parasi-
tic rays), which are given off from the
glass walls of the Crook's tube.
Contrast through the denser parts of
the body may be secured by the employ-
ment of a tube whose vacuum is suffi-
ciently high to secure proper penetration,
and yet not so high as to obliterate the
contrast. The effects of the secondary
rays can be minimized by the employment
of suitable diaphragms, preferably the
compression cylinder diaphragm of
Schonberg.
Besides the question of contrast, the
position of the target of the tube in refer-
ence to the part examined is of vital im-
portance. If a fracture of the lower end
of the radius, for example, is suspected,
the target of the tube should be placed
directly above the part to be examined;
this point may be accurately determined
by a suitable plumb-liner "Ifv the target of
498
RADIOGRAPHS— HICKEY.
Jour. M. S. M. S.
the tube is placed considerably to one side,
there will -result, following the laws of
physics, a wSO-called distorted image.
Having secured a negative possessing
the maximum contrast from exposure to a
tube properly placed, it should be exam-
ined by a suitable light. This may easily
be secured by placing the negative upon
the upper sash of a window and allowing
the light from the sky to shine through,
excluding extraneous light; or it can be
illuminated by artificial light with a
ground glass screen interposed to secure
proper diffusion.
The original negative is the proper text
to examine. No method of photographic
printing will preserve all the detail and
the contrast. It is important to remem-
ber that in prints from X-ray negatives
the question of right and left is re-
versed. Not long since I was censured,
by a physician who was examining a pho-
tographic print from an X-ray negative
for having radiographed the wrong hand,
as he did not know that the prints re-
versed the relations.
The most important topic in connection
with the interpretation of radiographs is
the experience of the one who makes the
interpretation. We are accustomed to de-
mand training on the part of those en-
gaged in diagnostic work with the mi-
croscope, the ophthalmoscope and other
scientific instruments of precision. It is
rare, however, to meet with one who does
not feel perfectly competent to make a
diagnosis of a radiograph at first glance.
In considering radiographs of the joints
of children it is most important to have a
thorough knowledge of the epiphyses.
The radiograph of the elbow, which I
show you, is one of the normal elbow at
the age of 15. This appearance of the
olecranon, however, has been repeatedly
mistaken for a fracture, even by those
whose surgical skill is excellent. To avoid
mistakes the injured joint should be com-
pared with the corresponding sound joint
of the same child.
We must constantly bear in mind, in
examining X-ray negatives, that our judg-
ment should be based upon a proper un-
derstanding of what we see. This may,
perhaps, seem a trite saying, but we
should endeavor not to be prejudiced by
pre-conceived conclusions. This is one
reason why the photographic plate is su-
perior to the fiuoroscope. It has aptly
been said that while a radiograph will af-
ford us a great deal of knowledge as to
the condition of the bones, it will not tell
what they smell like, and so we should
not expect too much information or more
than can be afforded by a record of den-
sity.
One of the most important teachings
which radiography has promulgated is
that our old ideas of the healing of frac-
tures should be revolutionized. In consid-
ering the interpretation of fractures, we
should approach the subject from a
strictly modern standpoint and not with
ideas of pre-radiographic times. The
Roentgen ray has demonstrated that the
former exact coaptation which was sup-
posed to be obtained when a fracture was
reduced, was and is often only a beautiful
idea on the part of the attending medical
man; in other words, that perfect reduc-
tion of a fracture is rarely secured, and
that nature is, indeed, very kind in taking
care of our surgical shortcomings. It is
obviously improper, therefore, to critidse
the setting: of a fracture as shown by a
J
NOVBMBER, 1904.
RADIOGRAPHS— HICKEY.
499
good radiograph, from the standpoint of
our old ideas. Criticism of radiographs of
fractures should be made only with a full
understanding of what radiography has
revealed in the healing of these breaks. It
is obvious that such knowledge and under-
standing is not possessed by the laity ; and
it is, therefore, a great injustice, to ever
submit a radiograph of a fracture to a
jury of lay minds.
Radiography is coming to be applied as
an aid in the diagnosis of thoracic lesions.
We have here a field which presents great
opportunities for investigation ;' as much
so as was opened up by the stethoscope
when Laennec presented it to the profes-
sion. Interpretation of radiographs of the
chest demands much future study in order
that we may utilize the benefit to be de-
rived from this method of physical exam-
ination. In the radiograph which I show
here of a normal chest we find various
shadows which are constantly present in
the normal chest. These have been yari-
ously interpreted as shadows of the bron-
chi, shadows of the interlobular pleura,
shadows of consolidation. It is the belief
of the writer, based upon studies of the
injected cadaver, that these tracings rep-
resent the course of the larger pulmonary
blood vessels.
In considering the future of radio-
graphy it is important to remember the
possibilities of the stereoscope. Various
devices have been employed for giving
proper relief and depth in the negatives to
be examined. Mr. E. W. Caldwell has
recently presented to the radiographic fra-
ternity a very simple stereoscope of which
I have here a rather crude model. It is
infinitely simpler than the Wheatstone
stereoscope which I had the pleasure of
demonstrating to you two years ago. The
use of the stereoscope at once removes a
criticism which is often seriously ad-
vanced that objects are all represented in
the same plane. In the image which re-
sults from the fusing of carefully pre-
pared stereoscopic negatives, the proper
relations and proportions of the various
objects represented are preserved. The
use of the stereoscope eliminates the ques-
tion of distortion. ^
The rapid improvement in the technique
of radiography during the past few years
causes good hope that similar advance-
ment is destined yet to come. When we
consider that we now make radiographs
of most of the different parts of the body
in a comparatively few seconds where
formerly it was a question of as many
minutes, we will hope that some time in
the future we may be able to take instan-
taneous radiographs through the thicker
parts of the body as is now done through
the thinner parts. If this is achieved, we
will probably secure a greater wealth of
detail in our pictures through the abdom-
inal organs with a corresponding aid in
diagnosis of the diseases of the abdominal
viscera.
Catarrhal Pyelitis. — (Conclusions).
1. Pyelitis is of much more frequent occur-
rence than is generally supposed.
2. It is a frequent cause of prolonged discharge.
3. Local treatment of the pelvis of the kidney
is the rational one for this disease and is quite
feasible.
4. Beginning nephritis, when due to pyelitis,
may be cured permanently by lavage of the renal
pelvis.
5. By curing the inflammation in the pelvis of
the kidney, nephritis may be guarded^ against
6. Catheterization of the ureters is not as diffi-
cult as is generally supposed, and it is not ac-
companied by such dangers as many deem it to
be. — (American Journal of Urology, October,
1904, Wm. Field Ayres.)
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500
EDITORIAL.
Jour. M.S. M.S.
The Journal of the
Michigan State Medical Society
All communications relative to exchange*, books for review,
manuscripts, advertising and subscriptions should i)e
addressed to Editor A. P. Biddle, 57 Fort Street West,
Detroit, Mich.
StttMcriptloii Price. Two Dollars per year, la Advaoce
NOVEMBER. 1904
BMtorial
IMMUNITY. ITS THEORETIC-
SCIENTIF^IC SIDE.
In a recent number of one of the Medi-
cal weeklies*, there appears an abstract of
an address delivered by Wassermann, of
Berlin, before the New York Pathologi-
cal Society. Some of the points made
appear to us as most interesting and
highly suggestive.
According to the side chain theory of
Ehrlich, specific substances, developed
in the serum by immunization, are noth-
ing else than those portions of cells of
the living organism for which the sub-
stances against which we immunize, pos-
sess a specific affinity. '^Receptors*' are
those portions in the organism for which
a substance possesses such specific rela-
tions. The toxiti is first bound to the
body cell. Follow^ing Weigert's law an
overproduction of the "receptors'' occurs.
The excess of these receptors is cast into
the blood stream. Wassermann has been
able to demonstrate experimentally three
stages : 1. The union of toxin and recep-
tor. 2. The overproduction of receptors.
3. The thrusting oflf of the superfluous
receptors into the blood.
In what way do toxins and anti-tox-
ins unite? Wassermann is evidently a
believer in the chemical theory. At first
there is only a loose combination between
*Nczu York Medical Journal, Oct. 1, 1904.
the two. This gradually and steidily
becomes firmer. His experiments along
this line are most interesting. They also
confirm the work of Meyer and Ransom
(reported by Inglisf) that the tetanus
poison finds its way to the spinal cord
by the nerve path, traveling up the axis
cylinders and not through the blood or
lymph circulation.
Following Ehrlich's theory, every in-
dividual portion of an organism, against
which we can immunize, corresponds to
a counter group, the receptor of the liv-
ing organism. The body of certain bac-
terial species is not a simple homogeneous
mass but is composed of several parts.
The serum then is made up of the sum
of the so-called "partial" elements. In
certain species of bacteria, there are races,
which from a biological standpoint are
differently constituted from other races
of the same species. We are therefore
compelled to make such sera by means of
a large number of cultures of the bacterial
species in question, which sera is styled
"multipartiar* or "polyvalent."
The diphtheria serum now in use acts
only on the toxin secreted by the diph-
theria bacillus. By a certain method of
immunizing animals, a new kind of diph-
theria serum has been made, which
specifically aflfects the diphtheria bacillus,
or substances present in it. This new
diphtheria serum is a "multipartial"
serum.
Martin, of the Pasteur Institute, at
Paris, and Wassermann, of Berlin, found
that the diphtheria bacilli could be made
to disappear from the throats of conva-
lescents and healthy children. The '*mul-
tipartiar' serum was dried in vacuo, pul-
â– fjournal Mich. State Medical Society, July,
1904.
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NOVBMBBR, 1904.
EDITORIAL.
SOI
verized and used as a pastille for the
throat and insufflated as a powder for the
nose. It was found that it caused an
agglutination of the great majority of
Klebs-Loeffler bacilli which could then
be removed by an indifferent fluid. The
clinical results so far have been very
favorable. If they continue good, "multi-
partiaP diphtheria serum should be a
great aid in the prophylaxis of this dis-
ease.
THE RELATION OF VISCERAL
DISEASE TO MENTAL PHE-
NOMENA.
It is generally accepted that mental un-
balance may accompany cardiac disease
or vascular degeneration, the poisoning
of kidney disease or the effects of alcohol
or other toxic agents, or change in a
gland necessary to normal bodily changes.
But the study of these visceral changes
from the mental standpoint has been
insufficient. Some three years ago Henry
Head drew attention to mental symptoms
seen iq diseases of the different viscera
which he regarded as distinct.
In a late issue of the Johns Hopkins
Hospital Bulletin, Dr. Gamble reports
ten cases illustrating this'fopic; that many
cases of mental illness start with, differ-
ent conditions of physical disease. In
three cases of mitral stenosis one exhib-
ited hallucination of sight; one alternation
depression and exaltation and one sus-
picion. . In one case of asthma there was
hallucination of smell and in another
unreasoning fear. A case of adherent
pericardium there had hallucination of
hearing wHh alternate depression and
exaltation. All these could be persua-
ded that their moods had a physical basis.
In another series of four cases such per-
suasion was impossible. Briefly, a case
of arterio-sclerosis had loss of attention
and memory, confusion of ideas; a case of
bronchial asthma had dreams of a gigan-
tic snake which he was fighting. At first
they occurred when half awake and he
shook them off when fully awake, but
gradually he was never rid of them. A
case of aortic regurgitation saw indis-
tinct figures, which gradually assumed
definite shapes and he believed they told
of the future.
A fourth case of mitral stenosis began
with pleasant dreams but they grew dis-
agreeable. She conversed with dead peo-
ple and believed she had the power of
prophesy.
Certainly these facts are suggestive,
and doubtless every practitioner can re-
call cases allied to them. If they shall
influence all to carefully observe every
case, great light may be cast on the be-
ginnings of mental diseases. Farther we
may finally, recognize the beginnings of
mental disease and stop its progress by
relieving the physical disease which is its
basis.
ETIOLOGY OF SUMMER DIAR-
RHCEA.
Some time ago the Rockefeller Insti-
tute for Medical Research begtm to inves-
tigate the bacteriology of the summer
diarrhoeas of children. The work has
been done in various cities under the su-
pervision of Dr. Simon Flexner. He
draws the following conclusion^:
(1) Bacillus dysenteriw can be isolated
from the intestinal discharges and the in-
testinal mucosa of a large percentage of
children suffering from the diarrhceal
diseases prevailing along tlye-Atlaiidp^ea-
502
EDITORIAL.
Jour. M.S. M.S.
board of the United States during the
summer months.
(2) Baccillus dysenterue is to be
sought especially in the mucus thrown off
by the intestinal mucosa in these diseases
and in the substance of the mucous mem-
brane itself. The bacillus exists in
smaller numbers in, or is recovered with
far greater difficulty from, the fecal mat-
ter that often is admixed with the mucus.
(3) Blood admixture makes the isola-
tion of the bacillus of dysentery from the
intestinal discharges more readily ac-
complished, as it generally indicates in-
fections of severer grade; but the mere
presence of blood is of less moment than
the occurrence of mucus, since it is in
the latter material that the bacillus of
dysentery resides.
(4) The number of colonies of Bacil-
lus dysentericB recoverable in cultures is
in a general way indicative of the sever-
ity of the lesions and symptoms of the
disease. Some cases, however, of marked
severity yield few colonies, and others of
marked mildness a larger number of
colonies of the bacillus.
(5) The total number of colonies of
Bacillus dysenterice obtainable, is, as a
rule, far below the number of colonies of
the usual intestinal bacteria which de-
velop upon the plates; but in a very few
instances the number of colonies of the
dysentery bacillus equals or exceeds that
of all other organisms, and in exceptional
specimens the bacillus alone appears in
the cultures.
(G) The type of Bacillus dysenteries
which preponderated in the children is
the so-called "Flexner-Harris" organism.
The "Shiga" type of the organism is ex-
ceptionally met with, and occasionally
both types are found in association.
(7) Types of Bacillus dysenteric of
less well-established properties have also
been encountered. Among these are ba-
cillus "4r" of Hiss, and Russell and an-
other indistinct type which demands ad-
ditional study before admission to the
group, whose special property is its power
to act upon lactose with acid production.
(8) The blood of the children suflFer-
ing from diarrhoeal disease agglutinates
at times the bacillus of dysentery in high
dilutions; but this agglutination by the
blood does not proceed hand in hand with
the occurrence of the bacillus in the in-
testine. The agglutination reaction is
not to be treated as an index of the pres-
ence of, or infection with, Bacillus dysen-
teria.
(9) The close association of Bacillus
dysenteries with the intestinal mucosa,
and the increased numbers of the organ-
ism found under definite pathological
conditions, the established pathogenic ac-
tion of the bacillus for human beings, and
the specific blood changes met with in
many of the cases of diarrhoeal disease,
all speak for a relationship of cause and
effect between the bacillus of dysentery
and the lesions of the intestine.
(10) It is probable, although it is not
proved, that Bacillus dysenteries appears
at times among the saprophytic bacteria
of the contents of the intestine. The fre-
quency of its isolation in all grades of
diarrhoeal disease in children would be in
conformity with the view of such a
saprophytic existence and the acquisition,
under pathological conditions, of patho-
genic and invasive properties.
(11) Should it be established that
Bacillus dysenteries is occasionally or reg-
ularly to be found among the bacteria of
the cavity of th^.jjit^tyii|^(^e dangers
November, J904.
EDITORIAL.
503
of the entrance from without of specially
pathogenic examples of the organism are
not to be disregarded. The contagious-
ness of baeillary dysentery among adults
and the rarer instances of diarrhoea! con-
tagion among children, prove the neces-
sity of recognizing such an extra-infec-
tious origin of the disease.
(12) Streptococci in large numbers
are found frequently associated in cul-
tures with Bacillus dysenteries Both or-
ganisms survive side by side and would
seem not mutually to inhibit each other's
development. What part is to be ascribed
to each in the production of the lesions
of the intestine and the symptoms of dis-
ease is not established by this investiga-
tion. Nor is the possible action of any
other of the many bacteria of the dis-
charges excluded by the special findings
of the investigation.
(13) The central fact brought out by
this collective investigation is the frequent
occurrence in the diarrhceal diseases of
children of a specific micro-organism,
which hitherto has been held to be of
special pathogenic action in human be-
ings, and to be the cause of that form of
dysentery among adults and also among
children which is characterized by neuro-
tic and pseudomembranous lesions of the
intestine and marked infectiousness.
(14) The lesions of the intestines ob-
sefved in the children who have suc-
cumbed to the diarrhceal diseases treated
of in this investigation have been very
varied in character; but there has rarely
been found among them the particular
kinds of pathological changes which char-
acterize pseudomembranous enterocolitis.
ICTERUS AND SYPHILIS.
There have already been a number of
cases reported where icterus recurred dur-
ing the secondary 'stage of syphilis.
There seems to be no uniformity in opin-
ion among the various writers as to its
etiology. The following have been given
as causes of the pigmentation :
(1) Enlarged glands which press
upon the bile ducts.
(2) Secondary eruptions in the intes-
tine causing an obstruction in the flow
of bile.
(3) A general catharrhal condition.
(4) Hyperaemia of the bile capillaries,
arising from inflammation of the liver.
(5) Changes in the blood and blood-
vessels.
(6) Changes in the nervous system.
The jaundice may accompany the sec-
ondary symptoms of syphilis or it may
appear alone; it may disappear and re-
appear again like the eruptions; it lasts
from a few days to a few months; and
untreated it may become chronic. Occa-
sionally the disease assumes a malignant
type with delirium, hemorrhage, coma
and death after fifth or sixth day.
Under specific treatment the jaundice
will fade away.
THE PASSING OF A VETERAN
EDITOR.
On Aug. 6th, the Medical Record an-
nounced the resignation of its editor Dr.
George F. Shrady. Since the founding
of that journal, thirty-eight years ago,
Dr. Shrady has been its editorial head.
Backed by the great medical publishing
house of Willianj.^)Vp^(jd(§(5;3g|^ has
S04
EDITORIAL.
Jour. M.S. M.S.
made the Record the mouthpiece of the
great American metropolis. Doubtless
neither the firm, its journal or editor
have commended themselves to all — ^but
such as desired to keep in touch with
New York City and its attaches were
compelled to study the Record. If they
desired to communicate with or favorably
influence medical New York, the Record
presented a valuable medium.
In' the ethical, factional, education-
al, or society conflict the Record has
always been found on the side which
advantaged the interests of the house,
primarially and other interests as much
as practicable.
Under existing conditions Dr. Shrady
pushed his journal to the front and vali-
antly promoted the interests of the medi-
cal profession. It collected news from
every portion of the world, and placed it
before its readers in a readable man-
ner; it discussed in editorial columns the
facts of greatest interest; it gave promi-
nence to the writings of the leaders in
medical science; medical discussions and
condensations from other publications
were duly considered.
As progressive physicians were com-
pelled to keep in touch with the activities
of New York, our readers are familiar
with Dr. Shrady's record as an editor.
Fewer knew him personally as he rarely
mingled with the great National Associa-
tion, or ventured far west of the Atlantic
Coast. Personally he was a most de-
lightful personality, true to his friends
and alJ who knew him were such. He
won considerable reputation as a surgeon^
Init his future fame will rest on his record
as a medical editor. We cannot recall
one who has continuously served more
than a generation in this field — a fact
which speaks well for all concerned — and
indicates the possibility of an editorial
specialty as a career. With one voice the